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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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Photographic Documentation
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Overview image: Whole face
Borders: Cranial: forehead hairline
Caudal: lower edge of the chin
Right/left: ear attachmen t
Detailed images:
Borders: Cranial: middle of the forehead
Caudal: middle of the nose
Right/left: ear attachmen t
– From the front
– ¾ Lateral (lateral canthus as the border)
– 90° Lateral (tip of the nose to the edge of the helix)
Functional images:
– Eyes fully closed
– Eyes closed tightly
– Looking upwards
– Looking downwards
Surgical Planning
5 Eyelid Surgery – Blepharoplasty
This procedure is always carried out under local anesthesia. The patient
is given 25–50 mg of Tranxilium (clorazepate dipotassium) by mouth to
achieve mild sedation.
The shape, size, and position of the eyes must be determined precisely,
preopera tively. Frequentl y, there is a difference between the two sides.
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Preliminary Marking of Incision Lines (Fig. 5.3)
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䊏
The incision lines are always marked while the patient is still conscious.
This is because the individual anatomy and physiology can only be
reproduced with the patient in a waking state.
䊏
Begin by marking the lower palpebral fold with dots. Then mark the
upper resection boundary. This is clearly demarcated by the sharp
boundary between the thicker facial skin cranially and the thinner skin
of the upper lid.
5 Eyelid Surgery – Blepharoplasty
䊏
To obtain a better overview, ask the patient to open and close his or her
eyes several times.
䊏
The resection boundaries follow the anatomi cal lines of the upper eyelid.
In most cases, it can be observed that the right and left eyelids are
asymmetrical. Care should be taken to reproduce this asymmetry during the marking procedure so that it can be corrected later by adjusting
the size of the resected area.
The incision in the upper eyelid region should have a curve slightly upward at the lateral edge. This is to tighten the skin and prevent drooping.
Local Anesthesia (Fig. 5.4)
䊏
Starting laterally, slowly infiltrate the surgical area with Scandicaine
with epinephrine (mepivacaine hydrochloride). Use a 20-gauge needle;
keep the tip pointed upward to prevent injury to the eyeball. The thin
skin of the eyelid can be easily detached in this manner. The solution
diffuses toward the medial corner of the eyelid. A total of two to three
injections and 4 ml of Scandicaine will usually be sufficient.
䊏
174
Disinfection
Disinfect the face with a 1% cetrimide solution. Insert oph thalmological
ointment into the conjunctival sac to protect the conjunctivae.
The surgical area is now covered with sterile drapes.
Fig. 5.3
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5 Eyelid Surgery – Blepharoplasty
Fig. 5.4
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5 Eyelid Surgery – Blepharoplasty
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Type of Incision (Fig. 5.5)
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As a rule, start with the right eye
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The novice should check the incision boundaries and reapply the incision markings.
䊏
Care should be taken that the incision runs roughly parallel to the arch
of the eyebrow, which serves as a guideline for the eyelid arch and, thus,
the new palpebral fold.
The local anesthetic causes the skin on the upper eyelid to swell and
tighten. This is of great assistance to the surgeon making the incision.
䊏
The assisting surgeon now pulls the upper eyelid downward with his or
her left index finger while the surgeon pulls the skin upward until it is
taut with two fingers of his or her left hand. The lower incision boundary is now under tension and an incision can easily be made from the
medial to lateral orbital margin with a number 15 blade. Now, the
upper incision boundary is put under tension, and an incision is made
– again from medial to lateral – along the incision marking.
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Fig. 5.5
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5 Eyelid Surgery – Blepharoplasty
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5 Eyelid Surgery – Blepharoplasty
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Skin Resection Under T ension (Fig. 5.6, 5.7)
䊏
The assisting surgeon now gently pulls the two cut edges apart, taking
care not to crush the eyeball.
䊏
Using delicate surgical tweezers, the surgeon pulls the lateral end of the
stripofskinupwardata90°angleanddissectsit–firstwiththenumber 15 blade and then with the delicate eyelid scissors – moving medially. Since the eyelid skin has already been detached by the infiltration
of the local anesthetic, it is impossible to miss the correct tissue layer
located directly above the muscle.
䊏
Hemostasis is now performed with an electrocoagulation forceps and a
small, flattened moist compress.
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Fig. 5.6
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5 Eyelid Surgery – Blepharoplasty
Fig. 5.7
179
Medial and Intermediate Lipectomy (Fig. 5.8–5.12)
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Lipectom y is never performed in the lateral angle of the upper eyelid
because of the danger of injuring the lacrimal gland at this location.
䊏
The surgeon initially exerts light pressure on the eyeball with his or her
index finger to determine the size and exact location of the fat deposits
under the orbital septum.
䊏
Frequently, skin resection is sufficient here.
5 Eyelid Surgery – Blepharoplasty
䊏
Using the above-mentioned delicate hook, the assisting surgeon pulls
the skin taut in the surgical area. The surgeon now splits the orbital
septum medially with the fine eyelid scissors and then bluntl y dissects
the excess fat; this can be squeezed out by applying light pressure. The
tarsal muscle is visible but remains intact.
䊏
Hemostasis is again performed. (Fig. 5.9)
180
Fig. 5.8
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5 Eyelid Surgery – Blepharoplasty
Fig. 5.9
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5 Eyelid Surgery – Blepharoplasty
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䊏
Using the delicate surgical tweezers, the surgeon extracts the fat pad
with the delicate surgical tweezers and pulls it upward and out. The
base of the fat pad is grasped with a mosquito hook. (Fig. 5.10)
䊏
Withthebentmosquitohookleftinplace,theremainderoftheexcess
fat is resected with the delicate eyelid scissors. (Fig. 5.11)
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