What is dermatochalasis

Dermatochalasis also known as “baggy eyes”, is defined as loosening of the skin around the eye or redundancy of upper or lower eyelid skin and muscle ¹. Dermatochalasis is common in elderly persons and is occasionally seen in young adults. Gravity, loss of elastic tissue in the skin, and weakening of the eyelid connective tissues contribute to dermatochalasis, which more frequently involves the upper lids, but is also common in the lower lids ². Dermatochalasis is caused by changes due to loss of elastic tissues, thinning of the epidermis, weakening of connective tissue in eyelids, mechanical forces (rubbing), and aging. Dermatochalasis may be either an acquired with different associations such as aging and floppy eyelid syndrome or a congenital condition ³. Systemic diseases such as thyroid-related orbitopathy, renal failure, trauma, cutis laxa, Ehlers-Danlos syndrome, amyloidosis ⁴, hereditary angioneurotic edema, and xanthelasma may predispose to dermatochalasis. Genetic factors may play a role in some patients. Genetic influences are also strong. Dermatochalasis causes differences in biomechanical properties of the skin, and histologic samples of the connective tissue show related alterations in the skin and the ocular surface of patients with this condition ⁵. The skin of the eyelid and the ocular surface both contain large amounts of collagen and elastic fibers. The biomechanical alterations seen in the dermis and the cornea of dermatochalasis patients may therefore result from disruptions of these collagen and elastin fibers ⁶.

Dermatochalasis can be a functional or cosmetic problem for the patients. Specifically, significant dermatochalasis of the upper lids may contribute to lateral hooding and superior visual field obstruction. 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 refers to the fat protrusion in the upper and lower eyelids, which may also cause a cosmetic concern to patients. 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.” Significant steatoblepharon or dermatochalasis is an indication for upper or lower lid blepharoplasty.

Blepharochalasis vs Dermatochalasis

Blepharochalasis is a very rare disorder characterized by episodes of non-tender, non-pitting eyelid edema progressing to periorbital skin atrophy ⁷. Other presenting symptoms include ptosis, conjunctival redness, blepharophimosis, erythema, and proptosis ⁸. Blepharochalasis should be a differential diagnosis for young children presenting with unilateral or bilateral ptosis with periorbital skin abnormalities. Rarely, unilateral involvement may progress bilaterally as subsequent exacerbations occur. According to Koursh et al ⁸, only 67 cases of blepharochalasis had been described in the literature by 2009; they found that the initial onset of symptoms occurred at an average age of 11 years. Both sexes are equally affected and the onset of the disease is usually during childhood and adolescence, with an average presenting age of 11 years ⁸. Most episodes last anywhere from hours to days. These episodes become less frequent with age, and most patients enter a quiescent stage ⁹; however, one patient has been described as having episodes for 40 years ¹⁰.

Diagnosis can be difficult since there is no confirmatory test as blepharochalasis is diagnosed clinically. Computed tomography (CT) scans in previous cases have shown no abnormal findings; biopsy results are nonspecific, showing mostly a decrease in elastic fibers ¹¹. Differential diagnoses include local transient edema, orbital cellulitis, recurrent angioedema, hereditary angioedema, and recurrent contact dermatitis ⁸.

Treatment is also very challenging since it is often refractory to anti-histamines and corticosteroids; however, the use of short course prednisone taper has shown improvement during exacerbations ¹¹. Surgery was the only option for many years, but it does not cure blepharochalasis. Once remission occurs, these patients should be monitored since recurrences have been reported to occur up to six years after the previous episode ¹².

Dermatochalasis 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:

• Trauma can be associated with dermatochalasis.
• Patients with severe periorbital edema may develop redundancy of the eyelid skin and muscle. This can be severe enough to cause a functional visual field defect.
• Chronic dermatitis can be caused by dermatochalasis, or it can be the cause of dermatochalasis. Chronic inflammation of the eyelid skin can lead to recurrent edema and redundancy of the eyelid skin.
• Thyroid eye disease frequently can be associated with dermatochalasis and steatoblepharon. It is associated with infiltration of the orbital fat and extraocular muscles with immunoglobulin complexes. Clinically, this is seen as steatoblepharon and resultant dermatochalasis.
• Chronic renal insufficiency can be associated with periorbital edema. When chronic, this edema can result in stretching of the eyelid skin and redundancy of the eyelid skin and muscle.
• Amyloidosis rarely can be associated with extracellular deposition of glycoproteins in the orbicularis oculi muscle. This can result in ptosis and dermatochalasis.
• Blepharospasm is a disorder of unknown etiology whereby the patients experience uncontrolled, sustained, and severe spasm of the orbicularis oculi muscles. This disorder frequently is associated with hypertrophy of the orbicularis muscle and resultant dermatochalasis.
• Floppy eyelid syndrome is a disorder of the eyelids that is associated with severely redundant and lax eyelids. Both the skin and the muscle are affected, and the tarsal plate develops a rubbery consistency and is significantly redundant and lax. When chronic, this leads to markedly redundant and lax eyelid skin and orbicularis muscle.
• Genetics may play a role in some patients who develop dermatochalasis. These patients frequently develop early signs of dermatochalasis in their 20s.

