Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009

INTRODUCTION

Blepharoplasty is the surgical removal of the excessive eyelid tissues (skin, orbicularis muscle, and orbital fat), which can be for functional or aesthetic purposes. It is a useful procedure, not only isolated but also in conjunction with other procedures, such as ptosis repair, eyebrow suspension, among others.

Nowadays, there are an increasing number of patients seeking this type of surgery. The youngest patients typically go to the oculoplastic surgeon to improve their appearance, to raise their selfesteem or to be more competitive in the job market. On the other hand, the oldest individuals seek the surgeonwithhopetoimprovetheircomplaintofocularfatigue and/orobstructionofthetemporalvisualfield.Bothconditions caused by the excessive skin on the upper lid. These are certainly functional reasons for the blepharoplasty.

Before removing any amount of skin or fat from the lids, it is of utmost importance to do a careful preoperative evaluation.

PREOPERATIVE EVALUATION

Careful medical history must be taken, including questions concerning the motives that drive the patient to undergo a

210 Oculoplasty and Reconstructive Surgery

blepharoplasty surgery. Some patients relate emotional reasons for the surgery, hoping that even a slight shift on their appearance could reverse some ongoing problem on their lives, such as marital troubles or better job opportunities. It is of good sense to lower the expectations, or in more complicated cases, to postpone the surgery or even rule out such patients.

Patients should be asked about pre-existing conditions such as systemic hypertension, diabetes, blood discrasias, current drugs in use (salicilates, anti-inflammatory, or anticoagulating drugs), or smoking. Laboratory work should include complete hemogram, coagulogram and blood fastglycemia. Also, if the patient is over 60 years old, a cardiac assessment should be performed by a cardiologist.

Ophthalmologic evaluation includes: visual acuity, extrinsical ocular motility and biomicroscopy, in order to rule out amblyopia, low vision, and strabismus. Biomiscroscopy must be thoroughly assessed. It can show Bell’s phenomenon, cornea disorders such as puntacte keratitis, and lacrimal film disorders such as dry eye. Such conditions can get worse if too much skin is removed.

Ectoscopy is performed to assess the eyebrow position, the amount of redundant lid skin, the existence of fat bags (pockets) or the presence of lid ptosis. This will show if the blepharoplasty should be performed solo or along with other procedure such as brow correction or removal of fat bags. Careful measurements of the marginal reflex distance and the elevator muscle function determine if the patient also needs a ptosis repair. One can take advantage on this step, and give the patient a mirror to discuss along with him/her about the surgery.

Both physician and patient should get to an agreement about the right amount of skin that is to be taken. During this

Upper Lid Blepharoplasty 211

talk, the doctor can take some time to explain how the anesthesia is done (local only or with sedation), how long the surgery should take and how long should the patient recover in the clinic before going home. Also, the post-surgical care to be done at home should be discussed (local ice bag, antiinflammatory drugs, local ointment, resting).

Photography is of extreme importance before any plastic surgery to document the patient’s baseline. Full frontal face and close pictures should be taken, in order to compare the postoperative outcome.

The patient must be given the chance to ask any questions he/she may have regarding the procedure. Some doctors may think of it as “wasted time”, but this is very important to strengthen the patient/doctor relationship, thus increasing the satisfaction with the results.

SURGICAL PROCEDURE

Anesthesia can be done either before or after the marking of the redundant lid skin. Some doctors understand that the volume of anesthetic can make the marking more difficult, losing the reference of the correct amount of skin to be taken.

Eyelid surgery is usually performed under local anesthesia, which numbs the area around the eyes, along with oral or intravenous sedatives. It requires approximately 5.00 cc of local infiltrative anesthesia per lid, using 2% Xylocaine with 1:100,000 epinephrine. We prefer to use intravenous sedation, because it makes the patient relaxed during the procedure. We should wait at least ten minutes for the epinephrine to make a good vasoconstriction, thus reducing the need for electrocautery during surgery. Mild compression of the lids can be done to help spreading the solution.

