Surgery: Upper Lid Blepharoplasty

Dr. Reddy: The lid crease is marked and measured using the calipers. In this male patient, the central lid crease height is eight millimeters, which is symmetric to the other side. Note that the lid crease, tapers nasally and temporally. There are two methods to determine the amount of excess skin to be removed. In the first method, calipers are used to ensure 20 millimeters of residual tissue. Because the lid crease is marked at eight,12 millimeters are now measured from the inferior brow fat pad to mark the superior border of the excision. The second method is called the pinch test. Here non toothed forceps are used to measure the amount of skin pinched that results in the lid, everting at the lashes or lagophthalmos. The remainder of the blepharoplasty incision is made by following the contour of the superior orbital rim and measuring equal amounts from the lateral canthus, for the lateral extent of the incision.
Lidocaine with epinephrine is injected into the subcutaneous avascular space. Injection proceeds from an area that’s already numb to an area that has not been anesthetized. I find one to two cc per lid sufficient, although some surgeons inject as many as three cc. It is also helpful to wait several minutes for the epinephrine to take effect prior to incision. The inferior lid crease incision is made first using the opposite hand to provide counter traction so that the blade glides smoothly. A four by four gauze is always kept nearby to block the incision and provide a clear view. Either the skin or the skin and orbicularis can be excised as one flap, here only the skin is excised using the Westcott scissors for sharp dissection. Periodically stretching the skin flap and examining the underside ensures that the right depth is maintained. Here we see that only skin and not orbicularis was removed. Hemostasis is achieved with monopolar or bipolar cautery because we’ve stayed in the avascular plane, there’s minimal bleeding. Stretching the wound superiorly, the septum is open near the orbital rim to allow prolapse of the fat. Local anesthetic is injected to the preaponeurotic fat pad prior to its being clamped with a hemostat and cut with a Wescott scissors.
A Bovie is used to cauterize the stump of the pedicle and forceps are used to grasp the pedicle prior to releasing the hemostat for additional hemostasis, before the fat retracts into the orbit. The skin can be closed in a variety of ways, I find hanging a skin hook at the edge of the incision convenient for aligning the wound. Here a single 6-0 nylon suture is past the center of the wound for closure. And the remainder of the wound is closed using the continuous 6-0 nylon. Sutures are passed one millimeter from the wound edge directly across the wound. Please observe how the needle holder is rotated such that it’s ready to pass for the next throw. When available, an assistant retracting the suture or following the surgeon is convenient to keep the suture out of the way.
Sutures are passed two to three millimeters away from the previous pass. Residents should practice evenly, spacing out the sutures and passing each suture in equal distance from the wound edge on each side of the wound. The beginning and end of the incisions are closed using a 2-1-1 tie. This video demonstrates the same surgery from the surgeons view. Here we see more clearly that the surgeon is always cutting towards her or himself beginning nasally and ending temporarily. The opposite hand provides counter traction so that the incision follows along the marked incision line. The monopolar cautery can also be used to complete the skin flap or the skin and orbicularis flap excision. The non-dominant hand pulls the skin flap superiorly towards the ceiling, while the dominant hand exposes the plane by providing counter traction to the floor. The skin flap is spread out, we see minimal orbicularis loss. The clamp cut cauterized technique is being shown here to remove the central preaponeurotic fat pad. Skin closure proceeds as previously shown, in this case with a single interrupted 6-0 nylon suture, followed by a continuous 6-0 nylon suture. Dissolvable sutures, proline, silk, and other materials can also be used. Passing the needle perpendicular to the wound, such that two thirds to three fourths of the needle is exposed on the far side, allows easy grasping for the next forehand pass.
Alternatively, a forceps can be used to stabilize the needle on the other side prior to regrasping it. This is shown here. After removing the corneal shield, antibiotic ointment is placed over the incision lines and cold compresses applied. The patient typically returns in one week for suture removal.