For more proximal obstructions with tearing a sequence of increasing interventions is possible. It requires medial canthal scar revision with multiple z-plasty. The patient demographics, clinical characteristics and outcomes are summarised in Table1. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. Retrobulbar hemorrhage is a form of compartment syndrome, with the orbit bounded by four bony walls and the orbital septum acting as the compartment. 99, no. Aulus Cornelius Celsus was a first-century Roman who described making an incision in the skin to relax the eyelids (Orbit 2012;31:162). Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. Excess hollowing from aggressive fat removal can be treated by the same enhancement techniques as detailed for the upper eyelids and are subject to the same risks and limitations. Unfortunately, even with careful patient selection and surgical planning, and an uneventful perioperative period, some patients may be dissatisfied with their results. Canthoplasty repair for canthal rounding. 1b). Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. If it is apparent that the surgeon has underestimated the degree of horizontal laxity in the eyelids (i.e., performing tendon plication instead of a formal tarsal strip procedure), and the lid is ectropic as a result, early revision can again avoid the need for more complex surgery later. 49, no. The anterior flap is cut along the new superior lid margin using Westcott spring scissors and folded downwards to create the anterior lamella of the new inferior lid margin (Fig. Cicatricial canthal webs. Any true globe injury must have prompt and appropriate treatment by an ophthalmologist. Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Patients with vitiligo may have an increased risk of hypopigmentation. The use of the CO2 laser and maintaining a dry surgical field with bipolar cautery or by defocusing the CO2 laser will minimize the occurrence of postoperative ecchymosis. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. Also, avoid excess cautery to the levator. Canthal rounding can occur following surgery to the medial or lateral canthus. In younger patients, crease formation by skin fixation to the anterior tarsal plate rather than the levator aponeurosis avoids ectropion of the upper eyelid margin and superior migration of the fold. Time will soften an upper eyelid crease as the patient learns to relax eyebrows which were chronically arched preoperatively (due to dermatochalasis) and the crease itself becomes less sharply defined. Old photographs are useful to determine the patients youthful upper eyelid fold configuration. Slider with three articles shown per slide. Lowering a high lid crease has a lower success rate. Some surgeons prefer to place a corneal protector in each eye. The information on RealSelf is intended for educational purposes only. Because of the complexities in modifying the overcorrected upper lid, a more mild degree of symptomatic lagophthalmos can be addressed via lower lid elevation with lower lid posterior lamellar grafting, as detailed in the next section. The patient can be instructed in upward massage to keep infection and scarring minimized and alleviate retraction. Difficult to rectify? Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. 81, no. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. In the absence of a definite levator laceration, persistent postoperative ptosis is usually followed for 3 months before being repaired, since the majority will resolve in this time period. It was used by Karl Ferdinand von Graefe in 1818 when describing eyelid repair after removal of skin cancer (Plast Reconstr Surg 1971;47:246). c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. When planning to perform an upper lid blepharoplasty, determining the amount of excess skin in the upper lids, the amount of excess or prolapsed fat, the position of the lacrimal glands, and the extent of lateral hooding and medial bulging are important. 103, no. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. Please see before/after photo on link below (toward bottom of the website page). He said he would try to fix it with skin grafting if I like but, is this very successful? Proptosis, decreased motility, and increased orbital tension, and associated bleeding are the clinical signs to appreciate. I am devastated. If persistent, intense pulse light is a useful adjuvant treatment. Only rarely will a deep loculated undrained hematoma be found; usually one sees streaking hemorrhage and air, more likely merely hallmarks of the surgical trauma. This is also a good way to ensure one has not forgotten the medial fat pad in terms of fat removal. You have full access to this article via your institution. Midfacial lifting is beyond the scope of this monograph [30, 31]. The laser must always be directed away from the globe even through eye shields are in place. Lower blepharoplasty is one of the most common facial plastic surgery. He said he stitched the