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.

The most common visual difficulties encountered include loss of the superior visual field, difficulty in reading, and loss of peripheral vision when driving.

In addition, patients with moderate-to-severe dermatochalasis chronically elevate their brows to improve their visual field. This frequently is associated with frontal headaches.

Ocular irritation, dry eyes, and dermatitis also may be the presenting signs of dermatochalasis.

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.

The eyelid skin should be evaluated carefully. The amount of eyelid skin redundancy, the thickness of the skin, skin inflammation, and skin lesions should be noted carefully.

The amount of excess skin in the upper eyelid can be assessed by the pinch technique, as shown in the image below. The pinch technique can be used in the lower eyelid when the patient maintains a sustained upgaze with the mouth open. This stretches the lower eyelid skin and helps ensure that overresection of lower eyelid skin is not completed.


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Pinch technique for measuring redundant skin in upper eyelid blepharoplasty.

The presence of an upper eyelid crease should be noted and measured. The normal upper eyelid crease falls 8-12 mm above the lid margin and is generally higher in women than in men. Some patients may be noted to have a double eyelid crease or epiblepharon, which commonly is seen in Asian patients. Some patients may not have an eyelid crease. In addition, the presence of a nasojugal fold and inferior tarsal eyelid crease should be noted.

The orbital fat should be assessed in persons with dermatochalasis. Orbital fat herniation can be accentuated by gentle ballottement on the eye. There are 2 fat pads in the upper eyelid and 3 fat pads in the lower eyelid. The presence and amount of fat pad herniation should be noted.

Lateral bulging in the upper eyelid frequently results from lacrimal gland prolapse, which should be noted preoperatively, in that lacrimal gland resection can cause serious complications.

The eyelid margin position also should be noted. The normal upper eyelid margin position should fall approximately 1 mm below the superior limbus. This distance also can be measured with the marginal reflex distance (MRD) test. The normal distance from the eyelid margin and the light reflex is at least 4 mm. MRD is associated closely with superior visual field defects. The smaller the MRD, the more the visual field loss. Some authors have suggested that the MRD can be substituted for visual field measurement in assessing the functionality of a patient's dermatochalasis.

It is critical to recognize lid ptosis preoperatively. Occasionally, the blepharoplasty surgery can be complicated by postoperative ptosis. The position and the contour of the brow must be noted and any ptosis of the brow identified. This frequently plays a role in patients' expectations. Many patients with dermatochalasis also have brow ptosis. To correct the dermatochalasis and visual field loss adequately, brow surgery should be performed concomitantly with blepharoplasty surgery. Blepharoplasty surgery performed alone has not been shown to change the brow height.

The ocular surface should be assessed in all patients considering blepharoplasty surgery. Patients with a significant history of dry eyes should be evaluated carefully. This evaluation should include biomicroscopic examination of the ocular surface, evaluation of the tear film, position of the puncta, and, in some patients, measurement of the tear-breakup time (BUT) or basic secretor testing. Many studies confirm that tear BUT, Schirmer testing, and basic secretor testing are inaccurate and inconsistent measures of a dry eye syndrome. Instead, the patient's constellation of findings should be viewed in the light of their history. Other important findings to note include the presence of conjunctival filtering blebs, superior limbic keratitis, pterygia, pinguecula, corneal dystrophies and scarring, and corneal dellen.

Bell phenomenon also should be assessed. A normal Bell phenomenon involves the rolling of the eyeball up and out upon eyelid closure. This is important in patients with a dry eye syndrome and/or lagophthalmos. Some patients may be noted to have no Bell phenomenon or a reverse Bell phenomenon where the eye rolls down upon eyelid closure. Lagophthalmos should be evaluated carefully. Blepharoplasty frequently can be associated with postoperative lagophthalmos. This resolves in most cases once the eyelid edema subsides. The presence of lagophthalmos can be used to judge the amount of skin to be resected.

Proptosis and enophthalmos must be noted in all the patients with dermatochalasis. The position of the eyeball can affect the position of the eyelid on the globe and cause a pseudoptosis.

Hypertrophic orbicularis muscle must be noted preoperatively. Most commonly, it is noted in the lower eyelid pretarsal region. The treatment is directed toward resection of the hypertrophic orbicularis muscle.

Scleral show must be noted preoperatively. When present in the upper eyelid the etiology must be identified. The frequent etiologies include the following: thyroid eye disease, proptosis, amyloidosis, and postblepharoplasty surgery.

Scleral show in the lower eyelid may be due to the above mentioned causes, plus the following: horizontal eyelid laxity, anterior lamellar shortening or posterior lamellar shortening, and scarring.

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.

In rare cases where hereditary angioedema is suspected, a C1-esterase inhibitor level should be performed.

Similarly, if amyloidosis is suspected, then a protein electrophoresis is appropriate.

If thyroid disease is suspected, thyroid-stimulating hormone serum (TSH) should be estimated.

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.

The upper eyelid creases are marked (usually 8-12 mm) and measured to ensure symmetry. The pinch technique is used to measure the amount of skin to be resected.

One end of a toothed forceps is placed on the eyelid crease, and the other end of the forceps is used to pinch the skin in the upper eyelid.

The amount of skin pinched should not cause the eyelid to open upon pinching. Multiple measurements are made on both sides to ensure symmetry.

