Upper eyelid plasty surgery (blepharoplasty)

Most often, upper eyelid plastic surgery can be performed on an outpatient basis, under local anesthesia with minimal preoperative and intraoperative drug support.

Planning cuts

The operation begins with marking the eyelids. To reduce the washability of the markings and to keep the applied lines thin, the eyelids must be completely cleaned of natural sebum. All makeup is removed the evening before the operation. Before marking, the eyelids are degreased with alcohol or acetone.

First, the natural sulcus of the eyelid is marked, which is almost always visible with bright light and sufficient magnification. The eyelid crease is at the superior margin of the underlying superior tarsal plate. If the natural sulcus of the eyelid is 8 mm or more above the lid margin, it is always best to use this natural landmark. The lid creases on both sides are usually level. If there is a 1 mm discrepancy between the lids, the eyelid crease marking is adjusted so that it is 8 to 10 mm above the lid margin. The medial end of the incision is placed close enough to the nose to capture all of the thin wrinkled skin, but never beyond the orbital depression of the nose. Bringing the incision too far onto the nose causes almost irreversible adhesion. Laterally, the eyelid crease line follows the natural crease of the sulcus between the orbital rim and the eyelid. At this point, the line is drawn laterally or slightly superiorly.

With the patient in the supine position, the actual quantitative excess of upper eyelid skin can only be determined after physically moving the brow downwards. In the supine position, the mobility and weight of the scalp and forehead pull the brow above the orbital rim. This is not the correct, natural position of the brow. The excess upper eyelid skin is temporarily reduced. For proper planning of upper eyelid surgery, the brow must be gently moved downwards, toward the orbital rim, to the position noted when the patient was sitting or standing. The upper eyelid skin is then gently grasped with a clamp. One of the jaws of the clamp is placed on the previously marked eyelid crease. The other jaw holds enough skin to smooth the surface of the eyelid, but does not move its edge upwards. In other words, if the skin is removed between the jaws of the clamp, eyelid retraction and lagophthalmos will not occur. This marking technique is applied in several places along the eyelid. When these points are connected, a line is formed parallel to the eyelid crease line. Medially and laterally, the lines are connected at an angle of 30 degrees. The medial excess skin should always be slightly understated in patients with a large amount of medial fat. The defect created by excising a large amount of this fat may cause subcutaneous dead space. If slightly less skin is excised medially, the sutured medial end of the eyelid will turn inward rather than hang over the area where the fat was removed. If there is overhang of the eyelid skin medially, a dense scar will almost certainly result.

The extent of the planned lateral skin excision is determined by the size of the lateral hood. If the hood is absent in younger patients, the lateral edge of the excision is located immediately beyond the lateral edge of the palpebral fissure. If the lateral hood is excessive, the incision may extend 1 cm or more beyond the lateral edge of the orbit. The direction of the resulting scar should always be between the lateral edges of the palpebral fissure and the eyebrow. An incision of this direction may be hidden in women with eye shadow. The area outlined with a surgical marker should be slightly wavy.

Anesthesia

After marking is complete, infiltration anesthesia can be administered. 2% xylocaine with epinephrine 1:100,000, buffered with 8.4% sodium bicarbonate, is recommended. The ratio is 10 ml xylocaine to 1 ml bicarbonate. Approximately 1 ml is infiltrated subcutaneously into the upper eyelid with a 25-27 G needle. For maximum effect of epinephrine, at least 10 minutes should elapse before making the incision.

Initial incision and excision of muscle

The initial incision is made by tugging the eyelid skin so that the line drawn with the marker is straightened. The eyelid skin is excised within the marking with a scalpel blade. A #67 Beaver blade is preferred because it is sharp and small. A superior incision is made and the skin is removed with a clamp and Stevens curved scissors. At this point, the underlying orbicularis oculi muscle is dissected. Some muscle is removed in almost all cases. Typically, in older patients with thin skin, less muscle needs to be removed, whereas in younger, thick-skinned patients, more muscle needs to be removed to achieve a good aesthetic result.

The muscle is excised along the direction of the skin excision. The width of the excised strip of skin is determined individually. The excision is performed in depth up to the orbital septum.