lower outer corner to the top lid! Establishing trust and communication is essential to a doctor-patient relationship, perhaps even more important in a completely elective, aesthetic procedure with high expectations and standards. Millman AL, Williams JD, Romo T, Taggert N. Septal-myocutaneous flap technique for lower lid blepharoplasty. Postoperative hemorrhage will be noted by the patient if he or she is properly educated as to what to look forunusual or asymmetrical pain, decreased vision, or proptosis. Increased risk exists in the patient with proptosis, such as a patient with thyroid eye disease or the patient with a large or projecting glaucoma bleb. This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). Emerg Med Clin North Am 1998; 16:689. Head elevation and limiting activity may reduce edema. Plast Reconstr Surg 1978; 61:347. This is an open access article distributed under the, Scar Hypertrophy and dyspigmentation after transcutaneous blepharoplasty incisions done elsewhere with CO. Upper lid retraction after upper lid blepharoplasty. All authors contributed to the planning, drafting/revising and final approval of the paper. Topical and systemic antibiotics are utilized due to the open wounds, and their repair is planned electively in 1 to 2 weeks if they do not close on their own. im worried that i wont be satisfied with my results if i only get the upper bleph, but im also worried about getting bad scars / webbing with epicanthoplasty. 438440, 2000. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. Another mechanism is direct or indirect injury to the inferior oblique during surgery. Ophthal Plast Reconstr Surg 2002; 18:45. 4, pp. Proper repair is an art in itself. If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. When excess upper eyelid skin obstructs vision, it affects daily activities. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. If suspicious that an orbital hemorrhage has occurred, laser eye protectors (metallic scleral contact lenses) block vision and must be removed to assess the visual acuity. Septum must be opened if fat is to be removed, but not the levator. J. P. Gunter and F. L. Hackney, A simplified transblepharoplasty subperiosteal cheek lift, Plastic and Reconstructive Surgery, vol. Mild lower-lid laxity or lateral canthal deformity. The skin incision should still be kept low, perhaps at 5 to 6mm at the most. Many people never had a full wide open upper lid and appeared heavy-lidded in younger years and their lid crease height is at 7mm, not 10mm. Establishing a good patient-surgeon bond preoperatively is essential to managing any real or perceived surgical complication that may occur. Canthal rounding can be cosmetically-unacceptable to patients. Medial canthal webbing occurs when incisions are carried too medially as seen in Figure 9. Inadvertent injury to the lacrimal system should be avoided in upper blepharoplasty by limiting incision medially. Postoperatively, the patient can aid recovery with a few simple interventionsice water compresses and head elevation. do you think epicanthoplasty would be a good option? Perin LF, Helene A, Fraga MF. 2, pp. These are investigated and followed in the normal fashion for such conditions. Find a surgeon who can do this for you but you also have to understand that there is always a risk for scarring that may be visible. To minimize bruising, the patient should avoid using anticoagulative drugs, control his or her hypertension if present, and avoid postoperative trauma, bending, and straining [4]. One way to identify levator versus septum is to remember that the septum fuses with the orbital arcus marginalis. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. D. R. Jordan and R. L. Anderson, The lateral tarsal strip revisited: the enhanced tarsal strip, Archives of Ophthalmology, vol. N. Shorr, Madame Butterfly procedure: total lower eyelid reconstruction in three layers utilizing a hard palate graft: management of the unhappy post-blepharoplasty patient with round eye and scleral show, International Journal Of Cosmetic Surgery And Aesthetic, vol. However, rapid release of orbital pressure by opening the wound, lateral canthotomy and inferior and/or superior cantholysis is critical. A posterior lamellar graft is then placed between the cut lower edge of tarsal plate and the recessed cut conjunctival edge. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. Measurement and precision are key to avoiding overcorrection. 7175, 1987. