19
Keys to Success When Marking the Skin in Upper Blepharoplasty
John R. Burroughs and Richard L. Anderson
•There are few procedures in oculofacial plastic surgery more gratifying to the surgeon and patient than upper blepharoplasty. Keys to success are a strong patient–physician relationship and making certain that the desired goals are also realistic expectations.
•We avoid removing upper eyelid skin that would leave less than 20–22 mm between the eyelid margin and the brow cilia.
•Patients should marked in an upright position.
•We wipe the skin with alcohol to remove oils prior to marking to ensure the surgical markings will remain after patient prepping.
•We use the extrane point skin marker by Scanlan™ (1-800-328- 9458) as it has an ultra-fine tip and allows extremely precise marking
(Figure 19.1). The white cap on the bottom of the marker is approximately 10 mm in length and readily serves as a quick way to estimate the placement of the incision markings (Figure 19.2)
•We advise against placing the lower skin incision any lower than 9–10 mm in most eyelids unless the natural crease is lower. Simply marking the patient’s natural eyelid crease can be quite variable, and in acquired ptosis patients may be remarkably higher than normal. Symmetry in the lid crease markings is key in upper blepharoplasty.
•We then mark the upper incision in the sitting upright position by having the patient gaze straight ahead to help determine the upper extent of the upper blepharoplasty incision.
•The bottom white portion of the of the Scanlan marker (Figure 19.2) is used to quickly check that at least 10 mm of eyelid skin remains above and below the marked areas for skin removal.
It is critical to maintain symmetry in the height, depth, and fold of the eyelid crease, which is paramount in the success of the upper blepharoplasty.
We avoid medial webbing by drawing a gentle upturn to the medial incision markings. Laterally we extend the markings to approximately 5 mm above the lateral canthus, then upturn to hide the lateral incision and to avoid elevation of the temporal eyelid crease (Figure 19.3).
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Chapter 19 Keys to Success When Marking the Skin in Upper Blepharoplasty 63
Figure 19.1. ScanlanTM marking pen with white end-cap that is approximately 10 mm in length.
Figure 19.2. Blepharoplasty skin marking showing gentle medial and lateral upturn. White end-cap showing at least 10 mm of skin between upper marking and browcili.
64 J.R. Burroughs and R.L. Anderson
Figure 19.3. Gentle medial upturn to avoid medial webbing andmarking within 5 mm of lateral canthus. Lateral upturn helps hide the incision temporally.
20
Skin Marking in Upper
Blepharoplasty—Avoiding Pitfalls
Cat Nguyen Burkat
At surgery, the skin marking is probably one of the most important steps and therefore warrants careful attention to detail. The placement of the skin incision is crucial to the perceived success of the surgery postoperatively as the eyelid crease is the most distinguishing feature of the upper lid. I prefer to mark the incisions with a fine-tip marking pen prior to injection of local anesthetic to avoid distortion of the tissues from the anesthetic. The eyelid crease heights are first measured and compared on both upper eyelids. If they are symmetric and appropriate for gender (8–11 mm for women, 6–8 mm for men), the creases are marked with the pen (Figure 20.1). Occasionally, the crease heights are asymmetric, contain double lines, or are discontinuous. Therefore, careful comparison between the two sides will help guide the proper placement. In addition, if involutional ptosis is also present, the eyelid crease will be anatomically elevated up to height of 15–20 mm (due to dehiscence of the anterior fibers of the levator aponeurosis that attach to dermis and skin at the level of the lid crease). Placement of the incision at these elevated crease levels would result in a suboptimal and unnatural appearance to the eyelids.
Gender and ethnic considerations are also incorporated into placement of the skin marking, with the crease incision rounder and more arched in women, as opposed to a flatter and lower crease incision in men. In Asian eyelids, the medial aspects of the flap markings should blend into the epicanthal fold. In addition, the height of the eyelid crease in Asians will be much lower at 4–6 mm. Placing the incision at the normal 8- to 11-mm height would result in a westernized Caucasian eyelid that would be unfavorable to the Asian patient.
In general, the upper eyelid skin should measure 19–20 mm from eyelid margin to the transition to eyebrow skin. This measurement eliminates the risk of postoperative lagophthalmos from aggressive tissue excision (Figure 20.2). In addition, it is a useful tool for teaching residents in training. Therefore, the height of the eyelid crease is subtracted from a total of 20 mm (Figure 20.3). This amount is then measured from the inferior edge of brow skin, which will thus represent the superior border of the skin ap to be removed (Figure 20.3). This is measured at
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66 C.N. Burkat
the central lid first and then medially. Many times surgeons tend to excise too much skin medially and cause medial lagophthalmos or webbing (Figure 20.4). Laterally, an extra 1–2 mm may be removed as there is usually some degree of lateral eyebrow ptosis. Care should be taken to avoid confusing the true junction of the inferior brow (where the thin eyelid skin transitions to thicker, larger porous brow skin with a different color) in women who pluck their eyebrows to a higher height (Figure 20.5). Measuring the upper incision to the plucked eyebrow level would thus result in erroneous excess skin removal.
