Fig. 14.4 Injection of local anesthetic to the upper eyelid via a 30-g needle

5–6 mm from the ciliary margin in order to create a natural appearing, low crease design. The degree of skin excision should allow approximately 3 mm between the upper and lower limbs of the incision, but should be tailored to each patient. It is recommended to err on the side of conservatism. Additionally, any preoperative asymmetry of skin excess must be compensated for during the skin marking.

14.6.3 Anesthesia

Some surgeons prefer patient cooperation throughout the procedure to help achieve symmetry, and avoid deep sedation if possible. Others prefer sedation or general anesthesia to facilitate patient comfort during the procedure. Local anesthetic, 0.5 cc of 1% lidocaine with 1:100,000 epinephrine mixed with 0.5 cc of 0.25% bupivacaine with 1:100,000 epinephrine, is infiltrated into the upper eyelid skin with a 30-g needle, by raising a subcutaneous wheal laterally which is then manually distributed along the entire length of the

incision (Fig. 14.4). This method diminishes the likelihood of hematoma formation from multiple needle sticks.

14.6.4 Surgical Technique

The skin is incised to the level of the orbicularis oculi muscle with a scalpel blade (Fig. 14.5). The skin is excised with a scalpel, iris scissors, or electrocautery bovie unit. Meticulous hemostasis is achieved with cautery to maintain a bloodless, clear surgical field. The same steps are performed on the contralateral side and are continued in this alternating fashion to ensure symmetry.

If the patient does not have dry eye symptoms preoperatively, and the lid shows sufficient prominence, an iris scissors is used to excise a 1–2 mm strip of orbicularis muscle from the inferior edge of the wound (Fig. 14.6). Fibers of the underlying orbital septum are often times incorporated, to further decrease the fullness. This tissue “debulking” can enhance the final crease appearance.

The eyelid fat is addressed next. Balloting the eyeball can facilitate identification of the eyelid fat pads by forcing them forward for better identification. A small fenestration along the lateral extent of the wound edge just at the point where the strip of orbicularis was previously removed is made. With counter traction and balloting of the globe, dissection continues through the orbital septum until the preaponeurotic fat is identified (Fig. 14.7). This portion of the procedure requires meticulous attention to detail, to avoid injury to the levator aponeurosis. The fat pad identified is superficial to the levator aponeurosis and no deeper dissection is needed in blepharoplasty surgery. Once the fat is identified, the orbital septum can be opened to its full extent for exposure of the nasal and central fat pads (Fig. 14.8). A cotton-tipped applicator is used to bluntly dissect the preaponeurotic fat pad away from the underlying levator aponeurosis for exposure (Fig. 14.9).

Fig. 14.7 Exposure of the preaponeurotic (postseptal) fat through an opening in the orbital septum

Fig. 14.9 Postseptal fat brushed away from fully exposed levator aponeurosis

Fig. 14.10 Artist’s drawing of crease fixation suture. A suture passes through the skin and orbicularis muscle at the superior margin of the wound, the levator aponeurosis, and through the skin and orbicularis muscle at the inferior margin of the wound. When tied, the suture creates a controlled adhesion of the levator to the orbicularis and skin. This creates a normal anatomic eyelid crease

Fig. 14.11 A surgical photo demonstrating the placement of a 5–0 Nylon suture through the levator aponeurosis to set the height of the upper eyelid crease

14.6.4.1 Levator-to-Skin Fixation

To achieve a more open eyelid configuration, many surgeons remove excessive eyelid fat. However, in the authors’ experiences, suture fixation of the levator aponeurosis to the eyelid skin is sufficient to achieve the desired open appearance of the palpebral aperture in 80% of cases. Therefore, excision of central preaponeurotic fat is rarely required. On occasion, nasal fat is conservatively sculpted.

The crease is now formed. The patient is asked to open his/her eyes to identify the mid-pupil location on forward gaze. A 6–0 nylon suture is placed through the upper skin edge at the mid-pupil line. The suture is then passed through the levator aponeurosis at its lower edge, and then through the lower skin edge at a corresponding point as the upper lid entry bite (Figs. 14.10 and 14.11). The patient is then asked to open his/her eyes after one suture is placed to determine proper crease depth, definition, and eyelash position (Fig. 14.12). The ideal suture will create a defined crease with slightly everted eyelashes. The eyelashes can be further everted with the aid of the electrocautery bovie applied to the orbicularis muscle just above the crease incision prior to suture placement. After suture placement, the crease height

Fig. 14.12 A surgical photo corresponding to Fig. 14.10. The 5–0 Nylon crease fixation suture is placed. The patient is asked to open his/ her eyes to assess positioning and symmetry