10 Adjunctive Procedures in Upper Eyelid Blepharoplasty… |
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lacrimal gland to the lateral margin of the levator aponeurosis. Posteriorly and superiorly, the gland is supported by fascial bands connected to periosteum. Medially, a fascial band connects the gland to Whitnall’s ligament [2, 7].
There are two surgical techniques utilized to address lacrimal gland prolapse: the resection technique which removes the prolapsed part of the gland, and the repositioning technique which reinforces the prolapsed part of the gland [18–20]. Resecting the prolapsed part of the lacrimal gland has lost favor due to dry eye consequences. The accessory glands are insufficient for basal tear production. Repositioning and reinforcing the lacrimal gland to the lacrimal fossa is the generally accepted technique employed today. This simple procedure poses minimal risks for decreasing tear production since it does not violate either the lacrimal gland parenchyma or the excretory ducts.
10.5.1 Surgical Technique
As with the aforementioned procedures described in this chapter, repositioning the prolapsed lacrimal gland is performed at the time of standard upper lid blepharoplasty, through an eyelid crease incision. The skin and underlying orbicularis oculi muscle are excised and the septum is opened. The medial and central fat compartments are sculpted. The lacrimal gland is identified by its tan color and firmer consistency than the surrounding orbital fat (Fig. 10.11a). A doublearmed 5.0 chromic or 5.0 PDS suture is passed through either the anterior or the inferior part of the lacrimal gland capsule (Fig. 10.11b). The gland is secured to the periosteum inside the lacrimal fossa (Fig. 10.11c). One should avoid passing the sutures through the lacrimal gland parenchyma, as this may cause bleeding and postoperative dacryoadenitis.
10.6Conclusion
Understanding the mechanisms responsible for “heavy lids” is critical in choosing the best therapeutic approach for surgical upper lid rejuvenation. It is not uncommon for brow ptosis, dermatochalasis, glabellar furrowing, and lacrimal gland prolapse to simultaneously contribute to the fullness of the upper lids. It is essential to identify all contributing factors and select the surgical plan that best suits the patients’ needs. In this chapter we have reviewed how, via an upper blepharoplasty incision, the eyebrow fat can be sculpted, the brow elevated, the glabellar muscles weakened, and the displaced lacrimal gland repositioned. These are useful procedures that provide the surgeon with an effective means of directly addressing all associated deficiencies at the time of blepharoplasty via one incision.
Fig. 10.11 Lacrimal gland resuspension technique. (a) Intraoperative photograph showing a prolapsed lacrimal gland after the orbital septum had been opened. (b) A double-armed 5.0 chromic gut suture is passed through the inferior aspect of the lacrimal gland capsule. (c) The gland is then secured to the periosteum inside the lacrimal fossa
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