The pinch technique is then performed to confirm that an adequate 19–20 mm of skin is preserved, done by pinching together the skin between the inferior and superior markings and measuring the remaining skin from the eyelid margin to the brow skin. If the skin pinch results in a tightness to the thin eyelid skin, vertical striae to the skin, or retraction or eversion of the eyelid margin, too much skin is being excised (Figure 20.6).
Other important pearls are keeping the medial extent of the skin marking no further medial than the upper punctum. Incisions that extend medial to the punctum increase the risk of webbing in the nasal eyelid region (Figure 20.4). In the event that there still remains an excess of skin medially, a Burow’s triangle is sometimes helpful while still avoiding medial webbing.
The lateral extent of the skin marking should also be measured from the lateral canthal angle with a caliper. This ensures that the incisions extend for the same length bilaterally, which is often noticeable to the patient. In addition, the lateral extent should not extend into the thicker temporal skin.
Figure 20.1. Measuring and marking the eyelidcrease incision from the eyelid margin.
Chapter 20 Skin Marking in Upper Blepharoplasty—Avoiding Pitfalls 67
Figure 20.2. Postoperative lagophthalmos following aggressive skin incision.
A 
|
Figure 20.3. Marking |
|
the superior incision |
B |
from the thick |
eyebrow skin. |
68 C.N. Burkat
Figure 20.4. Webbing of skin medially due to extension of incision past the superior punctum.
Figure 20.5. Arrows demarcate the transition from thin eyelid skin to thick eyebrow skin, which may be considerably below the level of plucked eyebrows.
Figure 20.6. The pinch technique
con rms that 20 mm of skin has been retained.
21
Upper Blepharoplasty:
Pearls for the Procedure
Evan H. Black, John D. Siddens, Frank A. Nesi,
Shoib Myint, and Geoffrey J. Gladstone
1.Meticulous marking is critical. We recommend marking prior to injection. A fine-tip marker is preferred, as the larger markers smear and do not allow the precision necessary for eyelid surgery.
2.The supratarsal lid crease should be marked from punctum to lateral canthus. If the patient’s natural creases are appropriate and symmetrical, they can be used. Otherwise adjustments should be made.
3.The pinch technique will determine how little skin can be excised to achieve optimum results. Be careful to make the endpoint the eversion of lashes. This part is critical to prevent lagophthalmos. Care is taken not to remove sub-brow skin to prevent postoperative brow ptosis. Less is more with skin removal.
4.The lid crease marking should slope gently upward medial to the punctum and lateral to the lateral canthus. Avoid aggressive medial skin excision or going too close to the lid margin medially, as this can cause webbing.
5.To achieve adequate hemostasis, 2% lidocaine with 1 :100,000 epinephrine mixed with 0.5% marcaine with 1 :200,000 epinephrine is used. Hyaluronidase can be used in the mixture to help dispurse the anesthetic.
6.When incising the skin–muscle complex, be careful not to damage the levator complex. This can result in ptosis. Orbital fat is a good landmark as it lies anterior to the levator.
7.Prominent lacrimal gland tissue may need to be tucked to create an aesthetically pleasing appearance to the lateral eyelid.
8.With fat removal, being conservative is better. A subjective preoperative grading system should be implemented to prevent under correction or overcorrection of the orbital fat. Prominent medial fat pads should be reduced.
9.Excessive cautery medially can damage the trochlear region, resulting in diplopia. One should be meticulous with hemostasis, however, to avoid the rare complication of orbital hemorrhage. Use of handheld or bipolar cautery is useful.
10.Lid crease fixation suture can be used to enhance the appearance of the crease, especially in females or when less skin is taken.
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72 E.H. Black et al.
11. The chance of milia, granuloma, or epithelial suture cysts can be reduced by using subcuticular closure with a nonreactive permanent suture such as 6-0 polypropylene. If an absorbable suture is used, the remaining sutures should be removed at about 7 days.