Dermatochalasis symptoms

Patients with dermatochalasis often report visual difficulties or “heavy” eyelids. 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.

Dermatochalasis diagnosis

A thorough eye examination by an ophthalmologist is necessary to rule out diseases of the eye itself that may limit ameliorative options for patients bothered by dermatochalasis. Furthermore, a detailed examination to look for anatomical changes or pathology helps to formulate the appropriate management plan.

Special attention to brow position and brow contour is important to differentiate between true and pseudo dermatochalasis. Measurement of redundant eyelid skin, levator excursion, prolapsed orbital fat, presence or absence of blepharoptosis is needed to quantify the type and degree of dermatochalasis. Additionally, evaluation of the presence of eyelid retraction, amount of eyelid laxity, and changes in the surrounding bony framework and periocular tissues is necessary .

Functional disability by dermatochalasis is documented by external photography and visual field testing with and without eyelid taping or elevation.

All patients undergoing eyelid procedures should be questioned regarding ophthalmologic pathology and should receive a full eye exam, complete with the retinal examination. Specifically, patients should be questioned regarding preoperative visual acuity, symptoms of dry eyes, and visual obstruction. Furthermore, the full medical history should include pathology related to systemic disease with ophthalmologic manifestations, including thyroid disease, diabetes, hypertension, or inflammatory diseases treated with steroids. A history of bleeding or clotting disorders should also be elicited. The following tests are useful in the workup of patients undergoing blepharoplasty to identify contraindications based on specific complaints.

Shirmer’s Test

Measures basal tear secretion and identifies patients that are at risk for dry eyes postoperatively. Absorptive paper strips are placed inside the lower lid for 5 minutes, and the amount of moisture on the paper is measured. Greater than or equal to 15 mm is considered normal, while less than 5 mm is indicative of deficient tear production.

Visual Field Testing

Identifies any areas of visual fields that may be obstructed by ptosis or dermatochalasis. The test is typically performed once with the lids in the normal position, and then with tape securing excess skin above the level of the lid margin.

Jones Test

The Jones I and Jones II tests are used to evaluate patency of lacrimal ducts. During the Jones I test, fluorescein dye is injected into the lacrimal sac and given 5 minutes to flow from the lacrimal sac into the opening at the inferior meatus. If dye is present after 5 minutes, the test is positive, and the ducts are open. If no dye flows through, the Jones II test is performed in which a lacrimal syringe is used to irrigate the lacrimal ducts, and flow to the intranasal opening is again evaluated. If a positive test is identified in which the dye flows through, this confirms a functional problem with the lacrimal drainage system. If no dye flows through with lacrimal irrigation, a mechanical obstruction is identified.

Physical examination

The physical examination in patients with dermatochalasis should begin by documenting the best-corrected distance visual acuity. 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 eyelids should be everted. Facial asymmetry or facial nerve weakness should be documented.

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.

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. marginal reflex distance is associated closely with superior visual field defects. The smaller the marginal reflex distance, the more the visual field loss. Some experts have suggested that the marginal reflex distance can be substituted for visual field measurement in assessing the functionality of a patient’s dermatochalasis.

It is critical to recognize lid ptosis, or variability in lid height, preoperatively. If ptosis is seen, document any anisocoria or dysmotility. Alternate cover testing occasionally reveals hypotropia as a cause of pseudoptosis. 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 or basic secretor testing. Many studies confirm that tear breakup time, 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 causes include thyroid eye disease, blepharoplasty surgery, marked proptosis, and, rarely, amyloidosis.

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.

Dermatochalasis treatment

Dermatochalasis is generally treated with blepharoplasty. Many patients will seek blepharoplasty for cosmetic concerns related to the amount of dermatochalasis of either the upper or lower lids. Cosmetically, the goal for the upper lid is resection of skin and fat to allow a mild hollow and shadow related to the superior orbital rim and eliminate lateral hooding. Care must be taken not to remove an excessive amount of skin or fat, as either may cause a severely hollowed appearance of the upper lid or postoperative inability to close the eyelids (lagophthalmos) ¹³. The goal remains the same for the lower eyelid, though lower lid procedures also focus on alleviating the sagging of the lower lid and treating the lid-cheek junction ¹⁴.