212 Oculoplasty and Reconstructive Surgery

The inferior extent of the upper lid resection is demarcated over the natural skin crease with a marking pen, at least 8 to 10 mm superior to the lid margin (Figure 1A). Next, we draw a line that goes just from above the lacrimal punctum, passing through the previously marked line, extending to the lateral cantus, following the natural existing crow’s feet or laugh lines, if there is extra tissue in this area. If not, this marking may extend laterally 10 to 20 degrees to the horizontal line. We then pinch the redundant lid skin with an Addison forceps, always conservatively, and mark on the top of it (Figure 1B). We repeat the process laterally and medially, and then we draw a line joining the 3 existing marks to complete the inferior and superior extents of the marking lines

(Figure 1C).

After placing a corneal protector, we proceed to the skin resection. The incision can be made with a 15 blade, radiofrequency, or CO2 LASER, usually starting medially in the lower line, extending laterally. We follow the same procedure in the upper line. A slight portion of preseptal orbicullaris muscle should also be resected. This will help to form the lid crease (Figure 1D). Meticulous hemostasis is obtained using an electrocoagulator, or the laser beam in a defocused mode. If excess orbital fat exists, we should open the orbital septum with delicate scissors. The orbital fat will protrude with a gentle pressure of the ocular globe. After prolapsing, the fat should be clamped with a hemostat and the distal part to the instrument should be resected either with scissors or a blade (Figure 1E). Electrocautery is then applied over the entire extent of the cut surface within the hemostat, and after being sure that there is no bleeding, the hemostat can be released. The fat removed can be placed over gauze, for better comparison of the volume taken on each side. There is no need to suture the septum. A continuous or separated

214 Oculoplasty and Reconstructive Surgery

skin suture with 6.0 nylon or 6.0 prolene is used to approximate the margins of the wound (Figure 1F). It is advisable to deepen the suture in three or four points taking skin, muscle and septum to create a lid crease. Sometimes it can be necessary to take extra skin in the medial third of the superior margin, especially in older people. For that, a Burrow’s triangle can be resected.

POSTOPERATIVE CARE

Ice packs are used over the closed eyes to minimize edema and postoperative hemorrhages, extending its use for 48 hours. The sutures can be removed from 4 to 6 days. We use to remove them as soon as possible.

An antibiotic ointment is used 3 times a day for 15 days, in order to prevent infection and to keep the wound moistened, avoiding crusts around it. Oral anti-inflammatory drugs are prescribed for 7 days, and moderate rest is advised.

COMPLICATIONS

The most serious complication of blepharoplasty is visual loss which may be caused by an orbital hemorrhage. The surgeon should be skilled to perform a lateral canthotomy or should this occur. A careful attention to hemostasis, good blood pressure control, and discontinuation of anticoagulants are of paramount importance to prevent this complication. If hemorrhage is observed, the wound can be reopened and an incision on the septum performed, in order to alleviate the intraorbital pressure.

Damage to the extraocular muscles can cause strabismus. Excessive fat removal can cause an aesthetically displeasing, hollow appearance to the orbit. If too much skin is taken, that can lead to insufficient lid closure and lagophthalmos,

Upper Lid Blepharoplasty 215

followed by keratopathy. Other infrequent complications described are hypertrophic scaring, cheloid, ptosis, optic atrophy and even blindness.

Careful preoperative examination, as well as a thorough understanding of the eyelid anatomy and surgical techniques are essential to prevent unwished complications and to achieve natural and pleasant results.

BIBLIOGRAPHY

1.Bosniak S. Cosmetic Blepharoplasty, Upper Lid Blepharoplasty, 1992;37-53.

2.Matayoshi S, Forno E, Moura E. Manual de Cirurgia Plástica Ocular 2004:149-65.

3.Reeh M, Beyer C, Shannon G. Practical Ophthalmic Plastic and Reconstructive Surgery 1976:133-40.