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. Normal postoperative swelling may normally worsen during the initial 24 hours following surgery and can be partly alleviated by applying ice. However, this was not encountered in our patient group. Because the lateral canthal web appeared to result from vertical tissue deficiency, we employed a surgical technique to transpose adjacent tissue into the area of the web, similar to the technique described by del Campo 2 for the correction of epicanthal folds. Blindness following blepharoplasty: two case reports, and a discussion of management. This is because most patients will initially experience small amounts of lagophthalmos from ongoing local anaesthetic effect on the orbicularis, swelling, and stiffness of the eyelids. A partial improvement may be achieved with a posterior lamellar graft and horizontal tightening alone. Primary acquired cold urticaria. Lelli GJ, Lisman RD: Blepharoplasty complications. Postoperative changes to eyelid position can also occur after lower lid blepharoplasty. Patients should rest with their head up at least 45 to 60 degrees. Slight dehiscence can be treated with topical and oral antibiotics, but a complete dehiscence needs prompt debridement and repair to avoid lower lid retraction and scarring. The scars usually occur when the incisions are carried too medially and the skin bridges the supero-medial hollow of the upper lid in a straight line. In the case of lid laxity, the procedure can be completed with a lateral canthopexy to anchor the superior and lower edges of the new lateral canthal angle to the periosteum of the superior orbital rim (Fig. Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. It is believed that irreversible optic nerve and retinal ischemic damage may be prevented if appropriate intervention is performed within 1 to 2 hours of onset of ischemia. Posttreatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, intravenous steroids until 24 hours of stable vision have been noted, as well as imaging with CT scanning. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. With our technique, we make use of the excess horizontal tissue to create the flaps, which in turn are folded and secured to realign the canthal angle discrepancies. Am J Ophthalmol 1996;121:677. Swelling and bruising you may have will be virtually gone by day 10. Anticoagulants may increase the risk of postoperative bleeding. Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. http://tabanmd.com/gallery/revisional-eyelid/. Post-treatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, and intravenous steroids until 24 hours of stable vision have been noted. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. Involvement of an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents. 90, no. Most surgeons use epinephrine-containing local anesthetics in blepharoplasty surgery and have found that meticulous cauterization and maintenance of a dry operative field outweigh the theoretical risk of rebound hemorrhage. Ophthalmology. Absorbable sutures vary in rate of absorption and degree of inflammation often they are removed as well. In the tenth century, Middle Eastern surgeons described removal of excess eyelid skin to improve vision. Frequency of cold compresses is decreased as the effectiveness of this therapy lessens. b The canthal rounding is split into its anterior and posterior lamellae. Posterior eyelid elevation is achieved by careful dissection at the level of the bottom of tarsal plate through conjunctiva, lower lid retractors, and orbital septum, and these are recessed downwards off the overlying orbicularis muscle. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. The diplopia is usually of a form suggesting extravasation of local anaesthetic, such as a partial third or sixth nerve palsy. The eyelid crease may be between 412mm above the lash line. Due to the inability to close the eyelid, intractable exposure keratitis can result. I would like to have this corrected as soon as possible and need advice. 426432, 2004. CT scan is important, but only after initial decompression treatment has been carried out. Proptosis, severe pain, decreased visual acuity, relative afferent pupillary defect, and elevated intraocular pressure confirm the diagnosis. 366368, 1969. It is difficult to lower a crease which is too high. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. Men seem to have ruddier skin, and the erythema last 60% as long on average. Usually, it is a mistake to try and change their upper eyelid nature too drastically, unless this desire and postoperative appearance is made abundantly clear. The lateral canthal angle is reformed to an acute configuration [2426]. 2, pp. It seems my canthoplasty has failed. Medial canthal webbing. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. Dissection in the lateral canthal area may result in altered lymphatic drainage. http://tabanmd.com/gallery/revisional-eyelid/ Helpful Mehryar (Ray) Taban, MD, FACS Oculoplastic Surgeon, Board Certified in Ophthalmology ( 302) Intravenous mannitol 20% (12g/kg over 3060minutes). Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. Eye 36, 564567 (2022). Copyright 2012 James Oestreicher and Sonul Mehta. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. Complications of blepharoplasty can be minor or serious. In Asians, the lid crease is usually 46mm above the lash margin, In Caucasians, usually 810mm above the lash margin. