Dermatochalasis

Dermatochalasis is redundant eyelid skin, with or without protrusion of orbital fat, caused by age related loss of dermal elasticity, orbicularis laxity and weakening of the orbital septum.

• Common after age 40; earlier with family history, thyroid eye disease or chronic oedema.
• Upper lid dermatochalasis is most important functionally. Lower lid involvement is mainly cosmetic with festoons and eye bags.
• Blepharochalasis is a separate condition: recurrent episodes of eyelid angioedema in young patients leading to thin, wrinkled, atrophic skin.

• Hooding of the upper lid with skin overhanging the lash line, heaviness, forehead strain, a tired look.
• Superior visual field loss that is worse on reading or looking downward; lashes pushed downward.
• Pseudoptosis (skin weight lowers the margin; true levator function is normal).
• Dermatitis or intertrigo in lid folds, and ocular surface irritation if lashes are mechanically displaced.
• Associated brow ptosis frequently coexists; lifting the brow reveals the true amount of excess skin.

• Measure margin reflex distance 1 (normal 4 to 5 mm), levator function (normal 12 to 15 mm), skin crease height (female 8 to 10 mm, male 6 to 8 mm), brow position.
• Automated visual field testing with tape lifting the redundant skin; improvement of at least 12 degrees or about 30 percent in the superior field supports functional indication.
• External photographs for records. Exclude thyroid eye disease, ptosis, floppy eyelid, and facial palsy.

• Observe if asymptomatic.
• Upper lid blepharoplasty: elliptical skin excision, with or without orbicularis resection and conservative fat removal. Skin crease marked at 8 to 10 mm above the lash line. Leave at least 20 mm of vertical skin between brow and margin, and preserve at least 10 mm of upper lid skin below the brow to avoid lagophthalmos.
• Correct brow ptosis first or concurrently (direct brow lift, endoscopic brow lift).
• Lower lid: transconjunctival fat repositioning for bags; skin pinch only if redundancy is clear. Add lateral canthal support to prevent retraction.
• Complications: dry eye, lagophthalmos, ptosis, haematoma and retrobulbar bleed (an emergency requiring urgent lateral canthotomy), asymmetry, scarring.
• Postoperative: cold compresses 48 hours, lubricating ointment at night, head elevation, avoid aspirin and anticoagulants where safe for 1 to 2 weeks before surgery.