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A 73-year-old nonsmoking, nondiabetic white man with hypertension complained chiefly of bilateral visual field defects resulting from palpebral dermatochalasis of the upper lids and redundant skin and fat on the lower lids. Because of the visual field defects, he was referred for consultation for a blepharoplasty by his primary care physician. During the examination, the patient was found to have 3.5 cm of excess skin of the upper lids bilaterally and weakness in the lower lids, with early senile ectropion, protuberant periorbital fat, and moderate skin laxity. I suggested a bilateral upper lid blepharoplasty, primarily involving skin resection with a small rim of orbicularis muscle. The lower lids would be treated with a lateral canthopexy, elevation of a skin muscle flap, and resection of herniated periorbital fat. The patient agreed to this procedure after I explained the risks and benefits and alternative procedures.
In spite of the patient’s history of hypertension and mild cardiovascular disease, his primary care physician believed he was a good candidate for surgery. Additional risk factors included urinary retention resulting from benign prostatic hypertrophy, and the daily use of aspirin as a prophylaxis against future cardiovascular problems. However, the patient did not take any aspirin before surgery or any other medication that would have altered his bleeding time or affected his clotting studies. The surgery was performed on an outpatient basis with the patient receiving intravenous sedation and a local anesthetic.
In most surgical procedures, bleeding is a self-limiting problem. Small punctate bleeding is controlled with cautery, and large bleeding by ligation. Bleeding during blepharoplasty can be kept to a minimum with meticulous dissection and close attention to tissue management, which allows for hemostasis to be maintained throughout all stages of the procedure. During this procedure bleeding became a significant problem in spite of all attempts to minimize it. Two factors brought about the bleeding: (1) The patient’s hypertension, which was believed to be well controlled before surgery, was extremely labile during the procedure; mean arterial pressures were as high as 136 mm Hg and never dropped below 113 mm Hg. (2) The patient’s anxiety, brought about by his urinary retention, persisted in spite of what should have been adequate intravenous sedation. The bleeding resulted in postoperative ecchymosis and intraoperative ecchymosis, even with a dry surgical field at the time of wound closure. The right eye, which had been operated on first, became swollen and ecchymotic during surgery on the left eye. Before completion of the left blepharoplasty, the right-side wounds were opened and explored, but no points of active bleeding were noted. By the end of the operation, the right periorbital tissue was profoundly ecchymotic, and both eyelids were swollen shut. The left side had also begun to swell and became ecchymotic.
After surgery, the patient and his family were given routine postoperative care instructions: ice packs as needed, artificial tears three times daily, pain medication, antibiotic, and the protease-based enzyme dietary supplement EnzAID® (Enzymes Inc., Kansas City, MO) (each 520 mg capsule contained protease, calcium, citrate, kelp, algae, calcium ascorbate, Irish moss algae, rutin, protease concentrate, quercetin, neutral bacterial protease, acid-stable protease, bromelain, grape seed extract, and papain in a base of pure plant fiber). The follow-up office examination on the second postoperative day revealed no periorbital swelling. The ecchymosis was limited to a 1.0 x 2.0 cm area of yellow discoloration along the inferior orbital rim bilaterally. By the fifth postoperative day, the discoloration was 0.5 x 1.5 cm and was not visible when the patient wore his regular glasses.
In the patient who has significant ecchymosis after undergoing blepharoplasty, the ecchymosis usually does not start to resolve earlier than the fourth or fifth day after surgery and may persist for up to 10 days. In my experience this type of patient should have had swelling and bruising for at least a week and possibly longer. The only change made in routine postoperative care was the addition of the protease-based dietary supplement. The rationale for use of protease-based enzymes is found in a large body of scientific data. In spite of what is commonly taught, evidence exists to support the intestinal absorption of hydrolytic enzymes; up to 40% of enzymes may be absorbed intact by the process of phagocytosis. These enzymes may also be absorbed functionally intact. If macromolecules such as enzymes are absorbed functionally intact, is there evidence to support the use of enzymes in the postsurgical period? Data have been collected on both trauma and surgically created hematomas indicating a benefit from proteolytic enzymes. Studies have shown how enzymes reduce the severity and duration of inflammation. Clinical data exist to show how orally administered enzymes help reduce posttraumatic and postsurgical pain. In this patient the recovery time was much shorter than would have been expected by routine treatment. Although a single case does not constitute clear proof of their function, it is well documented that oral enzyme compounds play an important role in the postsurgical treatment of patients undergoing cosmetic surgery, especially in the reduction of hematomas, edema, and pain after surgery and trauma. In this patient, enzymes may have played a significant role in reducing the postoperative morbidity, but a more thorough study is needed to prove such an assumption.
Clinical studies are underway to evaluate this enzymebased product. It is expected that this product will be available on the market within the year.
Taken from AESTHETIC SURGERY, St. Louis Vol. 18, No. J, pp. 40-41, February, 1998 (Printed in the U.S.A.)
(Copyright© 1998, by American Society for Aesthetic Plastic Surgery, Inc.)