decreases the acidity and minimizes discomfort. This is done before the surgical prep and additional full-strength local anesthetic anesthetic is added, without discomfort, prior to the surgical incision. Generally, 1–3 cc of local anesthetic per eyelid is adequate. The initial injection is placed superficially into the eyelid skin to ease dissection and to encourage vasoconstriction (Fig. 9.16). Additional local anesthetic is injected into the medial fat pad with care taken to direct the needle away from the eye. Blocks to the supratrochlear and supraorbital nerves are an option, but rarely necessary.

9.8The Surgical Prep

A full-face prep from below the jaw line up to the hairline is performed using Betadine solution (paint). Betadine scrub (soap) is toxic to the cornea and is never used for the face. A cotton tipped applicator dipped in Betadine is used to prep the lash line. The prep is always preceded by a topical anesthetic drop to block ocular irritation. Prep sponges are used in a dabbing fashion over the eyelids so as not to erase the carefully crafted surgical markings. The remainder of the face is painted with the Betadine solution and blotted dry. The patient is draped with the mouth and nose left open in the surgical field. Full face exposure decreases the risk of oxygen tenting, which can result in a fire hazard, and is less claustrophobic.

Fig. 9.18 The surgeon’s nondominant hand applies gentle counter traction against the lid margin suture. Minimal cutting energy is necessary to observe wound separation. This keeps incision depth to a minimum, protecting deeper structures

9.9The Surgery

Incisional options include a #15 scalpel blade, electrosurgical radio frequency or monopolar cutting devices ,or laser. While any of these options allow for an accurate incision, it is the author’s preference to use radio frequency or monopolar instrumentation. Prior to incision a 4–0 silk suture is placed through the lid margin and placed on traction (Fig. 9.17). The lower lid crease incision is performed first. The hands are positioned as described for drawing of the surgical markings. Using the nondominant hand to elevate the brow, and as a rest for the operating hand, improves control. A right-handed surgeon has more control when sweeping the cutting instrument backhand from left to right. The surgeon’s hand applies gentle counter traction against the lid margin suture and minimal cutting energy is necessary to observe wound separation (Fig. 9.18). This minimizes the risk of incising beyond the very thin eyelid skin and injuring other lid structures or the cornea. It is prudent to use a corneal protector.

After the lid crease incision is completed, the superior incision is opened in a similar fashion. Using cautery a skin flap is then dissected from the orbicularis (Fig. 9.19). Several bleeding vessels will be encountered and should be cauterized.

Fig. 9.19 Gentle cautery is used to separate the thin eyelid skin from the underlying orbicularis oculi muscle

The surgeon now has a view of the orbicularis oculi muscle across the wound bed. Preservation of all or some of the orbicularis muscle will decrease the potential for lagophthalmos and dry eye [10]. In patients with full lids, partial debulking of the orbicularis may be necessary to create a more aesthetic result. If no lid crease fixation is to be performed, then a higher opening in the orbicularis medially and centrally will allow access to the fat pockets while preserving orbicularis oculi muscle. If lid crease fixation to the levator aponeurosis is anticipated, the opening should occur lower in the wound bed with excision of a small band of orbicularis.

The orbicularis muscle is opened at its most medial extent with the incision extended to approximately mid-pupil. This should allow adequate access to the nasal (medial) and

Fig. 9.20 A horizontal incision is made through the orbicularis oculi muscle and orbital septum exposing the nasal and central fat pads. A conservative excision of fat is performed based upon the amount of fat present and the degree of lid sculpting desired

central (preaponeurotic) fat pads (Fig. 9.20). The nasal fat is often paler than the preaponeurotic fat, which is more yellow in color. The preaponeurotic fat is relatively avascular and minimal cautery is necessary during excision. The nasal fat pad is more vascular and it is prudent to apply bipolar cautery to its base prior to excising the exposed fat (Fig. 9.21). Gentle spreading in the medial pocket with tenotomy scissors may help to better expose the more fibrotic fat in this area. It is common for the minimally sedated patient to experience greater discomfort in this area and require injection of additional local anesthesia. Gentle globe pressure may also help to identify the fat pockets for excision. Care should be taken not to overexcise fat and create a hollow, gaunt appearing upper eyelid. It is important to remember that generally patients lose fat in the periorbital area with age and overexcision will result in even greater hollowing of the eyes later in life.

Care must be taken when exposing the anterior surface of the levator aponeurosis to avoid disinsertion from the tarsal plate with resultant blepharoptosis. The levator aponeurosis will be identified just posterior to the preaponeurotic fat. If the orbital septum is opened more superiorly, the potential for injury to the levator aponeurosis is minimized. This will also provide excellent access to the nasal and central fat pads, which can be excised in accordance with the preoperative plan and the amount of visible fat prolapsed.

