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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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Tips and Tricks: Rhytidectomy
https://t.me/med1917
– Sutures in the SMAS are to be kept very flat and parallel to the
course of the nerves in order not to damage the nerves.
– If the repositioned fat seems too prominent, the lower surface of
the lipocutaneous flap can be sculpted.
– One of the most important steps during rhytidectomy is that, fol-
lowing extensive dissection of the lipocutaneous flap, rotation of
the lipocutaneous flap is in the correct and thereby natural direction along the envisaged line from the earflap in a craniodorsal
direction, and not in a lateral direction. Only in doing so can a
natural result be achieved that is free of creases.
– The temporal hairline can only be rotated slightly in a craniodor-
sal direction, as otherwise the stigma an incorrectly carried-out
facelift will be seen in the long-term.
– In the retroauricular region, step formation along the hairline is
to be stringently avoided.
– In patients with a senile hairline or if extensive cutaneous resec-
tion of more than 3 cm in the preauricular region and 4–5 cm in
the postauricular region is expected, a cut should be made in the
pretrichial region corresponding to a hairline cut. Postauricular
step formation as well as extreme repositioning of the temporal
hairline will be avoided by doing so. The hairline cut is also often
necessary in repeat procedures.
– If the chosen temporal dissection plane is too superficial, it can
lead to destruction of the hair roots and thereby permanent hair
loss. Therefore, the dissection should take place at the deep fascia
with ligature of the anterior superficial temporal artery and vein.
– For correction of the nasolabial and labiomental region, loosening
of the inferior distal zygomatic ligament as well as of the mandibular ligament is important. (Note: facial nerve!) The novice should
take care, feel the area, observe the anatomy, and prepare carefully . Then a facelift is a safe operation.
– Any tension on the sutures should be avoided to prevent hyper-
trophic scars.
– On the lower surface of the prepared cutaneous flap, at least 3 mm
of fatty tissue should be left. Only in doing so can the lines and
wrinkles be counteracted, which will become visible once the
swelling has subsided. In addition, perfusion of the flap will be
improved.
4 Rhytidectomy (Cervicobuccal Plasty)
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4 Rhytidectomy (Cervicobuccal Plasty)
https://t.me/med1917
Tips and Tricks: M-Lifting
The M-Lift (known as the Mini Lift or Mang Lift) is simple, low-risk
tightening of the buccal region. The SMAS is rotated en bloc with
the cutaneous flap by 70° in a cranial direction with no dissection.
Advantages:
– Noriskofinjuringthenerves.
– No disturbances to perfusion, as only minimal undermining is
carried out.
– Short operation time under local anesthesia.
– Good long-term result in the nasolabial and buccal regions. (Mar-
ionette lines from the age of 40).
– Due to anatomical studies, there is evidence that with minimal
cutaneous dissection and protection of the ligaments, tightening
of the SMAS en bloc with the skin is possible.
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5 Eyelid Surgery – Blepharoplasty
https://t.me/med1917
UpperEyelidSurgery–Blepharoplasty
䊏
Introduction 167
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Anatomical Overview 169
䊏
Instruments and Medication 170
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Duplicate Patient Instruction 172
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Ophthalmological Status 172
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Photographic Documentation 173
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Surgical Planning 173
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Preliminary Marking of Incision Lines 174
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Local Anesthesia 174
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Disinfection 174
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Type of Incision 176
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Skin Resection Under Tension 178
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Medial and Intermediate Lipectomy 180
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Removal of a Strip of Connective Tissue and Muscle 184
䊏
Cutaneous Sutures 186
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Postoperative T reatment and Precautions 190
䊏
Results 191
5 Eyelid Surgery – Blepharoplasty
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5 Eyelid Surgery – Blepharoplasty
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LowerEyelidSurgery–Blepharoplasty
䊏
Introduction 192
䊏
Anatomical Overview 193
䊏
Instruments and Medication 194
䊏
Duplicate Patient Instruction 196
䊏
Ophthalmological Status 196
䊏
Surgical Planning 197
䊏
Preliminary Marking of Incision Lines 198
䊏
Local Anesthesia 198
䊏
Disinfection 198
䊏
Type of Incision 200
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Excision of the Musculocutaneous Flap 204
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Medial, Intermediate, and Lateral Lipectom y 208
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Removal of a Muscular Strip From the Orbicular Muscle of the Eye 212
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Skin Resection 214
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Sutures and Dressing 216
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Postoperative T reatment and Precautions 222
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Results 223
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Tips and Tricks 224
The symbol indicates parts of the procedures shown in the video
166
Upper Eyelid Surgery – Blepharoplasty
https://t.me/med1917
Introduction
The origins of corrective eyelid surgery go back to the tenth century .
