Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 850 - файл
.pdf
10.5 Operations 139
https://t.me/medicina_free
a b
10-15 mm
2mm
c
d
f
e
g
Fig.10.13 Fox’s frontalis suspension. a Mark two lid entry points 2 mm above the lashes, two
further points at the upper edge of the eyebrow, and a horizontal skin incision approximately 4 mm
long 10–15 mm above the centre of the eyebrow. b Make horizontal stab incisions using a no.
11 scalpel in the marked points and make the forehead incision. Slightly undermine the forehead
incision bluntly to create a small pocket. c Insert the Wright’s fascia needle into the lateral eyelid
incision down to the tarsal plate and advance it to exit the second skin incision. Thread the silicone
sling material through the eye of the needle and withdraw the needle pulling the sling through.
d Insert the empty Wright’s needle vertically into the lateral brow incision and advance the needle
to exit the lateral lid incision. Thread the lateral end of the silicone into the needle and withdraw
the needle and tubing from the lateral brow incision. Repeat steps for the medial brow incision.
e Enter the medial end of the forehead incision with the empty Wright’s needle, to emerge from the
medial brow incision. Thread the silicon into the needle and pull it through to the forehead incision.
Repeat on the lateral forehead. f Pass both ends of the silicone sling through a 4–5 mm length of
silicone sleeve (Watske sleeve). Adjust the tension in the sling. g Close the forehead incision with
two vertical mattress 6/0 sutures
140 10 Ptosis
https://t.me/medicina_free
dangerous. The needles bend easily as you advance them through the lid so you
receive no tactile feedback and cannot control where the tip is. Being so sharp inadvertent eye penetration is a real risk. Use instead a Wright’s fascia needle which is
non-malleable and semi sharp. The finger loop allows good needle tip control. Join
the ends of the sling together using a silicone sleeve which allows easy adjustment.
10.5.6.2 Case Selection
Severe ptosis with poor levator function (≤4 mm) interfering with vision (lid
margin encroaching on the visual axis).
10.5.6.3 Steps (Fig. 10.13)
1. Mark two skin entry points 2 mm above the lashes and aligned to be vertically
above the medial and lateral corneal limbus in primary gaze (i.e., about 11–
12 mm apart).
2. Mark two further points at the upper edge of the eyebrow. The lateral point
must be vertically lateral to the lateral canthus and the medial point vertically
medial to the medial canthus.
3. Mark a final horizontal skin incision approximately 4 mm long 10–15 mm
above the centre of the eyebrow (in a frown line if one is present). Position it
roughly above the pupil (Fig. 10.13a).
4. Make horizontal stab incisions using a no. 11 scalpel in the marked eyelid
points (protecting the eye with a metal shield) and in the two brow points
(down to bone). Do not extend them.
5. Make the forehead incision by stabbing down to bone at one end of the marked
line, then holding the scalpel still against the bone, pull the forehead skin onto
the blade to complete the 4 mm incision. This is more controlled than trying
to move the scalpel freehand. Slightly undermine the forehead incision bluntly
by inserting closed scissors or an artery clip and opening it to create a small
pocket (Fig. 10.13b).
6. Insert the Wright’s fascia needle into the lateral eyelid incision down to the
tarsal plate and advance it on the tarsal surface to just past the medial incision.
It is usual to feel considerable resistance to the needle’s passage as it is semisharp by design.
7. Lift the tip to feel its location and then push the needle out through the medial
skin incision.
8. Thread the silicone sling material through the eye of the needle and withdraw
the needle pulling the sling through (Fig. 10.13c).
9. Insert the empty Wright’s needle vertically into the lateral brow incision down
to bone. Rotate it horizontally and advance slightly. Now lift the tip to confirm
that it has not engaged the periosteum.
10. Advance the needle to just past the lateral lid incision. Ensure that the eye
is protected by a metal shield held firmly by an assistant in the upper fornix
and deep to the orbital rim. Monitor the tip’s progress throughout its passage
by intermittently lifting it and feeling for it by rolling the skin and orbicularis
over it with a fingertip. The needle’s passage should be as deep as possible
10.5 Operations 141
https://t.me/medicina_free
within the lid while not breaching the conjunctival surface. It is usual to feel
resistance as noted in 6 above.
11. Lift the needle tip and advance it out through the lid skin incision taking care
to avoid damaging the silicone tubing.
Note: Silicone tubes are only strong until they are nicked by a sharp instrument
such as the needle tip or toothed forceps after which they tear and break easily.
12. Thread the lateral end of the silicone into the needle and withdraw the needle
and tubing from the lateral brow incision (Fig. 10.13d).
13. Repeat steps 9–12 for the medial brow incision.
14. Enter the medial end of the forehead incision with the empty Wright’s needle,
weaving the tip in and out as you advance to engage the frontalis. Make the
tip emerge from the medial brow incision. Again, take care to avoid damaging
the silicone sling material with the point of the needle (Fig. 10.13e).
15. Thread the silicone into the needle and pull it through to the forehead incision.
16. Repeat steps 15 and 16 from the lateral end of the forehead incision laterally.
17. Now that both ends of the silicone sling are in the forehead incision, pass
them through a 4–5 mm length of silicone sleeve (Watske sleeve). Do this by
wetting the sleeve and pushing it onto closed fine artery forceps.
