๐ ็ธฝ็ฎ้ ๏ฝ ๐ ่ฑๆๅๆ๏ผๆฌ็ฏ๏ผ ๏ฝ ๐ ๅฎๆด็ฟป่ญฏ ๏ฝ โญ ็ฒพ่ฏ็ญ่จ
POSTOPERATIVE CARE โ Part 2
placed flatly on the cheek. If the pressure continues to be elevated, the superior crus of the tendon can also be released.
Postoperative infection is rare since there is a robust vascular supply to the periorbital region. The most common infectious organisms are staphylococcus and streptococcus species.139 However, methicillin-resistant Staphylococcus aureus and necrotizing fasciitis have been reported,141,142 as well as atypical mycobacteria.140 Early diagnosis is critical to avoid rapid spread of infection and vision loss. There is a higher risk of infection in immunosuppressed patients. Symptoms of preseptal cellulitis usually include edema, erythema, and drainage from the wound. An atypical mycobacterial infection should be considered if there are multiple erythematous sites or in cases of significantly delayed wound healing. Preseptal infection can be treated as an outpatient with oral antibiotics and close follow-up. However, change in vision, limitation of extraocular motility, abnormal pupil responses, and proptosis can be signs of orbital cellulitis, which should be managed with inpatient admission, IV antibiotics and imaging. If an orbital abscess is present and there is no improvement in clinical examination after 24 to 48 hours of IV antibiotics, surgical drainage should be considered.
Diplopia occurring after blepharoplasty can be monocular or binocular. Monocular symptoms are present even when one eye is occluded, and causes include uncorrected refractive error, tear film disruption, corneal injury, or ointment use. Binocular symptoms disappear when one eye is occluded. After blepharoplasty, binocular diplopia can be either transient or permanent. Normal postoperative edema can cause transient binocular diplopia, which will resolve as the swelling subsides. Inadvertent extraocular muscle injection of local anesthestic can cause transient binocular diplopia.143,144 However, toxicity to the muscle belly can cause hypertrophy and fibrosis, leading to permanent muscle dysfunction. This is most commonly seen with the inferior rectus muscle in lower lid blepharoplasty. If permanent binocular diplopia occurs, the patient should be referred to an ophthalmologist for further management. Another reason for persistent diplopia can be injury and subsequent scarring of the trochlea, the pulley of the superior oblique muscle, during over aggressive nasal fat pad excision.145 Inadvertent injury to the inferior oblique muscle, which runs between the medial and central lower lid fat pads, can also occur. Finally, there can be inadvertent tethering of an extraocular muscle fascial sheath into a fat redraping suture or during septal resuspension.146
There are about 100 intraoperative fires per year in the United States, and at least 15% of these result in serious injury.147 Fires occur because of use of electrocautery, oxygen cannulas, and ethanol-based cleaning products. To decrease the risk of fire, the nasal cannula should be above the drapes to prevent oxygen trapping. If possible, oxygen should be turned off when cautery is being used. If it is not possible to
discontinue oxygen, the FiO2 should be reduced to less than 30%. Lashes and brow cilia should be moistened prior to cautery use.148
Regardless of suture choice, wound dehiscence is possible. The risk of dehiscence is minimized with postoperative instructions to avoid heavy lifting, rigorous exercise, and placing the head below the waist. If dehiscence occurs, the wound edges should be freshened, de-epithelialized and, depending on the size of the opening, sutured closed. If the length of the dehiscence is less than 1 cm, the wound may be left to close by secondary intention with a good ultimate cosmetic outcome.15 Occasionally, focal inflammation occurs and results in a suture granuloma. This is more common medially and laterally where the suture knots are placed.15 Most suture granulomas resolve with time, although in refractory cases topical steroids or excision may be necessary.
STEP-BY-STEP GUIDE THROUGH UPPER AND LOWER LID BLEPHAROPLASTY