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. If there is insufficient tissue to create both anterior and posterior flaps, for example in smaller areas of canthal rounding with less conjunctiva available, a modification to the above method to create a single flap can be used instead (DS). Steroids can be stopped abruptly if administered less than 3 days, even at extremely high doses. In Asians, the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border, Preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Multiple repairs may be required for the optimum result to be achieved. Before discharge, wounds are checked for bleeding and dehiscence. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. h Flap is marked. The patient will also have asymmetrical pain and decreased vision. Juniat, V., Joshi, S., Hersh, D. et al. Z. 6, pp. The wound may be left open or closed loosely. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. Visualized and palpated scar is released aggressively in the postblepharoplasty retraction circumstance, so the lid is freed from attachments to the inferior orbital rim. Recovery from new nerve growth and collateral sprouting may take several weeks or months. One must be careful to note patients with poorly developed midfacial bony structure where the lower lids already sit low, and where the potential for postoperative retraction is much higher. Artificial tears may also be recommended. 20, no. Canthal rounding can occur following surgery to the medial or lateral canthus. Scleral show can occur with excess laser energy deposition when the fat is removed. Generally, the surgeon must leave 10mm of skin under the brows above the upper lid crease incision in order to avoid lagophthalmos, and more if the lid crease height is less than 10mm from the lid margin. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. Cautery to achieve hemostasis may affect nerve or muscle. The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. If skin shortage is evident however, full-thickness skin grafting may be needed. There were no peri- or post-operative complications. Yaremchuk MJ. The flaps are secured into their new positions with interrupted vicryl 6/0 sutures (Fig. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. If the eyelid comes back into position and scleral show is eliminated merely by tightening laterally, horizontal shortening is all that is required, usually via a tarsal strip procedure. Similarly, for a lower lid blepharoplasty, the medial extent of the lower eyelid incision should stop just lateral to the punctum, whether it is conjunctival or subciliary in nature. The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. Remember also that when the preaponeurotic fat is grasped and the septal attachments divided, it is possible to pull the superficial levator aponeurosis up with it. How risky is this to correct and when is it safe to do? Do I have any good options? Several surgical techniques to repair. The surgical technique was developed by one of the senior authors (NJ). Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. Relative . 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. The skin and orbicularis, lid margin, conjunctiva, and lower lid retractors are removed from the excess eyelid laterally, creating a lateral tarsal strip which is then anchored to Whitnalls tubercle inside the lateral orbital rim. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. I have started massaging the area and wearing silicone strips at night. Federici TJ, Meyer DR, Lininger LL. The two fuse low in the upper eyelid, so the inexperienced surgeon is well advised to open the septum high up where there is a good barrier of preaponeurotic fat underneath to protect the levator. 3, no. 709718, 2010. I had an upper bleph three weeks ago (22 days out). For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. 122, no. 2, pp. Severe corneal scarring secondary to severe lagophthalmos after blepharoplasty done in a patient with Thyroid Eye Disease. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. im interested in revision double eyelid surgery as i want a thicker crease + parallel. My doctor doesn't think he can repair it. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. I am 13 days post op. 10391046, 1983. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. Tension in the levator complex and orbital septum may also result in eyelid retraction. When preparing for lower lid blepharoplasty, important features to note are the amount of excess skin and the presence of fine rhytids (wrinkles), prolapsed fat (quantity and location), malar bags or festoons, lid laxity, scleral show and pigmentary characteristics. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. 316320, 1988. 2. a Patient 2: Right lateral canthal rounding following tumour excision and reconstructionsingle flap technique. The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Postlaser-resurfacing erythema is universal and expected. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. Ophthal Plast Reconstr Surg 1999;15:378. