Chapter 11: Dermatochalasis

INTRODUCTION

Dermatochalasis is a condition characterized by upper and/or lower eyelid skin, muscle redundancy and laxity, and fat pad herniation. It is mainly attributable to chronological aging and chronic sun exposure.

EPIDEMIOLOGY

Incidence: very common

Age: most frequently observed in individuals older than 50 years

Sex: no predilection

Race: most common in fair-skinned individuals (skin phototypes I and II); less common in darker-skinned individuals (skin phototypes IV–VI)

Precipitating factors: chronological aging; chronic sun exposure; thyroid disease

PATHOGENESIS

Upper and/or lower eyelid skin and muscle hypertrophy and prolapse; fat pad descension.

PHYSICAL EXAMINATION

Early findings include a double lid crease with only modest hooding. Severe findings include prominent eyelid hooding with upper and lateral visual field obstruction. Coexisting brow ptosis may further compromise the peripheral vision.

Tests for lower lid laxity help determine if a lid-tightening procedure is needed.

Lower lid horizontal laxity is measured by the distraction test that requires pulling the lower lid anteriorly away from the globe. A greater than 7-mm lid excursion indicates laxity.

Orbicularis oculi tone is measured by the snap test that is performed by pulling the lower lid inferiorly. If the lid does not spontaneously return to the normal position prior to the next blink, the test is positive indicating lower lid laxity.

DIFFERENTIAL DIAGNOSIS

Blepharochalasis (recurrent idiopathic eyelid inflammation with resultant relaxation of the upper lid skin); upper eyelid hooding secondary to eyebrow ptosis.

DERMATOPATHOLOGY

Epidermal acanthosis with flattening of the dermal–epidermal junction; dermal collagen breakdown with formation of amorphous masses and increase in glycosaminoglycans.

COURSE

• Chronic progressive course; visual eye fields may be affected.

KEY CONSULTATIVE QUESTIONS

• Any associated symptoms including visual obstruction, dry eyes, excessive tearing

• Underlying medical conditions, especially eye disease and thyroid conditions

• Prior treatment and response

MANAGEMENT

• Prevention: strict sun avoidance

• Control underlying thyroid disease

TREATMENT

• Topical therapy: daily sunscreen application with UVB/UVA coverage

• Surgical therapy

  • – Coronal browlift—upper face rejuvenation

  • – Trichophytic browlift—upper face rejuvenation

  • – Blepharoplasty—upper and lower eyelid rejuvenation (Fig. 11.1)

• Laser therapy

  • – Placement of protective ...