Lower eyelid surgery: the course of the operation

For the plasty of the lower eyelid, the following basic surgical approaches are used:

• transconjunctival,
• through a cutaneous-muscular flap,
• through a skin flap.

Transconjunctival access

Transconjunctival access during the plasty of the lower eyelid was first described in 1924 by Bourquet. Although this is not a new operation, in the past 10 years there has been a surge in interest and an increase in the number of supporters of this access. Transconjunctival plastic of the lower eyelid preserves the integrity of the circular muscle, the active supporting structure of the lower eyelid. This minimizes the risk of developing ectropion. Also, there is no external scar.

For transconjunctival surgery, the correct selection of patients is required. Ideal candidates are elderly patients with false hernial protrusions of ophthalmic fat and a small excess of skin, young patients with familial hereditary hernial protrusions of ophthalmic fat in the absence of excess skin, all patients requiring correction of previous blepharoplasty, patients who do not want to have an external scar, patients with predisposition to keloidosis, as well as swarthy patients who have a certain risk of hypopigmentation of the external scar. Since some authors reported a significant decrease in the number of early and late complications after transconjunctival plasty of the lower eyelids compared to the musculoskeletal method, indications for this operation are gradually expanding. The presence of excess skin on the lower eyelid does not prevent the use of transconjunctival access. In the practice of the first author of this chapter, the most frequently performed operation on the lower eyelids consists in transconjunctival excision of fat, pinching of the skin and peeling with 35% trichloroacetic acid (described below). After removal of fat to correct the contour of the lower eyelid, excision of the skin is required. Often after fat loss, excess skin is less than previously thought.

• Preparation

The patient, while sitting, is asked to look up. This helps to refresh the surgeon's memory of the most prominent fat pads, the latter being labeled. Then the patient is placed on his back. In each lower arch, two drops of ocular 0.5% tetracaine hydrochloride are added. Before performing local anesthetic injections, our patients usually receive some sedation, by intravenous administration of midazolam (Versed) and meperidine hydrochloride (Deme-rol). To reduce the postoperative edema, 10 milligrams of dexamethasone (Decadron) is administered intravenously. Then, in the conjunctiva of the lower eyelid, a locally anesthetic mixture consisting of equal parts of 0.25% bupivacaine (Marcaine) and 1% lidocaine (Xylocaine) with adrenaline 1: 100,000 is added to the conjunctiva of the lower eyelid, to which is added a tenfold diluted sodium bicarbonate. Experience has shown that this mixture provides a long anesthetic effect, minimizing acute pain from primary infiltration due to alkalinization. The needle moves through the conjunctiva until it touches the bone edge of the orbit. Anesthetic is slowly introduced in the medial, lateral and central directions of x, as the needle moves. Some surgeons prefer to inject into the V2 area through the skin, although we believe that this is usually not required and can lead to unnecessary injury.

• Incision

After a 10-minute pause, necessary for the onset of vasoconstriction, the assistant gently pulls the lower eyelid with two small two-pronged hooks. Under the upper eyelid, a ball is placed to protect it. To carry out a transconjunctival incision 2 mm below the lower edge of the lower eyelid plate, either an isolated needle electrode is used, at low current settings, or a scalpel number 15. The lower edge of the lamina of the eyelid through the conjunctiva looks gray. The medial part of the incision is on the same level as the lower lacrimal point. The incision is not brought to the lateral angle of the optic gap by only 4-5 mm.

Immediately after the transconjunctival incision is carried out on the conjunctiva, as close as possible to the arch, a single suture is applied to the nail 5/0, which is used to divert the posterior lamina of the eyelid from the cornea. The seam is held in tension by a "mosquito" clip, fastened to the operating linen covering the patient's head. The conjunctiva serves as a fuse of the cornea, and the upstroke makes it easier to determine the plane of dissection. Both dermal hooks are carefully extracted, after which the Desmarres retractor is used to unscrew the free edge of the lower eyelid.