The lids are injected with 1% Xylocaine with epinephrine and hyaluronic acid mixture. The upper border of the incision should not be closer than 7-8 mm from the brow.

The skin is excised using a No. 15 blade, laser, or radiofrequency device; then, a 2- to 3-mm strip of preseptal orbicularis is excised with tenotomy scissors. Some surgeons preserve orbicularis muscle. Certainly in patients with a severe dry eye, thought should be given to preserving the orbicularis muscle. Meticulous hemostasis is maintained throughout the procedure.[8]

The 2 upper eyelid fat pads are gently and meticulously dissected free, and then resected, and the fat pad stump is cauterized.

The wound is closed appropriately with care being taken to ensure that the orbital septum is not incorporated into the closure.

Occasionally, a modified W-plasty is indicated for the medial aspect of the wound. In some patients, resection of the retroorbicularis oculi fat pad (ROOF) is indicated to minimize brow fullness.

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]

The lower eyelid is everted over a Desmarres retractor, and the inferior conjunctival fornix is incised. The globe is protected with corneal protectors. Blunt dissection is used to identify the 3 lower eyelid fat pads.

The inferior oblique muscle and the "valley of the inferior oblique" are identified and preserved. Care is taken not to resect too much fat, causing a hollow look to the lower eyelids.

The conjunctiva is closed loosely with a 6-0 plain absorbable suture. A tight closure can result in a compartment syndrome should the patient experience postoperative hemorrhage. This can be combined with a canthopexy if lower eyelid laxity is identified.

Another technique has been described whereby the 3 lower eyelid fat pads are draped over the inferior orbital rim to prevent a tear trough deformity. This is performed after the arcus marginalis has been incised; then, the fat pads are sutured to the periosteum on the anterior surface of the maxilla. The fat draping can be tailored to the individual patient’s needs (ie, draping the medial fat pad and resecting the middle and lateral fat pads).

Alternatively, the fat pads and/or the orbital septum can be shrunk with a Colorado needle tip and/or carbon dioxide laser without resection to achieve an aesthetically pleasing result.[10]

A subciliary technique can be used if dermatochalasis is identified in the lower eyelid using the pinch technique with the patient in upgaze and the mouth open. The procedure is similar to that described above, except that a skin muscle flap is elevated in the lower eyelid prior to resecting or redraping the lower eyelid fat pads. However, the pretarsal orbicularis should be preserved when using this technique. This also can be combined with a canthopexy if indicated. It is often preferable to combine skin tightening using a laser or chemical peel than to overresect skin and cause eyelid deformities.

With the open subciliary technique, the arcus marginalis can be released and the septum can be redraped over the infraorbital rim to smooth the transition from the lid to the cheek.

Transcutaneous or transconjunctival blepharoplasty may also be combined with orbitomalar ligament suspension to improve aesthetics and to lessen the risk of postoperative eyelid retraction.[11]

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

Lagophthalmos can be a potentially serious complication if overjudicious resection of the skin and/or muscle is performed or if the orbital septum is incorporated into the wound closure or undergoes excessive scar contraction.

Some patients may have lagophthalmos prior to surgery. It is unlikely that resection of a small amount of preseptal orbicularis oculi causes lagophthalmos or dry eye.

Keratitis in dermatochalasis

Keratitis can be a potentially serious complication. This is most commonly due to lagophthalmos but can occur in its absence. It is imperative that patients be evaluated preoperatively for dry eye.

Dry eye is treated with topical lubricants, taping the eyelid shut at night, and punctal plugs.

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]

Ptosis in dermatochalasis

Ptosis is a rare complication of upper eyelid blepharoplasty. It is imperative that ptosis be ruled out prior to surgery.

In most cases, ptosis is due to prolonged eyelid edema with dehiscence of the levator aponeurosis or injury to the levator aponeurosis.

Eyelid retraction in dermatochalasis

Eyelid retraction is the most common complication after lower eyelid blepharoplasty. The incidence of this complication after transconjunctival blepharoplasty is approximately 0.5%, and, after subciliary blepharoplasty, it is 3-5%.

The treatment is directed initially at massaging the lower eyelid. Subcutaneous steroid injection can be considered.

If the retraction persists despite aggressive massage, canthopexy, tissue grafts (eg, skin, hard palate, Alloderm, ear cartilage), and cheek elevation may be indicated.

Conjunctival chemosis in dermatochalasis

This usually resolves spontaneously in a few weeks but may persist for months.[17, 18]

Treatment consists of topical lubrication and topical steroids.

If chemosis persists, conjunctival incision and temporary tarsorrhaphy may be considered.

For chronic chemosis, subconjunctival injection of tetracycline 2% may be useful.[19]

The incidence has been reported as high as 26% and is more common in patients undergoing concurrent upper and lower blepharoplasty.[20]

Blindness in dermatochalasis

Blindness is a rare but devastating complication of blepharoplasty surgery.[21, 22]

In most documented cases, blindness results from retrobulbar hemorrhage with resultant optic nerve and vascular compression.

Central retinal artery occlusion has also been documented as a cause of blindness after blepharoplasty.

If orbital hemorrhage occurs, emergent canthotomy and orbital decompression should be performed.

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.

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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.