Fat removal

If there is excess fat, the central portion should probably be removed before the medial portion is removed. The central space can be opened by incising the orbital septum at one point or throughout its length. A small false protrusion of fat can be removed with a single clamp application. A larger protrusion may require dividing the central space into two or more sections. The medial fat is brought into the wound and excised. Although there is usually no lateral fat space in the upper eyelid, fat may be present lateral to the lacrimal gland, creating a lateral space. A small amount of local anesthetic is injected into the fat before clamping. Local anesthetic injected subcutaneously does not usually penetrate the orbital septum. Unless additional anesthesia is given, the patient will feel pain when the fat is clamped. A portion of the fat is grasped with a small, fine hemostatic clamp. It is then excised with electrocautery of the base. It is important not to pull the fat being removed too vigorously out of the orbit and into the wound. Only the fat that easily passes into the wound should be excised. This is especially important in the area of the medial edge of the central space. If too much fat is removed here, it can lead to retraction of the eyelid and overhanging of the orbital rim. The result will be an aged appearance, which should be avoided.

The medial fat pad may be difficult to define. It is important to evaluate its extent preoperatively so that it can be removed intraoperatively. At times, depending on the patient's position, the medial fat will recess and not contribute to the appearance. If this tissue is identified preoperatively as causing problems, it should be identified and removed. Underestimation of medial fat excess is the most common aesthetic error in upper eyelid surgery. Medial fat is pale yellow in color and denser than the central fat. The location of medial fat is subject to greater variation than that of the upper and lower eyelid spaces. The central and medial spaces are separated by the superior oblique muscle of the eye. Unlike the inferior oblique muscle, this muscle is rarely seen in the upper eyelid. However, its presence should always be considered before applying a hemostatic clamp to the fat pad.

If the lateral eyelid fat pad is found to be an aesthetic problem during the preoperative examination, it can also be removed. To do this, the upper outer edge of the incision is pulled back. The lateral orbital fat pad is isolated by blunt dissection under the orbicularis muscle. The fat is removed with scissors. It contains several small vessels, the bleeding from which must be carefully stopped.

The medial fat can also be removed through the transconjunctival approach. The upper eyelid is lifted with a special retractor. The medial fat is pressed with the fingers and becomes visible under the conjunctiva as a bulge. Here, the levator aponeurosis does not lie between the conjunctiva and under the septal fat, as it does in the central space. An injection is made into the conjunctiva, as in the transconjunctival approach on the lower eyelid. The conjunctiva is incised; the fat is brought out into the wound, grasped with a clamp, and removed. Sutures are not required. This approach may be good when the only problem is the protrusion of the medial fat. It can also be used when medial fat remains after upper eyelid plasty. The superior oblique muscle should be avoided.

Cauterization

Contact thermal cautery is preferred; however, bipolar electrocautery may also be used. Monopolar cautery applied directly to the clamp may cause pain, especially with local anesthesia and light premedication. This is an apparent consequence of the electrical impulses being transmitted deep into the orbit. The patient will report "pain behind the eye." Animal studies at the University of Oregon have demonstrated heat transfer up to 1 cm beyond the application of monopolar electrocautery to the fat-retaining clamp. Heat transfer is minimized with contact thermal cautery and bipolar electrocautery.

Careful hemostasis should be performed before closing the wound. It is important not to use electrocoagulation too aggressively in the subcutaneous tissues at the edges of the incision, since thermal damage may prevent the formation of a thin scar.

Closing the wound

Prolene 6/0 is best for suturing eyelid wounds. The integrity of such a suture is almost never compromised, even in some unpredictable cases the suture usually remains in place longer than the ideal 3-4 days. Suture tunnels or milia are also rarely formed. The lateral part of the wound, where the tension is greatest, is sutured first. This area is closed with several simple interrupted sutures. After suturing the lateral quarter of the wound, a continuous subcutaneous suture is applied to the remaining part of it with Prolene 6/0 thread, starting medially. Prolene is usually tied at the entrance under the skin and at the exit from under it. The ends of the subcutaneous suture are taped to the forehead. If there is any doubt about the tension in the wound, the entire wound can be taped with 3-mm surgical strips.

At the end of the operation, attention is paid to the medial part of the eyelid. Any wrinkling of the skin should be eliminated by excising small triangles above and below the medial part of the incision. The triangular areas should be opposite each other or stepped. The base of the triangle is on the incision. The skin should be excised carefully so as not to touch the applied subcutaneous suture. These triangular defects can be sutured with 3-mm surgical squares. Sometimes a single 6/0 Prolene suture is used for this purpose. In most cases, the skin edges are correctly aligned and there is no need for additional debridement. This final maneuver flattens the medial part of the eyelid. If any divergence of the skin edges of the wound is noted at the end of the operation, an additional simple interrupted suture can be applied in this area of increased tension.

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