Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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INTRODUCTION
Through experience, I have found that the laser CO2 works well in aesthetic eyelid surgery. I believe it should be used in a conservative way by preserving the elimination of skin and never exceeding in the quantity of fat removed. This way the risk of a skull aspect can be avoided as a patient ages.
Laser surgery requires much expertise. It is very important to have perfect knowledge of the anatomy of the lids, which is very complex.
Transcojunctival blepharoplasty of the lower lid is my first surgery choice, CO2 laser works very well and it is possible to have a complete lipectomy of the bags. Orbital septum is not violated, the orbicularis muscle is preserved and the skin is not cut or removed. These factors in the skin-muscle flap technique are responsible for the retraction of the lower lid and ectropion after blepharoplasty.
Recovery time is shorter, with less edema, no stitches, no pain, less retraction of the lid, no scleral show and no changes in the shape of the lower lid.
Although the transconjunctival technique does place the inferior oblique muscle and lid itself at risk, with careful technique, complications are unusual.
Aesthetic Ophthalmoplastic with CO2 Laser 421
Figures 1A to E: (A and B) (Preop), (C) 7 days post-laser blepharoplasty 4 lids and skin resurfacing, (D) One month postoperative, (E) One month postoperative
To avoid skin laxity, the inferior lids could be treated with laser skin resurfacing (Figures 1A to E).
TECHNIQUE OF LASER BLEPHAROPLASTY
When using the CO2 pulsed laser, the machine must be set correctly, depending upon the model. The surgeon must also check some important things in the surgery room before starting the operation.
Laser Safety
To avoid fire hazards the oxygen source must be turned off. Use wet towels near the surgery field, use an appropriate smoke evacuator, do not use volatile skin preparations or
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anaesthetics and use patient corneas metallic protectors. Remember that CO2 laser can easy perforate the globe.
Preoperative Marking
I prefer to mark the preoperative area of the upper lid while the patient is still awake and in an upright position. The inferior lids are also marked if a transconjunctival approach and a skin laser resurfacing are scheduled.
The principles of marking are no different from the technique used with a cold steel or a Colorado needle (Figure 2).
A betadine solution or other not volatile solution is used for the disinfection of the lids and periocular region. Antibiotic drops are instilled.
The patient is draped and wet towels are prepared, the smoke evacuator is put in place.
Laser is set on pulse mode at a range of 5 or 6 watts and tested on a wet tongue blade; the beam must not penetrate the wood.
I suggest the use of pulse mode to any surgeon approaching laser blepharoplasty; it is far safer than CW mode.
Figure 2: Preoperative marking
Aesthetic Ophthalmoplastic with CO2 Laser 423
CW mode better controls bleeding but needs an expert surgeon who moves the laser beam precisely and quickly to avoid tissues heating and burning.
Anesthesia
Use lidocaine with epinephrine (1:200,000) with 1 cc of sodium bicarbonate per 10 cc. of lidocaine to avoid a burning sensation during injection.
Another syringe of 10 cc of lidocaine without epinephrine is prepared to use during surgery if necessary during lipectomy. Avoid using epinephrine in this step; it could induce a vessels constriction of the optical nerve with dangerous ischemic effects.
The cornea is anesthetized with 2 drops of 4% tetracaine and the metal scleral shield is lubricated with cellulose gel and placed on the cornea. The surgeon can then proceed to infiltrate the upper and lower lids. It is best to use the least volume of anesthetic possible and than perform a delicate massage to induce the penetration and spread of the anesthetic into the tissues.
Intravenous sedation analgesia is performed and controlled by the anesthesiologist.
The patient should be monitored with pulse oximetry and electrocardiography and should be given supplemental oxygen.
Upper Lid Laser Blepharoplasty
The laser incision follows the marks with constant, precise and rapid movements. Hesitation on any area could result in tissues being burnt.
This procedure requires extreme technical capacity and it is not for every surgeon.
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Figures 3A to D: (A) Right upper lid Incision of the skin and orbicularis.
(B) Right upper lid Laser excision of the skin muscle flap. (C) Before. (D) After upper lids laser blepharoplasty
Check that the cut is complete and no bridges of tissue are present. Raise the lateral part of the flap with forceps and use scissors for the first 2 cm. of skin-muscle flap dissection, than continue dissecting with the laser beam (Figures 3A and
B).
When the dissection is completed to the corner, remember to protect nasal skin by using a Jaeger bone plate or wet gauze pad to avoid accidental burns.
Bleeding must be controlled. The laser is defocused and used to coagulate any blood vessels.
With gentle pressure on the globe, the septum is incised in the medial and central part and fat is exposed.
Fat is gently grasped with forceps and placed on the zed plate, before the cutting laser beam is defocused to coagulate the vessels and refocused to cut the fat. Never pull up on the fat, it may cause severe bleeding.
