Surgery for upper eyelid surgery (blepharoplasty)

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

Section Planning

The operation begins with the marking of the eyelids. To reduce the erosion of marking and the preservation of applied lines, thin eyelids should be completely cleared of natural sebum. All make-up is removed in the evening before the operation. Before marking, the eyelids are degreased with alcohol or acetone.

First, a natural furrow of the century is noted, which is almost always visible under bright light and sufficient magnification. The fold of the eyelid is located at the upper edge of the underlying tarsal plate. If the natural furrow of the eyelid is 8 mm or more above the edge of the eyelid, it is always best to use this natural landmark. The folds of the eyelids on both sides are usually on the same level. If there is a 1-mm discrepancy between the eyelids, the marking of the folds of the eyelids is equalized so that it is 8-10 mm above the edge of the eyelids. The medial end of the incision is placed close enough to the nose to grasp all the thin wrinkled skin, but it never gets wounded by the oropharyngeal nasal impression. Setting the cut too far on the nose causes an almost irreversible fusion. The lateral line of the fold of the eyelid goes in the natural fold of the furrow between the edge of the orbit and the eyelid. At this point, the line is withdrawn laterally or slightly upward.

In the patient's position on the back, the real quantitative excess of the skin of the upper eyelid can be determined only after the physical displacement of the eyebrow downward. In the position on the back, the mobility and weight of the scalp and forehead pulls the eyebrow above the edge of the orbit. This is not a correct, natural position of the eyebrow. Excess skin of the upper eyelid temporarily decreases. For proper planning of the plastics of the upper eyelid, the eyebrow should be carefully shifted down to the edge of the orbit, to the position marked when the patient was sitting or standing. Then the upper eyelid skin is gently grasped by the clamp. One of the branched clamps is on the previously marked fold of the century. The other jaw retains as much skin as possible to smooth the surface of the eyelid, but do not move its edge upward. In other words, if the skin is removed between the jaws of the clamp, there will be no pulling of the eyelid and a lagophthalmus. This technique of marking is applied in several places along the century. When these points are joined, a line parallel to the fold line of the eyelid is formed. Medially and laterally, the lines are connected at an angle of 30 degrees. The medial excess of the skin should always be slightly understated in patients with a large amount of middle fat. A defect created by excising a large amount of this fat can cause the formation of a subcutaneous dead space. If a little less skin is dissected from the medial side, the medial end of the eyelid is screwed inward, rather than hanging over the area where fat is removed. If there is a hanging of the skin of the eyelid from the medial side, a dense scar is almost certainly formed.

The spread of the planned excision of the skin sideways is determined by the size of the side hood. If, in younger patients, the hood is absent, then the lateral margin of excision lies immediately behind the lateral edge of the eye gap. If the side hood is redundant, the incision may continue 1 cm or more beyond the lateral edge of the orbit. The direction of the resultant scar should always be between the lateral edges of the eye and eyebrows. The incision of this direction can be hidden in women by eye shadows. The area surrounded by a surgical marker should be slightly wavy.

Anesthesia

After completion of the labeling, infiltration anesthesia may be performed. Recommended 2% xylocaine with adrenaline 1: 100000, buffered with 8.4% sodium bicarbonate solution. The ratio is 10 ml of xylocaine per 1 ml of bicarbonate. Approximately 1 ml is subcutaneously infiltrated into the upper eyelid by a 25-27 g needle. To obtain the maximum effect from adrenaline, a minimum of 10 minutes should pass before the cut is made.

Initial incision and excision of muscle

The initial incision is made when stretching the eyelid skin so that the line drawn by the marker is straightened. The skin of the eyelid is excised within the marking with the scalpel blade. It is preferable to use the Beaver blade No. 67, since it is sharp and small. An upper incision is made, the skin is removed by a clamp and curved scissors Stevens. At this stage, the dissection of the eye of the circular muscle is performed. Some of the muscle is removed in almost all cases. Usually, older patients with thin skin need to remove less muscle, whereas younger and thicker skin patients need to remove more muscle to achieve a good aesthetic result.

The muscle is excised along the direction of the excision of the skin. The width of the excised skin band is determined individually. Deep excision is performed before the orbital septum.