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Fat Excision in Upper Blepharoplasty
Sheri L. DeMartelaere, Todd R. Shepler, Sean M. Blaydon, Russell W. Neuhaus, and John W. Shore
The nasal fat pocket can sometimes be difficult to access, is more vascularized, and is more innervated than the rest of the preaponeurotic fat. Additional local anesthetic injected within the fat pocket during excision will improve patient comfort. A small Desmarres retractor can be used to retract the skin nasally and better expose the nasal fat. The nasal orbital septum is carefully opened and the nasal fat pocket exposed. While grasping the fat with forceps, the surrounding tissue is pushed posteriorly using cotton-tipped applicators. The nasal fat can then be carefully excised with small snips of Wescott scissors or using pin-point monopolar cautery. Hemostasis should be achieved before the fat retracts back into the orbit.
In elderly patients, beware of the prolapsed superior ophthalmic vein presenting nasally within the preaponeurotic fat. Inadvertent disruption of this vein can cause significant hemorrhage, sometimes requiring suture ligation and placement of an orbital drain to manage. If a prominent vein is found medially on one side, expect to find it on the opposite side.
It is important not to remove too much fat, particularly in men. Consideration should be given to excising a minimum of fat out temporarily in order to avoid skeletonizing the orbital rim.
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23
Mobilizing and Excising the Nasal Fat
Pad in Upper Blepharoplasty
Jemshed A. Khan
After the initial incision and removal of skin and muscle, bluntly spread the fascia over the nasal fat pad with a hemostat. Ballottement the globe will prolapse the fat pad forward. Make an “X”-shaped incision over the nasal fat pad, deepening the incision until the fat prolapses. Grasp the protruding knuckle of fat with forceps and use a cotton-tip applicator to bluntly strip away tissues retaining the nasal fat pad. Supplemental local anesthesia injection is usually required at the base of the nasal fat pad. The fat pad may be excised across a closed hemostat or divided using a laser against a backstop. Adequate hemostasis is important because of the caliber of vessels associated with the fat pocket.
Reprinted with permission from: Chen WPD, Khan JA, McCord, Jr, CD. Color Atlas of Cosmetic Oculofacial Sugery. Philadelphia: Butterworth Heinemann/ Elsevier, 2004.
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24
Tissue Removal Considerations in
Blepharoplasty Surgery
Rona Z. Silkiss
When deciding how much tissue to remove in cosmetic upper blepharoplasty, it is important to remember a few critical mantras:
1.It is not the tissue that you remove, but what you leave behind that counts. As we are all asymmetric, measure not what you remove, but the residual eyelid tissue for symmetry.
2.Function trumps form every time. Blepharoplasty is not a procedure designed to achieve maximum tautness of the lids. This in fact is an aging change. It is critical to ensure that the patient can close their eyes completely on the OR table. It is not recommended that the patient have residual lagophthalmos. If the patient has lagophthalmos in the OR, he or she certainly may have lagophthalmos in the office the next day. This situation does not improve spontaneously. Additionally, it is important to leave the orbicularis. This is not a structure that becomes redundant with age. The orbicularis is important to ensure adequate eyelid closure, especially in a population at risk for dry eye.
3.Blepharoplasty is not a procedure designed to achieve maximum skeletonization or excavation of the eyelids. Fat is the lubrication of the eyelid. A cushion of fat is a sign of “youthfulness,” ensures adequate levator function, and decreases the possibility of postoperative scarring. Overexcision of fat can overly hollow the eyelids, leading to a “lost in time,” obviously surgical appearance.
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25
Fewer Hematomas in
Upper Blepharoplasty
Martin H. Devoto
The following text and photos illustrate how I perform upper blepharoplasty surgery. The settings are specific to the ERBE ICC 80 unit and may not be directly transferable to another brand of electrosurgery unit.
1.Carefully adjust monopolar cutting cautery settings for each step (“Effect 2” setting used throughout).
2.Use a ne needle tip, such as a Colorado® needle or equivalent clone.
3.Continuously ice the side you are not working on (Figure 25.1)
4.Skin incision cutting mode 7. Incise gently and smoothly to avoid excess heat (Figure 25.2).
5.Skin–muscle fl ap excision, coagulation mode 10 (Figure 25.3).
6.ROOF fat sculpting, coagulation mode 15 (Figure 25.4).
7. Hemostats are used to hold gauze that secures ice over each eye (Figure 25.5). This prevents ice from falling. Only the lower hemostat is moved to switch eyes.
8.Use of a tapaered needle prevents orbicularis bleeding with closure
(Figure 25.6).
9.Early postoperative photos (Figure 25.7).
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Chapter 25 Fewer Hematomas in Upper Blepharoplasty 77
Figure 25.1.
A
B |
Figure 25.2. |
78 M.H. Devoto
A 
B
Figure 25.3.
Chapter 25 Fewer Hematomas in Upper Blepharoplasty 79
A
B
Figure 25.4.
Figure 25.5.
80 M.H. Devoto
A 
B
Figure 25.6.
Figure 25.7.