18. Force the forceps open to stretch the sleeve widely enough to allow you to
feed one end of the sling through it.
19. Instruct an assistant to pull both ends of the threaded sling downwards while
you thread the second end of the silicone sling through the sleeve from the
opposite direction.
20. Push the sleeve off the artery clip while keeping it slightly open to avoid
pulling on the sling.
21. Adjust the tension in the sling by pulling on both ends until the lid is set at
the correct height (Fig. 10.13f) Remember that when you push the sleeve into
the forehead incision to bury it the sling will slacken slightly.
Note: The correct height depends on the cause of the ptosis. A young child with
congenital ptosis and a good Bell’s phenomenon will tolerate a degree of nocturnal
lagophthalmos that an elderly patient will not. If progressive external ophthalmoplegia is the diagnosis, the lids should be left closed at the end of surgery to avoid
corneal exposure.
22. Pre-place two vertical mattress 6/0 sutures across the forehead incision and
trim the silicone sling ends to about 10 mm. Tuck the sling ends into the
subcutaneous pocket and keep them buried by tying the preplaced sutures
tightly to close the wound.
Note: The mattress sutures prevent the sling ends from poking out through the wound
and prevent the incision from forming a depressed scar during healing.
142 10 Ptosis
https://t.me/medicina_free
The remaining incisions close spontaneously without sutures.
23. Place a lower lid margin traction suture and close the eye by taping it upwards
to the brow. Apply antibiotic ointment and an overnight pressure dressing.
24. Review the patient the following day to check the lid height, eye closure and
the cornea for exposure. Remove the traction suture unless there is significant
corneal exposure due to an overcorrection. In this case use the suture to protect
the eye until the overcorrection can be addressed.
10.5.6.4 Notes
•
Under or over correction can be addressed by opening the brow incision and
tightening or loosening the sling within the sleeve.
•
Alternative synthetic sling materials can be used but have no advantages. Do
not use Polyester mesh (Mersilene
incites marked fibrosis which makes it very difficult to remove should it become
infected.
•
Silicone slings are very easy to remove from within the capsule which forms
around them.
•
Consider giving a per-operative dose of prophylactic antibiotic to reduce the
chance of sling infection.
®
Mesh) as this is prone to exposure and
10.6 General Observations
10.6.1 Lower Lid Traction Suture Fig. 10.14 (See Chap. 5)
At the end of a ptosis correction consider placing a lower lid margin traction
suture to pull the lower lid upwards to help keep the operated eye closed under
a pressure dressing. This is better than pulling the upper lid down since the point
of ptosis surgery is to lift the upper lid. A traction suture is not required after a
Müller’s resection as no pressure dressing is necessary. It is optional after ptosis
surgery with normal levator function (white line advancement/aponeurosis reinsertion) and the decision depends on how likely a patient is to comply with the
instruction to keep the operated eye closed under the dressing. I strongly recommend a traction suture for ptosis correction in the presence of reduced levator
function (levator resection and frontalis suspension) to avoid corneal abrasion by
the pressure dressing.
10.6 General Observations 143
https://t.me/medicina_free
Fig.10.14 Lower lid traction suture. Insert a 4/0 monofilament tarsal traction suture to pull the
lower lid closed following ptosis correction to protect the eye under the dressing
10.6.2 ‘On Table’ Lid Height
Judging the desired lid height at operation can be difficult. It is influenced by
surgical swelling and the local anaesthetic induced paralysis of the orbicularis and
Müller’s muscles. The main clue is the pre-operative levator function.
As a rule of thumb under local anaesthetic set the lid 2 mm higher than desired
to compensate for orbicularis paralysis. Under a general anaesthetic assume that
lids with good levator function (12–17 mm) will rise from their ‘on table height’
when the patient is awake, those with moderate function (5–11 mm) will stay put,
and lids with poor levator function (0–4 mm) will drop. As mentioned earlier,
with white line advancement the ultimate lid height is usually correct (provided
the levator function is normal).
144 10 Ptosis
https://t.me/medicina_free
10.6.3 Post-operative Adjustment—Early Suture Removal
I recommend that all ptosis surgery patients (except those with Müller’s resection)
are reviewed on the first post-operative day for:
1. Pad removal
2. Lower lid traction suture removal (if present)
3. A check for possible overcorrection or eyelid contour deformity (peak). It is a
simple matter to remove the responsible suture(s) and correct the problem. Do
this by pulling on the knot’s suture ends (they were left long specifically for
this eventuality) to lift the knot and cut one side of the suture loop below the
lifted knot with pointed scissors. Pull the suture out. If the lid position does not
improve immediately stretch the insertion by grasping the upper lid lashes and
pulling firmly downwards while asking the patient to try and look up. If the
issue is still unresolved consider removing a further suture.
Should you notice an early under-correction reassure the patient that this is
likely to improve once the postoperative swelling resolves (and keep your fingers crossed). It often does. Wait two months before reassessing the patient for
possible ptosis revision surgery.