The word “blepharoplasty” was first mentioned in Europe by a surgeon
named von Graefe in 1818. After this, a large number of surgeons began
to develop new techniques for aesthetic lid surgery. Up to 1940, these
procedures involved only the excision of skin. Most articles published
after this date, however, mention the resectioning of fat around the eyes
as an essential constituent of corrective lid surgery.
In addition to otoplasty , blepharoplasty is the most highly refined – and
also the most frequently requested – procedure in the area of aesthetic
facial surgery . Although “baggy eyelids” can occur at any age, this
condition is usually the result of aging. Corrective eyelid surgery is
performedinpatientsaged35yearsandolder.Theresultsachievedby
blepharoplasty over a 10-year period compare favorably with the positive results associated with a facelift.
During upper eyelid blepharoplasty, the excess skin and fatty tissue has
to be removed in order to achieve good aesthetic results and to prevent
premature recurrences. The technique used for skin resectioning
should not put the wound edges under tension, since this might impair
normal lid-closing. At the inner ocular angle, particular care must be
taken to achieve precise fat resectioning.
5 Eyelid Surgery – Blepharoplasty
In the following, we have presented a standardized blepharoplasty
procedure step by step . Surgeons who have recently started performing
eyelid surgery will find this approach especially useful.
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Anatomical Overview (Fig. 5.1)
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5 Eyelid Surgery – Blepharoplasty
1. Eyebrow
2. Supraorbital incisure
3. Supraorbital nerve (medial branches)
4. Supraorbital margin of frontal bone
5. Supraorbital nerve (lateral branches)
6. Adipose body of orbit
7. Bulbar conjunctiva
8. Tarsal cartilages
9. Supratrochlear nerve
10. Upper lacrimal duct
11. Fornix of lacrimal sac
12. Medial palpebral ligament
13. Medial angle of eye
14. Upper lacrimal point
15. Upper eyelid
16. Lateral angle of eye
17. Lacrimal nerve (palpebral branches)
18. Orbicular muscle of the eye
(palpebral part)
19. Palpebral lacrimal gland
20. Orbital lacrimal gland
21. Levator muscle of upper eyelid
22. Tarsal membrane
23. Supraorbital nerve (lateral branches)
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5 Eyelid Surgery – Blepharoplasty
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Instruments and Medication (Fig. 5.2)
1 Scalpel handle
2 Delicate eyelid scissors
3 Tweezers Adson-Brown
4 Delicate surgical tweezers
5 Delicate long two-pronged wound retractor
6 Delicate long two-pronged wound retractor
7 Delicate long single-pronged wound retractor
8 Needle holder small
9 Dissecting and ligature forceps (mosquito forceps)
)
Delicate electrocoagulation forceps
)
Marking pen
)
Disposable hypodermic syringe (10 ml)
with a fine needle (20 gauge)
)
Ethilon su tur ematerial, 6/0 or 7/0,
with a small needle
)
White Steri-Strip™ tape
)
10 ml 0.5% Scandicainewith epinephrine
(mepivacaine hydrochloride) 1 :200,000
)
Small sterile compresses
)
NaCl 0.9%
)
Skin cleaning kit
)
Cetrimide solution (1%)
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5 Eyelid Surgery – Blepharoplasty
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Fig. 5.2
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5 Eyelid Surgery – Blepharoplasty
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Duplicate Patient Instruction
During the patient’ s first visit to the hospital before admission, he or
she is already given detailed instructions on the objectives and risks of
thecontemplatedprocedure.Anoteofthisismadeinthepatient’sfile.
One day before the actual procedure, the patient is again given comprehensive information on two separate occasions: once by the surgeon
and once by the surgical resident. All potential risks of the procedure,
including injury to the eyeball or the lacrimal gland, are set down in
writing.
An important point to make at this time is that eyelid surgery, called
“blepharoplasty ,” will have no effect on skin laxity in the latero-cranial
region of the upper lid. An endoscopic brow lift is the method of choice
here.
Ophthalmological Status
Prior to the eyelid operation, the anatomy and function of the eye
sockets have to be checked by an ophthalmologist.
The following examinations are recommended:
䊏
Visio n test to determine corrected and uncorrected visual acuity in the
rightandlefteye.Inpatientsover40years,visualacuityshouldbe
checked for both near and distance vision.
䊏
Examination to detect strabismus
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Eyelid position
䊏
Internal ocular pressure
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