Lid crease fixation is not performed in every patient. It may be indicated when the surgeon is attempting to balance preexisting lid crease asymmetry or to create a more defined pretarsal area beneath the lid fold. When utilized, it is performed as the last step prior to wound closure. Small bites of aponeurosis, positioned at the desired lid crease position,

Fig. 9.21 Bipolar cautery is applied to the more vascular nasal fat pad prior to excision. Bleeding vessels in the area can be more difficult to identify when the fat pad retracts into the orbit

can be incorporated into the running skin closure. Greater accuracy may be achieved with the use of separate interrupted fixation sutures. A 7–0 Vicryl (polyglactin) works well for this purpose. Three to five interrupted sutures are spread across the wound opening where it spans the aponeurosis. The knot is buried by first placing the suture, in a forehand fashion, through the levator aponeurosis at the appropriate height for the lid crease. This is determined by using forceps to elevate the inferior lip of the incision to the desired height. The suture is then placed through the orbicularis muscle, just deep to the skin, at the inferior wound margin. When securing the suture, it is tightened slowly to the point that the pretarsal skin is elevated to an appropriate height. Overtightening should be avoided, as this may create an overly deep lid crease. Identical sutures are placed across the eyelid as necessary (Fig. 9.22). Having the patient look up will allow the surgeon to assess the lid crease position as the levator elevates the wound margin.

Final wound closure is performed with a running 6–0 Prolene suture. The suture is placed through skin approximately 10 mm medial to the incision. It exits from the skin on the superior aspect of the wound where it begins medially. It is then run in a continuous fashion across the wound. The last bite enters the skin adjacent to the lateral most aspect of the wound, and the needle is directed 1 cm lateral to the wound where it exits the skin. This continuous suture is not tied at its medial or lateral extent (Fig. 9.23). Three small Steri-Strips, over Mastisol, are used at each end to fold the suture over in a fashion that will keep it from slipping (Fig. 9.24). This technique allows for some tissue expansion during healing which helps to improve the final appearance of the wound. The technique also facilitates suture removal as it can be snipped centrally with the medial and lateral halves each removed in one gentle pull. At the conclusion of

Fig. 9.22 (a) Lid crease fixation is defined with 7–0 Vicryl suture. The knot is buried by first placing the suture, in a forehand fashion, through the levator aponeurosis at the appropriate height for the lid crease. The suture is then placed through the orbicularis muscle, just deep to the skin, at the inferior wound margin. When securing the suture, it is tightened slowly to the point that the pretarsal skin is elevated to an appropriate height. Identical sutures are placed across the eyelid as necessary. (b) Artists drawing of lid crease fixation suture

the case, antibiotic ophthalmic ointment is applied to the wound.

9.10Postoperative Management

Patients are instructed in routine postoperative care. Cold compresses are applied to the eyes as tolerated for the first two to three postoperative days. Commercial gel masks are available and easy to use. Alternatively, small zip lock bags

Fig. 9.23 (Photo and illustration) The suture is placed through skin approximately 10 mm medial to the incision. It exits from the skin on the superior aspect of the wound where it begins medially. It then runs in a continuous fashion across the wound. The last bite enters the skin adjacent to the lateral most aspect of the wound, and the needle is directed 1 cm lateral to the wound where it exits the skin

Fig. 9.24 Three small Steri-Strips, over Mastisol, are used at each end of the wound. The free suture ends are folded and locked over small segments of Steri-Strips. This technique allows for tissue edema during healing and helps to minimize scarring

of frozen peas work nicely and can be rotated through the freezer for reuse. Patients are instructed to keep their head elevated using pillows, or a recliner chair, for the first 3 days postoperatively. Patients are advised to not bend at the waist or lift anything over five pounds. Antibiotic ophthalmic ointment is applied to the wounds twice a day. During the first few days the eyelids may not close completely, and it may be necessary to place antibiotic ointment in the eye as well. Patients should be advised that the ointment will blur their vision.

After 3 days, patients are instructed to use warm compresses. This will soften dried blood at the wound and allow for gentle cleaning of the area. On postoperative day 7, the wound will be cleaner, allowing for easier suture removal.

98

Fig. 9.25 (a) Forty-five-year- old male with dermatochalasia causing pseudoptosis.

(b) Postoperative photo shows symmetric pretarsal show and lid creases. Notice that the patient is still exerting brow elevation (creases) to maintain brow

in acceptable position.

(c) Sixty-seven-year-old male also with significant pseudoptosis. Hanging skin fold causes lash ptosis and blepharitis. (d) Postoperatively, this conservative result shows the lid margin and improved function and appearance. A small drop in brow position is evident but the patient was prepared for this during preoperative counseling. (e) Forty-two-year-old lady with familial history of heavy lid skin. (f) Postoperatively, she is pleased to be able to wear eyeliner and shadow. (g) Sixty-five-year-old lady with pseudoptosis and significant temporal hooding. (h) Reasonable resolution is achieved postoperatively although greater improvement with a brow lifting procedure would have been possible

A.D. Morton