Fat Removal

If there is an excess of fat, it is probably necessary to remove the central part before removing its medial part. Central space can be opened by cutting the septum partition in one place or all over. A small false protrusion of fat can be removed with a single clamp. A larger protrusion may require dividing the central space into two or more sections. The medial fat is excreted into the wound and excised. Although usually in the upper eyelid there is no lateral cell space, fat can be present laterally than the lacrimal gland, creating a lateral space. Before capturing the clamp, a small amount of local anesthetic is injected into the fat. The local anesthetic injected subcutaneously does not normally penetrate the orbital septum. If you do not do additional anesthesia, the patient will feel pain when seizing fat. Portion of fiber is captured by a small thin hemostatic clamp. Then it is excised with electrocoagulation of the base. It is important not to actively pull the fat removed from the orbit into the wound. It is necessary to excise only that fat which easily leaves in a wound. This is especially important in the area of the medial edge of the central space. If you remove too much fat here, it can lead to retraction of the eyelid and overhanging the edge of the orbit. The result is a senile appearance, which should be avoided.

A medial portion of fatty tissue can be difficult to detect. It is important to assess its severity in the pre-operative period in order to remove it during surgery. At times, depending on the position of the patient, the medial fat sinks, without taking part in shaping the appearance. If before the operation it was found out that this tissue creates problems, it must be isolated and removed. Underestimation of excess of medial fat is the most frequent aesthetic error in the plastic of the upper eyelids. The medial fat has a pale yellow color and is denser than the fat of the central space. The location of the medial fat is subject to greater changes than fat in the spaces of the upper and lower eyelids. The central and medial spaces are separated by the upper oblique muscle of the eye. Unlike the lower oblique muscle of the eye, this muscle is rarely seen in the upper eyelid. However, its presence should always be considered before applying the haemostatic clamp to fatty tissue.

If during the preoperative examination it was found that the lateral fat pad of the eyelid represents an aesthetic problem, it can also be removed. To do this, the upper outer edge of the cut is drawn. The lateral ophthalmic fat pad is excreted by blunt dissection under the circular muscle. Fat is removed with scissors. It has several small vessels, the bleeding of which must be carefully stopped.

Remove fat from the medial space through transconjunctival access. The upper eyelid is raised by a special retractor. The medial fat is pressed down by the fingers and becomes visible under the conjunctiva, like a bulge. Here, the aponeurosis of the lifting muscle does not lie between the conjunctiva and the septum fat, as in the central space. Injection into the conjunctiva is made, as with transconjunctival access in the lower eyelid. The conjunctiva dissects; Fat is excreted into the wound, captured by a clamp and removed. Stitching is not required. This approach can be good when the only problem is the protrusion of the medial fat. It can also be used when the medial fat is preserved after the plastic of the upper eyelid. You must avoid the upper oblique muscle.

Cauterization

Preferably contact thermal cauterization; however, bipolar electrocoagulation can also be used. Monopolar coagulation, applied directly to the clamp, can cause pain, especially with local anesthesia with mild premedication. This is an obvious consequence of the transmission of electrical impulses deep into the eye socket. The patient will report "pain behind the eye". Animal studies conducted at the University of Oregon demonstrated heat transfer up to 1 cm deeper than the place of monopolar electrocoagulation application to the fat-holding clip. Heat transfer is minimized by the use of contact thermal cauterization and bipolar electrocoagulation.

Before closing the wound, a thorough hemostasis should be performed. It is important not to aggressively use electrocoagulation in the subcutaneous tissues at the edges of the incision, as the temperature damage can prevent the formation of a thin scar.

Closure of wound

To suture the wound of the eyelids, it is better to use Prolene 6/0. The integrity of such a seam is almost never violated, even in some unpredictable cases, the seam usually remains in place longer than the required ideally 3-4 days. Selden tunnels or milium are also rarely formed. The lateral part of the wound, where the tension is maximum, is sutured first. This zone is closed by several simple nodal seams. After suturing the lateral quarter of the wound, a continuous subcutaneous suture is superimposed on the remaining part of the Prolene 6/0 thread, which begins medially. Prolene is usually tied at the entrance to the skin and when leaving from under it. The ends of the hypodermic suture are pasted to the forehead with plaster. If there is any doubt about the tension in the wound, the whole can be sealed with 3 mm surgical strips.

At the end of the operation, attention is drawn to the medial part of the century. Any wrinkling of the skin should be eliminated by excision of small triangles above and below the medial part of the incision. Triangular areas should be located opposite to each other or stepwise. The base of the triangle is on the cut. Cut the skin carefully so as not to touch the superimposed subcutaneous suture. These triangular defects can be sealed with 3 mm surgical squares. Sometimes for these purposes one seam is used Prolene 6/0. In most cases, the cutaneous edges are matched correctly, and there is no need to additionally process x. The described final maneuver flattenes the medial part of the century. If, at the end of the operation, there is any discrepancy between the cutaneous edges of the wound, an additional simple nodal suture may be superimposed in this area of increased tension.

[1], [2], [3]