Blepharoplasty with canthopexy in a patient with cutis laxa: A case report

Cutis laxa is a rare connective tissue disease characterized by dysfunction of elastic fibers. Individuals affected by this disease complain about their aged appearance. Treatments are based on the use of cosmetics or surgical techniques, with plastic surgery being an extremely relevant tool. Blepharoplasty aims to improve the senile appearance and provide rejuvenation in the area around the eyes, making the look appear more rested and alert. This is a retrospective observational study using medical record data. Case Report: A female patient, 17 years old, was referred to the Plastic Surgery Service of the Walter Cantídio University Hospital, Fortaleza-CE, for treatment due to dissatisfaction with her appearance. She underwent upper and lower blepharoplasty associated with canthopexy without canthotomy. In the postoperative period, a satisfactory result was observed for the proposed surgery and adequate correction of existing changes. Conclusion: The importance of facial surgical correction in cases of lax skin is observed, highlighting the relevance of applying appropriate surgical techniques and improving them in this patient profile.


INTRODUCTION
Cutis laxa is a rare multisystem disease of connective tissue, characterized by dysfunction of elastic fibers, generating inflexible skin with redundant folds and a wrinkled appearance.Thus, individuals affected by this disease complain about their aged appearance, in addition to having aortic aneurysms and pulmonary problems more frequently [1][2][3] .This disorder can be acquired or hereditary -dominant or recessive, the latter presenting symmetrical involvement and usually having a worse prognosis.
Elastic fibers are mainly composed of elastin, a protein from the collagen family that enables tissue flexibility and resistance to tension.In lax cutis, loss of elastin was detected, with the fragmentation of elastic fibers in the reticular dermis causing laxity in the skin, vessels, lungs, and other tissues 2 .
Treatments are based on the use of cosmetics or surgical techniques as a form of relief or correction, with plastic surgery being an extremely important tool for the therapy of these patients 4 .
Faced with changes in appearance, most notably in the face, neck, armpit and groin region, there is a great desire on the part of patients for surgical corrections, especially those related to facial changes 5 .
Of the possible surgical procedures, blepharoplasty surgery, both lower and upper, aims to improve the senile appearance and provide rejuvenation in the area around the eyes, thus making the look appear more rested and alert 6 .
Traditional lower blepharoplasty is a procedure that, in most cases, brings good results, resulting in a barely noticeable subciliary scar 7 .
Canthopexy is a surgical procedure performed after classic upper blepharoplasty and lower conjunctival blepharoplasty.In the anterior segment, an ellipse of tissue is removed, as well as a strip of preseptal orbicularis muscle.In the lower part, a conjunctival approach is used to excise the pockets of fat.The surgical technique begins by making an incision in the tissue with an approximate diameter of 2 mm, located instantly below the lateral eyelid corner 6,8 .

OBJECTIVE
This article aims to report the case of a young patient who underwent superoinferior blepharoplasty with canthopexy to correct anatomical and aesthetic periorbital changes resulting from lax cutis.

CASE REPORT
Female patient, 17 years old, referred to the Plastic Surgery Service of the Walter Cantídio During the pre-operative evaluation, complementary tests were carried out looking for cardiopulmonary, respiratory, or large vessel changes relevant to the investigation, which did not demonstrate any changes.During the pre-operative period, the patient signed the Free and Informed Consent Form as approved by the Ethics Committee of the Walter Cantídio University Hospital (CAAE: 50728421.5.0000.5045).
The procedure was carried out on December 15, 2021.Due to the patient's main complaint regarding her eyelids, we began her treatment with upper and lower blepharoplasty, removing ellipses of skin and fatty pockets, repositioning of the lacrimal glands associated with canthopexy without canthotomy and cantholysis, for better positioning of the canthal angle, refixing the inferior segment of the lateral canthal tendon more internally on the orbital rim close to its insertion.
In the postoperative period, the patient returned to the service's plastic surgery outpatient clinic on the seventh day to remove stitches from the skin synthesis.Periodic monitoring has been maintained since then.A satisfactory result was observed for the proposed surgery, identifying adequate correction of the existing changes, namely significant dermatochalasis associated with prolapse of the lacrimal glands, as well as the negative canthal angle (Figure 2).The patient evolved without postoperative complications, being quite satisfied with the result obtained.She continues to be monitored by the Plastic Surgery Service at the Walter Cantídio University Hospital with future proposals for rhytidectomy, chin advancement, or mental prosthesis and otoplasty.

DISCUSSION
Cutis laxa is a genetic disease that causes sagging and redundancy of the skin, leaving an aged appearance in these patients.The changes caused by the disease can lead to social isolation, difficulty interacting, and the worsening of mental illnesses.
Therapeutic planning to correct lesions must be individualized and carried out by surgeons who recognize the dermatological differences of these patients.There are few reports in the literature on the surgical approach to the eyelids in patients with lax skin 9,10 .
Ozsoy et al. 11 described a case of a 20-year-old patient diagnosed with cutis laxa who presented a satisfactory aesthetic result with bilateral upper blepharoplasty without excision of the adipose tissue.
Banks et al. 12 reported two cases of patients with lax cutis, one 44 years old and the other 5 years old, who underwent rhytidoplasty with blepharoplasty to correct the aesthetic defects caused by the disease.An acceptable result was observed in the immediate postoperative period, with good healing, but the disease recurred months after the surgical approach due to the chronic defect in collagen metabolism.

CONCLUSION
In view of the above, the importance of facial surgical correction in cases of lax skin is observed, highlighting the importance of applying appropriate surgical techniques and improving them in this patient profile.
Due to the multiplicity of changes, it is still necessary to inform patients that the treatment is not always completed with just one surgical procedure and that other defects are often recommended to be addressed in other operative stages, as proposed for the patient in this case.

Figure 1 .
Figure 1.Patient with lax skin in the pre-operative period.

COLLABORATIONSJIPAF
Analysis and/or data interpretation, Conception and design study, Conceptualization, Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Realization of operations and/or trials, Resources, Supervision, Validation, Visualization, Writing -Original Draft Preparation, Writing -Review & Editing.JAGFJ Analysis and/or data interpretation, Conception and design study, Conceptualization, Final manuscript approval.