Article

Eyelid surgery and patient satisfaction

How to control the inflammatory response that occurs during postoperative wound healing.

Blepharoplasty and other ophthalmic plastic surgery require an iatrogenic wound to the eyelid skin and deeper tissue. This wound initiates an inflammatory response, which is the first stage of wound healing. As eyelid surgeons, our job is to minimize initial tissue damage and provide postoperative care optimized to manage this inflammatory response for rapid wound healing and best final outcome.

DURING SURGERY

The incision

Management of postoperative inflammation begins with good technique during surgery. Our goal is to create an initial incision that produces minimal ancillary tissue damage. Skin incision by scalpel, carbon dioxide laser and radiofrequency ablation have all been advocated to minimize this ancillary damage.1,2 Scalpel incisions have the advantage of virtually no ancillary damage, while cauterizing methods, such as laser or radiofrequency, have the advantage of decreased hemorrhage. Meticulous wound closure with good wound edge apposition minimizes the need for collagen deposition and ultimately produces a finer incision scar.

Inflammation’s role in healing

Wound healing starts with hemostasis. The surgeon is the first factor in this process, using cauterization and surgical blood vessel closure to minimize hemorrhage and achieve intraoperative hemostasis. Injured blood vessels vasoconstrict, and platelets are activated to form a clot.

The inflammatory phase immediately follows, with vasodilation producing an influx of neutrophils — to clear bacteria and devitalized tissue — and the clot providing a scaffold for an influx of monocytes, fibroblasts and endothelial cells. These cells release inflammatory mediators that propagate the inflammatory response. Monocytes transform to macrophages starting around 48 hours after surgery, and activated macrophages secrete mediators that initiate the proliferative phase of angiogenesis and fibroplasia, which typically become evident about four days after surgery.

Simultaneously, epithelial cells, stimulated by factors secreted by macrophages and platelets, proliferate and reseal the wound by re-epithelialization. Thus, the inflammatory phase is integral to progression into the proliferative phase of healing.3

However, overly aggressive inflammation can actually slow the healing process in the context of surgeon-controlled hemostasis and a sterile surgical procedure with minimal ancillary tissue damage. Edema resulting from vasodilation can impair wound healing, and activated neutrophils can damage ischemic but otherwise recoverable tissue.4,5

Optimal healing after eyelid surgery does not require the vigorous inflammatory response that typically follows a traumatic eyelid injury. Thus, we generally employ methods to control the inflammatory response after eyelid surgery.

POSTOPERATIVE TECHNIQUES

Decreasing edema

The most commonly employed anti-inflammatory postoperative regimen is hypothermia to decrease edema. The goal of hypothermia is local vasoconstriction, thereby counteracting the reactive vasodilation that causes influx of inflammatory cells and thus triggers the entire inflammatory cascade. Reducing periorbital edema and postoperative ecchymosis, aside from its potential to decrease inflammation, is usually of utmost clinical importance after eyelid surgery — the short-term postoperative appearance of the eyelids can be quite distressing to the patient.

Hypothermia is most often accomplished with application of simple ice cold compresses, although the efficacy of this method has been challenged in controlled studies.6 Hilotherapy (continuous-flow water-cooling of the skin) has been advocated as being more effective.7 Constrictive taping or bandaging is also advocated to physically restrict blood flow and edema, at least for lower eyelid or especially following enucleation. In addition, head elevation while sleeping can reduce dependent edema.

Corticosteroids

Corticosteroid administration is a mainstay of any anti-inflammatory regimen, and is often employed either as a single operative dose or orally in the immediate few days following surgery. Steroids block the COX-2 induced activation of the keratinocytes, macrophages and endothelial cells that produce the soluble mediators of the inflammatory response when activated.3 Review of the literature shows an advantage to steroid administration in reducing edema in the first 48 hours postoperatively, although this does not confer a long-term advantage on final surgical outcome.5,8

Figure 1. Moderate, nonpathologic inflammation seven days after upper eyelid blepharoplasty.

CONCLUSION

Eyelid inflammation after oculoplastic surgery is, to some extent, unavoidable and even desirable as the initiating phase of wound healing. However, eyelid edema and ecchymosis are typically the most distressing aspects of postoperative healing for the patient and often a crucial determining factor in patient satisfaction with the procedure.

Impeccable surgical technique can minimize these factors. Also, a rigorous regimen of postoperative cryotherapy and corticosteroid administration can reduce these factors initially, thereby reducing the overall level of inflammation and improving patient satisfaction — even if the final outcome is not significantly improved. OM

REFERENCES

  1. Kashkouli MB, Kaghazkanai R, Mirzaie AZ, et al. Clinicopathologic comparison of radiofrequency versus scalpel incision for upper blepharoplasty. Ophthalmic Plast Reconstr Surg. 2008;24:450-453.
  2. Niamtu J III. Radiowave surgery versus CO laser for upper blepharoplasty incision: which modality produces the most aesthetic incision? Dermatol Surg. 2008;34:912-921.
  3. Broughton G, Janis JE, Attinger CE. The basic science of wound healing. Plast Reconstr Surg. 2006;117:12S-34S.
  4. Wallace HA, Bhimji SS. Wound, healing, phases. StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing: 2018.
  5. Da Silva EM, Hochman B, Ferreira LM. Perioperative corticosteroids for preventing complications following facial plastic surgery. Cochrane Database Syst Rev. 2014 Jun 2;CD009697.
  6. Pool SM, van Exsel DC, Melenhorst WB, Cromheecke M, van der Lei B. The effect of eyelid cooling on pain, edema, erythema, and hematoma after upper blepharoplasty: a randomized, controlled, observer-blinded evaluation study. Plast Reconstr Surg. 2015;135:277e-281e.
  7. Bates AS, Knepil GJ. Systematic review and meta-analysis of the efficacy of hilotherapy following oral and maxillofacial surgery. Int J Oral Maxillofac Surg. 2016;25:110-117.
  8. Pulikkottil BJ, Dauwe P, Daniali L, Rohrich RJ. Corticosteroid use in cosmetic plastic surgery. Plast Reconstr Surg. 2013;132:352e-360e.

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