Fig. 24.11 Excision of flap in a to-and–fro manner

24.6Lower Lid Transconjunctival Blepharoplasty

excision or combined ptosis repair is planned, open the orbital septum over a wet cotton swab (Fig. 24.13).

Fat can be resected with the laser in a slightly defocused mode over a wet cotton swab, or shrunken via laser-lipolysis technique also with the laser in the defocused mode. Finally, suture the wound with 6-0 monofilament suture in either an interrupted or running fashion. The suture is typically removed after 6–7 days. Instruct the patient to apply ice

Inject each of the three fat pads transconjunctivally with the anesthetic mixture (Fig. 24.14) previously described. The surgeon’s thumb is placed on the upper lid so that the patient cannot see the needle coming. The thumb is also used to push gently down on the globe while the third finger pulls the lower lid inferiorly. These maneuvers help evert the lower lid and expose the conjunctiva. Upon withdrawing the needle, a small amount of anesthetic is injected to minimally balloon the conjunctiva. The surgeon inserts a Jaeger lid plate to

Fig. 24.19 Laser finger elevating inferior oblique muscle

Fig. 24.20 Sub-ciliary incision for lower lid skin excision

The lid is repositioned, and retropulsion of the globe will identify the presence of residual fat. Further fat excision proceeds as need and the conjunctival wound is not sutured. If skin excision is planned it proceeds via a sub-ciliary incision (Fig. 24.20).

24.7Ptosis Repair

Ptosis surgery can be performed on its own or added to patients undergoing upper eyelid blepharoplasty. In this setting, infiltrate anesthetic without hyaluronidase to avoid spread into the levator muscle and introducing potential error in judging lid height and contour. If planned, blepharoplasty is first performed. The orbital septum is then divided as previously described, inserting a wet cotton swab beneath it to protect surrounding tissue (Fig. 24.21). Fat is removed as needed. The orbicularis muscle is isolated from tarsal plate with the laser held at an oblique angle (Fig. 24.22). The undersurface of the

Fig. 24.21 Cotton tip applicator placed beneath septum as a backboard to laser beam

Fig. 24.22 Tarsus exposed with inferior dissection of orbicularis off tarsal surface

levator aponeurosis is dissected free from Mueller’s muscle with the laser or bluntly with a cotton swab (Fig. 24.23). The levator aponeurosis is advanced and secured to the tarsal plate with a double armed 6-0 vicryl suture passed partial thickness (Fig. 24.24). Eyelid height and symmetry are noted and adjusted if necessary. The wound is closed with 6-0 Prolene suture.

24.8Direct Brow Lift

A direct brow lift is useful in male patients with brow ptosis and a receding hairline, who are not good candidates for an endoscopic or pre-trichial lift. The supraciliary skin of the brows is marked in an appropriate elliptical fashion. Incise the skin with the laser in the focused mode. In this procedure the laser is moved more slowly across the skin to create a deeper incision, as the brow skin is much thicker than eyelid

skin (Fig. 24.25). Incise with caution over the supraorbital neurovascular bundle. Remove the skin/subcutaneous flap in a side to side fashion with the laser in the slightly defocused mode (Fig. 24.26). Since the vessels are larger in this area, the bipolar cautery is necessary to attain hemostasis. Pinch the incision together to assess closure. Sculpt the subcutaneous fat with the laser in a slightly defocused mode. Close the wound with buried, interrupted 5-0 vicryl and a running/ locking 5-0 prolene.

24.9Laser-Assisted Tarsal Strip and SOOF Lift

A lateral tarsal strip and SOOF (midface) lift can be performed in conjunction with laser skin resurfacing (Chap. 23) or transcutaneous lower blepharoplasty (Chap. 15) to improve the appearance of festoons. The skin, inferior tarsal plate,

and orbital rim are anesthetized. A tarsal strip is isolated as described in Chap. 17. Conversely an inverted triangular wedge of full thickness lid can be excised for lid shortening. The terminal lid (skin, muscle, tarsus) is clamped prior to incision to aid in hemostasis (Fig. 24.27). A Jaeger plate is tucked inside the lateral orbital rim and the lid is shortened (a wedge excised) with the laser at 6 W in continuous wave (Fig. 24.28). Dissection is carried to the periosteum so that access is easier when the deep suspensory sutures are placed. The inferior crus of the lateral canthal tendon is released if necessary.

If a midface lift is planned, the lateral canthal incision is continued in a transconjunctival fashion across the length of the lid. Dissection is then carried in the post-orbicularis plane to the level of the periosteum on the anterior surface of the inferior orbital rim, to avoid fat prolapse into the field. The Jaeger plate is placed over the globe while a Desmarres retractor is used to engage the lower lid tissue