Blepharoplasty refers to the aesthetic or functional surgical manipulation of the upper or lower eyelids ¹³. Upper and lower lid blepharoplasty both have their own set of indications and may be undertaken during the same procedure or at different times.

Blepharoplasty may be performed in an office-based setting. Though the eyelids are amenable to complete anesthesia with local anesthetic, it is often helpful to give sedation during injection as this is extremely uncomfortable. As with any procedure, the use of intravenous (IV) sedation should be performed in the presence of an anesthesia provider familiar with airway management. Furthermore, if IV sedation is used, an inpatient facility or an operating room certified by the American Association for Accreditation of Ambulatory Surgery Facilities is strongly advised. Furthermore, to ensure the safety of the patient and the best possible outcomes, blepharoplasty should be performed by those with extensive training in the procedure including board-certified plastic surgeons, oculoplastic surgeons, or facial plastic surgeons.

Blepharoplasty is generally well-tolerated with oral analgesia and cold compresses in the early post-operative period. Some ophthalmic plastic surgeons add peri-operative intravenous and post-operative oral and/or topical antibiotics to minimize the already small risk of infection. Bruising can be expected for 1-2 weeks after surgery, and swelling is most noticeable for the first several weeks. Depending on the suture used for skin closure, sutures are removed at the discretion of the surgeon usually within 1-2 weeks after surgery. External photographs are typically taken to document postoperative changes and healing process. Complete healing of the scar and tissue swelling can take several months or more.

Dermatochalasis surgery

Upper eyelid blepharoplasty to correct dermatochalasis is one of the most frequently performed procedures by the ophthalmic plastic surgeon, whether for cosmetic or functional purposes. The procedure is performed by first outlining the tissue to be excised, beginning at the upper eyelid crease. Care should be taken to ensure enough skin remains for adequate eyelid closure. Oftentimes, portions of the preseptal orbicularis will be removed with the skin. If there is significant steatoblepharon, or fat herniation, the orbital septum may be opened and preaponeurotic fat trimmed or debulked, creating a more even upper eyelid contour. Fat removal should be done conservatively, to avoid a resulting hollowed appearance. Incisions are generally well hidden within the upper eyelid crease, and sutures are used to approximate skin edges.

Lower eyelid blepharoplasty may be performed for fat herniation and excess tissue of the lower eyelids. This is generally considered a cosmetic procedure and reduces the appearance of “bags” under the eyes. Midface of face lifting can augment the result of lower lid blepharoplasty surgery.

Additional wrinkle reduction may be achieved by laser resurfacing or chemical peels. Brow lift or brow pexy to correct the associated brow ptosis are often performed along with blepharoplasty.

Risks of surgery include bleeding, bruising, scarring, asymmetry, need for additional procedures and retrobulbar hemorrhage.

Blepharoplasty technique

Upper lid blepharoplasty involves excision of a wedge of the skin of the upper lid. The lower edge of the skin wedge excision approximates the point of the supratarsal crease, stretching from 4 to 5 mm superior to the medial and lateral canthi with its highest point in the center of the line extending 10 mm above the central aspect of the lid margin. The upper part of the wedge excision is marked as a gentle curve following the natural upward slant of the eyelid and orbit and is determined intra-operatively by pinching the skin of the upper lid. The surgeon must take care to leave approximately 1.5 to 2 cm of skin between the upper part of the excision and the brow, as this will prevent lid hollowing and lagophthalmos from excess skin resection. The excision markings may be extended approximately 1 cm lateral to the lateral canthus to excise lateral hooding.

There are several variations of upper lid blepharoplasty. The first involves variable excision of orbicularis muscle along with the overlying skin. Advocates of significant orbicularis resection will point to the fact that it contributes to upper lid fullness and should be resected. Over resection, however, can hollow the upper lid and destroy the attachments of the levator complex to the overlying skin. These complications could cause postoperative lagophthalmos or ptosis, respectively. Postseptal fat may also be removed during this procedure. The nasal fat pad is most often the offending agent in upper lid blepharoplasty and may be accessed through a 1 cm incision in the orbital septum medially. The surgeon will know he or she is in the correct compartment due to the white hue of the fat compared to the yellow color of other fat compartments. Again, avoiding overcorrection is key.