10.6.4 Hering’s See-Saw (Fig. 10.15)
The levator muscles follow Hering’s law of equal innervation. Consequently, the
additional innervation attempting to open the ptotic lid causes upper lid retraction
of the contralateral eye. Bear in mind that the latter will resolve after successful
ptosis correction.
Fig.10.15 Hering’s see-saw. Lifting a ptotic lid reduces the drive to the contralateral levator
which goes down as a consequence
References 145
https://t.me/medicina_free
10.7 Take Home Message
•
Involutional ptosis is the commonest acquired ptosis.
•
‘White Line’ aponeurotic repair is the simplest and best operation for correcting
involutional ptosis.
References
1. Harrad RA, Shuttleworth GN (2000) Superior rectus-levator synkinesis: a previously unrecog-
nized cause of failure of ptosis surgery. Ophthalmology 107(11):975–1981, ISSN 0161-6420,
https://doi.org/10.1016/S0161-6420(00)00170-6
2. Harvesting Autogenous Fascia Lata. https://youtu.be/RYDJbBvxK7Q
Dermatochalasis and Blepharoplasty
https://t.me/medicina_free
11
11.1 Overview
•
Skin and muscle blepharoplasty.
Patients are sometimes erroneously referred for ptosis surgery when in fact their
lid margin has not dropped, and an overhanging skin fold has masked the true lid
margin. This is known as ‘dermatochalasis’ (baggy lids). Some people erroneously
call it ‘blepharochalasis’ which is a syndrome affecting younger adults and characterised by recurrent, idiopathic, periocular swelling which eventually gives rise
to eyelid atrophy (cigarette paper thin skin, medial orbital fat pad atrophy, canthal
tendon and levator aponeurosis dehiscence). Dermatochalasis, on the other hand is
usually caused by aging but may also be familial.
11.2 Examination
Observe the position of the upper lid skin fold in relation to the lashes and lid
margin. If the skin fold is resting on the upper lid lashes it may cause trichiasis
(in turning of the lashes). If it overhangs the lid margin it causes a reduction in
the visual field. In both these situations clinically, significant dermatochalasis is
present and justifies surgical correction by excision of the superfluous skin fold.
11.3 Considerations
Blepharoplasty means the removal of superfluous tissue from the eyelid. In this
chapter only upper lid skin fold reduction is discussed. The secret of successful
skin and muscle blepharoplasty is accurate pre-operative marking to ensure that
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_11
147
148 11 Dermatochalasis and Blepharoplasty
https://t.me/medicina_free
sufficient skin remains for full eyelid closure during blinking and sleep, and that
the scar is hidden in the skin crease.
Prominent or prolapsed fat pads result from weakness of the orbital septum.
They can cause significant aesthetic concerns. Unfortunately, removing them only
adds to age related orbital volume deflation and as such is not an ideal solution.
An alternative is to shrink and tighten the overlying orbital septum using bipolar
diathermy. Perform this with the bipolar forceps tips apart. Place both tips on the
septum. Turn on the power and gradually bring the tips closer together until the
septum shrinks and tightens. This is simple to do and safe, but unfortunately its
benefits are short lived.
Prolapsed orbital fat can be removed by making perforations in the orbital septum and encouraging the fat to prolapse through these to be clamped, diathermied,
and excised. This can, on very rare occasions, cause blindness so should not be
undertaken lightly.
As aesthetic surgery is not the subject of this book, fat removal will not be
discussed further.
11.4 Upper Lid Skin and Muscle Blepharoplasty (Fig. 11.1)
11.4.1 Principle
Pinch and mark the excess skin fold with the eye closed. Then excise it.
11.4.2 Case Selection
Symptomatic overhanging skin folds causing a reduction in visual field or
trichiasis.
11.5 Steps
1. Pull the upper lid skin upwards to lift the overhanging skin fold. Instruct the
patient to keep both eyes gently closed while you mark the desired postoperative lid skin crease position (Fig. 11.1b). Do this before injecting local
anaesthetic using a fine tipped marker pen. In Caucasians the crease is usually
7–8 mm above the upper lid margin.
2. Gently pull and lift the skin fold away from the eye, with a pair of Moorfields
forceps, to take up all the slack. Ensure that the eyelids remain closed. Position
a second pair of forceps across the lifted fold with the lower tip on the premarked skin crease. Mark the position of the upper tip on the skin. This marks
the maximum extent of the redundant fold (Fig. 11.1c).
11.5 Steps 149
https://t.me/medicina_free
a b
c
d
X
y
X + y ≥ 20 mm
e f
g h
Fig.11.1 Blepharoplasty. a Lateral overhanging skin fold. b Mark the desired postoperative lid
skin crease position. c Mark the maximum extent of the skin fold with the eyes closed. d Complete
the skin marking by drawing an ellipse within the upper skin markings and based on the skin crease
marking. Leave at least 20 mm of skin. e Incise the skin and orbicularis. f Excisetheentireskin
and orbicularis ellipse. g Insert an orbicularis suture at the lateral angle to align the wound. h Close
the skin, taking bites of the underlying aponeurosis to reform the skin crease
Соседние файлы в папке @xirurgi_2025