The distance of the transconjunctival incision from the lower edge of the plate of the lower eyelid determines the choice of pre-peregorodochnogo or zagperegorodochnogo access to the ophthalmic tissue. We usually use the first access; so our cuts are always about 2 mm below the plate of the century. The pre-degeneration plane is an avascular zone between the circular eye muscle and the orbital septum. Since the orbital septum is not disturbed during dissection in the pre-degeneration plane, the orbital fiber does not bulge into the field of view. The obtained form is very similar to that of musculoskeletal blepharoplasty. In order to gain access to the underlying ophthalmic tissue, it will still be necessary to open the orbital septum.

Other surgeons prefer over-access to ophthalmic fiber. For direct access to the fat cushions, the conjunctiva dissects about 4 mm down from the lower edge of the lamina of the lower eyelid and directly toward the anterior infraorbital margin. The great advantage of this method is that the orbital septum remains completely intact. Supporters of this technique note that an intact septum septum provides better support for the lower eyelid. The lack of access is that the orbital fat immediately appears in the wound. To avoid the formation of synechia, it is impossible to carry a cut close to the blind sac of the conjunctiva. Also, the view from direct access is such to which the majority of plastic surgeons operating on the face are less familiar.

After applying the suture-holder and setting the retractor Desmarres, the pre-peregorodic space is worked through by combining the blunt dissection with a cotton swab and acute dissection with scissors. It is necessary to keep the operating field dry. Therefore, to stop the slightest sources of bleeding bipolar coagulation, a "hot loop" or monopolar cationing is used.

Medial, lateral and central fat pads are separately identified through the septum with a slight pressure on the conjunctiva covering the eyeball. Then the septum opening is opened with scissors. Excess fat is carefully removed from the edge of the orbit and the septum with a clamp or a cotton swab. It is necessary to remove only the excess and hernia-forming fat, since after removing excessive fat, eyes can acquire a sunken appearance. The main goal is to obtain a contour of the lower eyelid, which the image has a smooth, gradual concave transition to the skin of the cheek. Then, a small amount of local anesthetic is injected into the isolated excess fat with a 30 G needle. The leg of fatty protrusion is treated with a bipolar coagulator. After coagulation of the entire leg, she is cut off with scissors. Others, especially Cook, reduce the amount of fat, burning it with an electrocoagulator, thereby minimizing surgical excision. Many surgeons believe that it is first necessary to process the lateral fat pocket, since its participation in the general fat swelling becomes much more difficult to assess after removing the adjacent fat and associated central fat. After removing excess fat from each space, the operating field is inspected to detect bleeding. Although excision of fat with a CO2 laser was promoted due to haemostatic efficacy, accuracy and less tissue trauma, increased cost, the need for well-trained personnel and additional laser-related precautions led us and many others to opt-out of laser use in lower eyelid surgery.

To facilitate the evaluation of the contour of the eyelid, you need to periodically remove and move the Desmarres retractor by placing it on top of the remaining fat. The removed fat is laid out on the napkin in the operating field sequentially, from the lateral to the medial edge, which allows you to compare it with that removed from the other side. For example, if before the operation the surgeon believed that the right lateral fat pocket is much larger than others, during intervention from this space, you can remove the greatest amount of fat.

The medial and lateral spaces are separated by the lower oblique muscle. To prevent muscle damage, it must be clearly localized prior to the beginning of excision of excess fat from these spaces. Fat in the medial space is lighter than in the central and lateral. This helps to recognize it. The lateral space is usually isolated from the central fascial band from the lower oblique muscle. This fascial tape can be crossed safely.

After the successful processing of each space, the entire operating space needs to be inspected again for bleeding. All sources of bleeding are coagulated by a bipolar, the Desmarres retractor and the suture are removed. The lower eyelid is gently moved up, down, and then allowed to stand in place, in its natural position. This equates the edges of the transconjunctival incision. No suturing is required, although some surgeons feel more confident by closing the incision with a single immersion suture from the rapidly resorbing catgut 6/0. Both eyes need to be washed with sodium chloride (Ophthalmic Balanced Salt Solution, Ophthalmic Balanced Saline Solution).