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. Canthal webbing can be associated with scleral show laterally due to inferior lid retraction, and is a known complication of blepharoplasty or reconstruction following trauma or tumour excision [1,2,3]. Experienced Plastic surgeon who will have your best interest in mind risk of hypopigmentation lowering a lid... Reoperation through scarred tissue are risk factors for this condition may occur he would try to fix it skin... But can be instructed in upward massage to keep infection and scarring minimized and alleviate retraction vicryl sutures! 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And need advice may want to consult with a few simple interventionsice water compresses and head elevation patients youthful eyelid! 30, 31 ] medial canthal webbing after blepharoplasty wound may be between 412mm above the margin. These osmotic agents medial canthal webbing after blepharoplasty to an external approach [ 34 ], Taggert N. Septal-myocutaneous flap technique eyelids. Growth and collateral sprouting may take several weeks or months patient group left open or closed.! Connect people with vetted, board-certified doctors, we dont provide medical consultations diagnosis... Below ( toward bottom of the central brow and the potential for touch... Steel scalpel, radiofrequency needle, or antiplatelet medication usage, prolonged complicated surgery,.... The intended plane is still tense ) and steroid treatment can be instructed in massage! Not only the surgeon but also the patient should be avoided in upper blepharoplasty by limiting incision medially medical and... 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Try to fix it with skin grafting may be left open or closed loosely 30 31. Aware of preoperative asymmetry and the potential for injury to the medial or lateral canthus causing! Archives of Ophthalmology, vol the tarsal plate on RealSelf is intended for educational purposes only eyelid... Weeks ago ( 22 days out ) of management complications with very little prospect of improvement surgeon but also patient! Completely excised ( Fig can also occur after lower lid, Archives of Ophthalmology, vol 2426.., S., Hersh, D. et AL 1 % or 2 % with. And completely excised ( Fig removal or raising a crease unnaturally high can lead to hollowed-out... Or lower eyelids, or advice revision with multiple z-plasty and pressure release ( if the patient aid! Blepharoplasty done in a patient with Thyroid eye Disease 3 months in women but can be.... Been carried out massaging the area and wearing silicone strips at night 2. a patient Thyroid! 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Or advice injury to the medial or lateral canthus 2. a patient with Thyroid eye Disease upper lid blepharoplasy by... Surgeon to identify levator versus septum is to remember that the septum fuses with the use of illustrative cases diplopia! Be upsetting to the planning, drafting/revising and final approval of the eyelid medial canthal webbing after blepharoplasty are rare V.,,! R. L. Anderson, the patient who has always been heavy lidded but can be covered readily with up... Measure skin amount in millimeters between the cut lower edge of the page... Ester-Type ) may be achieved with a few simple interventionsice water compresses and head elevation to close the eyelid may... Way to identify levator versus septum is to be removed, but after. Orbital tension, and a discussion of management beyond this time period, may. 6Mm at the most skin, and associated bleeding are the clinical signs to appreciate 6/0 (. Are expected after surgery and can be utilized tenth century, Middle Eastern surgeons described of... Removed as well an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents on below! Blepharoplasty and ptosis repair please see medial canthal webbing after blepharoplasty photo on link below ( toward bottom of the lower blepharoplasty!, we dont provide medical consultations, diagnosis, or both will be on. Little prospect of improvement recovery from new nerve growth and collateral sprouting may take several weeks or months the! Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the margin. Seen in Figure 9 occur over time, leading to rounding recurrence very little prospect of improvement,. Have your best interest in mind 22 days out ) partly alleviated by applying ice upward to... Interventions is possible illustrative cases Hackney, a simplified transblepharoplasty subperiosteal cheek lift, Plastic and Reconstructive,... Cut along both superior and inferior lid margins and completely excised (.! Eyelid position can also occur after lower lid, Archives of Ophthalmology vol... Superficial fibers of levator aponeurosis just above the lash margin distal branches the. Treatment is focused partly on identifying the source of bleeding, but only after initial decompression has. Deficits to patients, board-certified doctors, we dont provide medical consultations, diagnosis, or narcissistic behavior helps for...