Aesthetic Ophthalmoplastic with CO2 Laser 425
If a large vessel is present I prefer to use an electric cautery and than cut with laser.
Explore the medial fat pad at completion to be sure that there is no bleeding. Any residual fat could be removed at this time.
Place a wet gauze on the upper lid and proceed to the other lid.
I close the wound starting from the nasal part using an itradermal suture with nylon 5-0.
The tail of the wound is suturated with 3 separated stitches, because in this area the obicularis muscle has a strong contraction and it would open the wound (Figures 3C and
D).
Lower Lid Laser Blepharoplasty
Transconjunctival lower lid laser blepharoplasty is my standard lower lid technique. I use it for young patients as well as for more mature patients; where there is present a slight excess of skin and/or fat. Operating and recovery time is shorter.
The benefits of the transconjunctival approach are primarily that it avoids surgical violation of the orbital septum, there is less aggressive lipectomy, there are no stitches, the skin is untouched and the risk of scleral show or ectropion are avoided.
This is not an easy technique; it needs a long period of training, good control of the laser beam and a perfect knowledge of the anatomy.
The metal scleral shield is put on the cornea, the lower lids are anesthetized, a 5-0 silk suture is passed at the middle of the lid at the level of the grey line into the tarsal plate and used for retracting the lower lid anteriorly on a cotton tip to better expose the fornix.
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A 5-0 silk suture is passed in the middle section of the conjunctival fornix used to retract the lower part of the lid.
The incision will be made for all the length of the lid, stopping before the lacrimal punctom, 4 or 5 mm below the lid margin. The incision will pass through to the end part of the vertically oriented blood vessels of the conjunctiva. At this point you reach the lid retractor muscles, where an incision made inferiorly, deep in the fornix, would result in excessive bleeding, poor exposure of fat, and possible injury to the inferior oblique muscle.
Set the laser in CW mode, start with 5 watts, if bleeding is present, increase to 5,5 or 6 watts.
Firstpasstoincisetheconjunctiva,thenpasstocutthrough the capsulopalpebral fascia and lid retractors muscles.
Forceps are then used to separate the tissues and expose the orbital septum. Simultaneously the assistant produces a gentle pressure on the globe to bulge the fat pads. Before cutting any structure try to obtain maximum visibility of the field using a metal Desmarres retractor.
Incise the septum over the nasal, central and lateral fat pads, and ballot the globe to bring the fat pad forward (Figures
4A to D).
Nasal and central fat pads generally prolapse quite easily. Make an accurate coagulation of any large vessels present in the nasal fat pad. Caution should be used if the inferior oblique muscle is visible along the inferior and lateral edge of the nasal fat pad.
The lateral fat pad is more difficult to mobilize because it is adherent to the lower eyelid retractors and covered by an often thick septum that is densely adherent to the inferior lateral rim. Even when properly mobilized, a deeper further fat may only become apparent after first removing the existing lateral fat and the globe.
Aesthetic Ophthalmoplastic with CO2 Laser 427
Figures 4A to D: (A) Right inferior lid. The central fat pad. (B) Right inferior lid Central fat pad prolapse. (C) Left inferior lid laser lipectomy.
(D) Laser lipectomy
Reposition the eyelid and ballot to look for any residual bulging fat, and check for any bleeding.
At the end of the surgery instil drops of antibiotic or use antibiotic ointment, which is applied to the inferior fornix
(Figures 5A to D).
Postoperative Recovery
1.Use icepacks for 5 days.
2.Use oral and topical antibiotics for 7 days.
3.Heed written instructions that include the warning signs of retrobulbar hemorrhage.
4.Avoid heavy lifting
5.Elevate the head of the bad, while sleeping, for 1 week.
6.Avoid contact lenses for 10 days
Patients are generally seen one week following surgery.
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Figures 5A to D: (A) Postoperative medications. (B) Before. (C) 7 days after lower lids laser transconjunctival blepharoplasty and erbium skin resurfacing. (D) 1 month after surgery
Laser Blepharoplasty of the Lower Lid with Skin-muscle Flap
Patients with excess fat and skin require a skin-muscle procedure.
Preoperative safety precautions are the same as described previously in the section on laser transcojunctival blepharoplasty.
One 5-0 silk suture is passed through the gray line into the tarsal plate and used as a retraction suture.
The incision line is marked approximately 1mm below the cilia from the medial canthus towards the lateral canthus.
Start from the lateral area to incise through to the orbicularis layer to fashion a myocutaneous flap. The assistant places two double hooks on the inferior cut border and holds the lower lid to expose to the surgeon the aereola plane between the orbicularis muscle and the underlying orbital septum.
When this layer is evident, a gentle pressure on the globe allows any fat to protrude forward. With the laser beam, incise the septum and remove prolapsed fat from the central, nasal and lateral pads.