In older patients with excess skin, chemical peeling or pinching of the skin can now be performed. Using a blood-clamping clamp or a Brown-Adson clamp, immediately under the ciliary edge, a 2-3 mm fold of excess skin is captured and raised. This fold is excised with sharp scissors, not cutting the lower lashes. The edges formed after excision are sewn by a continuous suture from the rapidly resorbing catgut 6/0. Some authors close such cuts with cyanoacrylic (Histoacryl) or fibrin glue.

In patients with fine wrinkles on the lower eyelids, correction can be done by peeling 25-35% with trichloroacetic acid. Trichloroacetic acid is applied directly under the zone of plucking excision. A typical "frost" is formed. We do not use phenol on the lower eyelids, since it gives a much longer erythema and inflammatory phase than peeling with trichloroacetic acid.

• Post-operative care

Immediately after surgery, the patient is at rest with a 45 ° raised head. Both eyes are covered with cold compresses, which change every 20 minutes. The patient is closely observed for at least an hour for any signs of postoperative bleeding. The patient is given specific instructions to limit physical activity throughout the week. Patients, during the first 48 hours, diligently observing the regime of cold compresses and raising their heads, swelling is much less. Some doctors during the first 5 days after the operation, to prevent infection when healing the transconjunctival incision, patients are assigned sulfacetamide eye drops.

Musculoskeletal Flap

Access through the musculocutaneous flap was probably the most widely used method in the 70s-early 80s of the last century. This operation is excellent for patients with a large excess of skin and circular muscle of the eye, as well as with fat pseudographes. The advantages of this approach are the safety and ease of dissection in a relatively avascular plane under the muscle and in the ability to remove excess skin of the lower eyelids. It should be understood that even with such access, the possibility of removing the skin is limited by the amount that can be excised without the risk of exposing the sclera and ectropion. Persistent wrinkles are usually preserved, despite attempts to resect the excess skin of the eyelids.

• Preparation

Preparation for this operation does not differ from that for transconjunctival access, except that tetracaine drops are not required. The incision is marked with a marker or methylene blue 2-3 mm below the edge of the lower eyelid in the patient's sitting position. All the prominent fat pads are also labeled. The importance of marking in a seated position is associated with changes in the relationship of soft tissues, resulting from infiltration and gravity. The medial end of the incision is marked 1 mm lateral to the lower lacrimal point, so as not to affect the tear ducts, and the lateral end of the incision is wound 8-10 mm laterally from the lateral angle of the eye gap (to reduce the possibility of rounding the angle of the eye gap and lateral exposure of the sclera). At this point the most lateral part of the incision is given a more horizontal direction, so that it lies inside the folds of the goose paw. When planning the lateral part of the incision, it should be borne in mind that the distance between it and the incision for the plasty of the upper eyelid should here be at least 5 mm, preferably 10 mm, to prevent prolonged lymphedema.

After completion of the labeling and intravenous administration of dexamethasone, our patients usually undergo an intravenous sedation, consisting of midazolam and meperidine hydrochloride. Before the restriction of the operating field, liners, the cut line (from the lateral end) and the entire lower eyelid, to the lower edge of the orbit, infiltrate (superficially septum) with the analgesic mixture described above.

• Incision

The blade of the scalpel No. 15 is starting with a medial incision, to the level of the lateral corner of the eye gap separating only the skin, and then to the side of this point - the skin and the circular muscle of the eye. With the help of straight blunt scissors, dissection under the muscle is made, from the lateral angle of the eye to the medial, and then the muscle intersects with the caudal direction of the blades (optimizing the integrity of the pretarsal muscle bundle). Then, over the edge of the fabric, above the cut, nylon 5/0, the Frost seam is applied to facilitate the anti-thrust. In a blunt way (scissors and cotton buds), the musculocutaneous flap is worked down to the lower edge of the orbit, but not below it, so as not to damage the important lymph channels. Any sources of bleeding here should be carefully stopped by bipolar coagulation, without damaging the hair follicles of the eyelashes at the upper edge of the incision.

• Fat Removal

If a pre-operative examination revealed the need to treat fat pads, piercing cuts of the orbital septum are made above pseudo-jaws, the location of which is determined by neat finger compression of the closed eyelid to the eyeball. Although there is an alternative in the form of electrocoagulation of the weakened orbital septum, which can prevent this important barrier, we are satisfied with the long-term results and predictability of our technique of direct access to fat pockets.