Upper lid blepharoplasty is often combined with correction of upper lid ptosis. The most common form of this procedure involves removing the levator aponeurosis from the tarsus, advancing the entire aponeurotic complex, and resecuring the tarsus to the aponeurosis complex. Following advancement and securing of the levator complex, the patient is asked to open and close his or her eyes. The degree of lagophthalmos is assessed. Up to 2 mm is considered acceptable. If the degree of lid lag is found to be appropriate, the excess muscle and tendon are resected, and the skin and orbicularis flap is closed.

Lower lid blepharoplasty is one of the most variable procedures in plastic surgery, and a full review of this technique is outside of the scope of this article. In general, the technique involves skin resection, postseptal fat resection, blunting of the lid-cheek junction, and tightening of the lower lid tarsoligamentous complex. Not all patients will require every aspect of this procedure. However, each will be addressed separately.

The amount of skin resection should be assessed pre-operatively to determine which incision will be used to access the lower lid. Those patients requiring skin resection will need an external incision on the lid, most often from a subciliary approach. Those patients not requiring skin resection may have postseptal fat resected from the transconjunctival approach. Excess skin resection of the lower lid may contribute to post-operative ectropion.

The excision of postseptal fat is common in lower lid blepharoplasty, as steatoblepharon is one of the main features of many seeking a lower lid blepharoplasty. Each compartment may be accessed separately from either the external or transconjunctival approach. When excising fat in the central or nasal fat pads, care must be taken to not injure the inferior oblique muscles. Meticulous hemostasis is crucial in all aspects of blepharoplasty but is particularly important in the fat resection. As fat resection occurs in the postseptal compartment, bleeding may contribute to retrobulbar hemorrhage, and in severe cases can cause blindness.

The treatment of the lid-cheek junction is a complex aspect of the procedure and can be accomplished in many different ways. The fundamental concept of this procedure is to cause blunting and a more gradual, youthful appearance of a facial line that has been caused by aging. To accomplish this, fat released from the postseptal compartment may be spread over the angle to cause a more gradual transition from the cheek to the lower eyelid. Conversely, the arcus marginalis may be completely released and then sutured over this angle to cause a more obtuse angle. Though there are countless other methods for addressing this problem and it is impossible to review them all here, it is important when evaluating these patients postoperatively to understand that this junction has likely been manipulated in some way.

Tightening of the lower lid tarsoligamentous complex is accomplished by traditional canthopexy or canthoplasty techniques. This typically involves a lateral canthotomy with inferior cantholysis. Part of the lateral tarsoligamentous complex may be resected utilizing a lateral tarsal strip procedure. It is imperative to inset the lower lid partially inside of the orbit and at a superior angle to the medial canthus to approximate the actual position of the lower eyelid. Some surgeons will choose to temporarily support the repair of the lateral tarsoligamentous complex with an external suture, tape, or gentle upward massage.

Both upper and lower blepharoplasty techniques may differ greatly between surgeons. However, being aware of the principles outlined above should give both specialist and general practitioners general guidelines on upper and lower lid blepharoplasty procedures.

Dermatochalasis surgery complications

Lagophthalmos

Defined by the failure of the upper lid margin to reach the lower lid margin, what is commonly referred to as “lid lag” can either be a complication or an expected outcome of the blepharoplasty procedure. With levator advancement procedures, up to 2 mm of lid lag can be acceptable and will resolve over time. Management of post-operative lagophthalmos includes corneal lubrication to protect against corneal abrasion. Patients should be monitored closely during this time to ensure any degree of lagophthalmos is resolving ¹⁵.

Ectropion

Ectropion can evolve during lower lid procedures with excess skin resection, scarring, or loosening of the tarsoligamentous complex. While conservative management such as upward massage or upward taping can be undertaken, ectropion is typically corrected by surgical retightening of the lower lid. Until that time, eye lubrication can be utilized to decrease discomfort.

Dry Eyes

Many patients may complain of dry eyes postoperatively. Utilizing Schirmer’s test pre-operatively can select for the patients at highest risk. Any manipulation of the lacrimal system, such as resuspension of the lacrimal gland, can also place patients at high risk for dry eyes. Corneal lubrication is the mainstay of treatment. Referral to an ophthalmologist may be necessary if these symptoms do not resolve.

Retrobulbar Hemorrhage

The most feared complication of blepharoplasty is a retrobulbar hematoma. Typically caused by bleeding following postseptal fat resection, this complication presents with severe ocular pain, proptosis, and visual complaints. Patients may have all symptoms or only one. In any patient presenting with these symptoms following blepharoplasty, the diagnosis of retrobulbar hematoma should be considered. The treatment is emergent orbital decompression with lateral canthotomy with inferior cantholysis.

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