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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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Anatomical Overview (Fig. 5.19)
1. Semilunar fold of conjunctiva
2. Lower lacrimal point
3. Lacrimal caruncle
4. Medial angle of the eye
5. Superior lacrimal canal
6. Fornix of lacrimal sac
7. Medial palpebral ligament
8. Inferior lacrimal canal
9. Lacrimal sac
10. Angular artery
11. Adipose body of orbit
12. Nasolacrimal duct
13. Orbital septum
14. Frontal process of maxilla
15. Supraorbital margin
16. Zygomatic bone
17. Inferior palpebral branches
of infraorbital nerve
18. Infraorbital nerve
19. Orbicular muscle of the eye
20. Lower tarsal cartilage
21. Lower eyelid
22. Eyelid edges
23. Inferior conjunctival fornix
24. Lateral angle of the eye
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5 Eyelid Surgery – Blepharoplasty
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Instruments and Medication (Fig. 5.20)
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 suturematerial, 6/0 and 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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Fig. 5.20
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Duplicate Patient Instruction
During the patient’ s first visit to the clinic before admission, he or she
is already given detailed instructions on the objectives and risks of the
contemplated procedure. A note of this is made in the patient’s file.
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 the development of an ectropion (eyelid eversion), are set
down in writing at this time.
Ophthalmological Status
Prior to the eyelid operation, the anatomy and function of the orbital
region 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 both for near and distance vision.
䊏
Examination to detect strabismus (owing to the danger of double vision
postoperativ el y).
䊏
Eyelid position (tendency to ectropion).
䊏
Internal ocular pressure in patients over 40 years because of the danger
of an increase in pressure following the administration of corticoid
medication.
䊏
Anterior segment and fundus.
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Surgical Planning
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This proced ur e is carried out under local anesthesia or under general
anesthesia administered through a mask. Inexperienced surgeons, in
particular, should be careful to excise only a narrow musculocutaneous
strip to prevent the occurrence of an ectropion. This is the major difference between upper eyelid blepharoplasty and lower eyelid blepharoplasty; during the former procedure, a substantially more generous
approach can be taken to skin removal.
It should be borne in mind that lower eyelid blepharoplasty is one of
the most difficult cosmetic operations undertaken in the facial region.
This procedure demands a high degree of experience on the part of the
surgeon.
In this film, we are demonstrating the classic standardized procedure
for lower eyelid tightening. Laser removal of orbicular fatty tissue is an
alternative procedure.
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Preliminary Marking of Incision Lines (Fig. 5.21)
䊏
The incision is about 1–2 mm below the eyelash line. Start in the
medial angle of the eye and continue laterally to form a natural crow‘s
foot pattern. Care should be taken not to exceed the lateral margin of
the eyebrow, which constitutes the lateral margin of the incision as well.
䊏
Like the skin of the upper eyelid, the skin of the lower eyelid is substantially thinner than the adjacent facial skin. Thus the boundaries of the
planned undermining are readily determined. These boundaries are
now marked (see film).
Local Anesthesia (Fig. 5.22)
䊏
About 5 ml of Scandicaine with epinephrine (mepivacaine hydrochloride) is infiltrated from a lateral to a medial direction on each side.
During infiltration the tip of the needle is held constantly in an upward
position to prevent injury to the eyeball. This procedure distributes the
anesthetic evenly in the area which has been marked and is to be
undermined. The boundaries of the planned dissection are thus already
clearly visible.
Disinfection
䊏
The entire face is disinfected with a 1% cetrimide solution. Ophthalmological ointment is inserted in the conjunctival sac to protect the conjunctivae.
䊏
The surgical area is now covered with sterile drapes; perforated drapes
are the optimal choice here.
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Fig. 5.21
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Fig. 5.22
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Type of Incision (Fig. 5.23)
䊏
As a rule, start with the right eye.
䊏
redraw the incision lines.
One should be aware that the anatomical unity of the lateral eyelid
region must be kept intact to avoid creating unattractive eye shapes.
䊏
Anumber15bladeisinsertedatthelateralendofthemarking.The
initial incision is made from here to the outermost corner of the eye;
the length of this incision should be 5 mm at the maximum. The assisting surgeon now gently pulls the skin of the lower eyelid in a downward
direction while the surgeon tightens the skin cranially. The incision is
now continued in a medial direction parallel to the anterior palpebral
limbus with the number 15 blade; the distance between the incision and
the eyelash line is always 1–2 mm.
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Fig. 5.23
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䊏
The small eyelid scissors are now inserted under the subciliary eyelid
skin. (Fig. 5.24)
䊏
The incision can now be continued effortlessly parallel to the edge of
the lower eyelid. It ends about 1 mm in front of the lacrimal point.
When making the incision, the surgeon must be very careful not to
come too close to the medial corner of the eyelid to prevent postoperative constriction of the palpebral fissure.
During this procedure, the eyelid skin should always be under tension.
(Fig. 5.25)
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