INTRODUCTION Dermatochalasis refers to a laxity of eyelid skin and loss of muscle tone. It is a common condition that primarily affects persons over the age of 50 years, although it may occasionally be seen in younger individuals. It can affect both upper and lower eyelids and is frequently associated with fat prolapse, or steatoblepharon due to laxity of the orbital septum. As the condition advances the fascial adhesions between the anterior and posterior eyelid lamellae stretch, exacerbating the clinical symptoms. Brow and forehead ptosis are frequent accompanying aging conditions which can mechanically depress the upper eyelid skin and therefore simulate or exacerbate upper eyelid dermatochalasis. Also often seen with brow ptosis is a descent of the sub-brow fat pad into the upper eyelid, simulating steatoblepharon. Excess skin and eyelid fat can also be seen in association with systemic diseases such as Graves' orbitopathy and in inflammatory conditions such as blepharochalasis. A number of genetic connective tissue disorders can also be associated with excess eyelid skin. These include cutis laxa, pseudoxanthoma elasticum, and lipoid proteinosis cutis. An acquired form of cutis laxa without predisposing factors has been described.
CLINICAL PRESENTATION Dermatochalasis may be of cosmetic importance only. When more severe in the upper eyelid the anterior skin-muscle lamella can overhang the eyelid margin and obstruct superior and temporal visual fields. In some cases the skin will rotate the lid margin downward so that the eyelashes contact the cornea. When associated with steatoblepharon there will be protrusion of fat pockets within the excess folds of skin. When the lacrimal gland descends due to laxity of its suspensor ligaments it causes a bulge in the lateral upper eyelid. In the lower eyelid dermatochalasis appears as horizontal and often cascading folds of skin more prominent laterally. It is frequently associated with horizontal eyelid laxity from lateral canthal tendon and the malar suspensory ligament stretching, resulting in lateral eyelid droop or even frank ectropion. As with the upper lid, concurrent steatoblepharon causes a forward protrusion of lower lid fat pockets.
TREATMENT Mild degrees of dermatocholasis may be managed with laser skin resurfacing or chemical peels that tighten the skin and encourage new collagen formation. In most cases, however, surgical excision of skin and muscle will be required to achieve an acceptable cosmetic and functional result. If there is significant loss of connection between the anterior and posterior lamellae, the eyelid crease should be reestablished at the same time to prevent an acquired epiblepharon. When there is concomitant brow ptosis, the brow should be repositioned first since some or even all of the excess skin will be corrected with this procedure. Any excess skin in the lid can then be removed. In the lower eyelid tension must be kept in the horizontal direction to prevent retraction, scleral show, and ectropion. Care must be taken not to put excessive tension on fat pockets especially in the lower lid since cases of blindness have been reported from deep orbital hemorrhage, typically within the first three to four hours after surgery. If necessary, the lateral canthal tendon should be tightened or repositioned in a posterior direction at the same time. Care should also be taken to avoid injury to the inferior oblique muscle which lies very superficially between the medial and central fat pockets in the lower lid. Suture canthpexy to reestablish the orbitomeatal ligament will help the lower eyelid contour. In patients with significant dry eyes care should be taken to preserve the orbicularis muscle and its innervation in the upper lid.
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