After the opening of the septum (usually 5-6 mm above the edge of the orbit), the fat slices are carefully removed above the edge of the orbit and the septum using a clamp and a cotton swab. The technique of resection of fat is described in detail in the section on transconjunctival access, and is not repeated here.

Access to the medial space can be partially limited by the medial part of the dredge. The cut can not be expanded; Instead, the fat needs to be carefully removed into the incision, avoiding the lower oblique muscle. The medial fat pad differs from the central one by a lighter color.

• Closing

Before excising the skin and closing the wound, the patient is asked to open his mouth wide and look up. This maneuver causes maximum arbitrary divergence of the edges of the wound and helps the surgeon perform an accurate resection of the musculocutaneous layer. In this position of the patient, the lower flap is superimposed over the incision in the upward direction and toward the temple. At the level of the lateral angle of the eye gap, the overlapping excess muscle is marked and dissected vertically. To keep the flap in place, a seam is applied quickly with a resorbable catgut 5/0. The overlapping areas are economically resected (medially and laterally from the retaining seam) by straight scissors, so that the edges of the wound are juxtaposed without their forcible removal. It is important to direct the scissor blades caudally to keep a 1-2 mm strip of circular eye muscle on the lower flap to prevent the protruding roller from forming when sewing. Some surgeons freeze the resected skin (retaining viability for at least 48 hours) in a sterile saline solution, in case a substitution transplantation is required after excessive resection leading to an ectropion. It is much better to prevent this complication by performing an economical resection.

After the removal of fat from the second century, the incision in the first century is sutured with simple quick-dissolving catgut sutures 6/0. Then, overlapping, clipping and suturing are performed in the second century. Finally, quarter-inch (0.625 cm) sterile strips are pasted over the seams, and a small amount of antibacterial ointment is applied to the incision, after washing the eye with an isotonic sodium chloride solution.

• Post-operative care

Care after musculoskeletal surgery, basically, corresponds to that after the application of transconjunctival technique. The eye ointment Bacitracin is applied to the subarachnoid incision. All patients are prescribed cold compresses, a head lift and a restriction of physical activity.

Skin flap

Working with the skin flap may be the oldest and rarely used approach. This method allows you to independently resect and match the skin of the lower eyelid and the eye that is subject to the circular muscle. It is effective in moving and removing a severely wrinkled, excess and deeply folded skin. In cases where there is hypertrophy or fescuity of the circular eye muscle, direct access is used for correction, which allows more extensive resections to be safely performed than would be possible with the isolation of the combined musculoskeletal block. The drawbacks of this approach are more tedious dissection, accompanied by greater skin trauma (manifested by increased bleeding and infiltration of the eyelid), an increased risk of vertical retraction of the eyelid, and a greater burden of preoperative evaluation of the fat pockets, since the orbital septum is closed by the circular eye muscle during the operation.

First, the cutaneous cut is made to facilitate the incision only in the lateral part, held under the eyelashes of the label. The assistant pulls the skin of the lower eyelid down (placing a hand at the edge of the eye socket), the lateral end of the incision is captured and pulled up; with a sharp path, scissors, skin flap gently cut to the level immediately below the edge of the eye socket. After completion of the cut, the sub-cuticle is prolonged with scissors. Aimingly coagulate all sources of bleeding.

If the only problem is excess skin or excessive wrinkling, the skin flap simply overlies the cut and is cut off, as described for the musculocutaneous flap. If access is required to the fat spaces of the orbit, it is performed by dissecting the circular muscle of the eye approximately 3-4 mm below the original cutaneous cut or from transconjunctival access. However, when there is hypertrophy or fesqueness of the circular eye muscle, the optimal correction is achieved by creating independent skin and muscle grafts. In this case, the muscle is dissected (with a bevel in the caudal direction) along and approximately 2 mm below the skin incision, to protect the pretarsal muscle stripe. Dissection of the muscular flap is carried out to the level immediately below the most dangling muscle roller (with festoons) or to a point that, after resection, will smooth out the protruding (hypertrophied) muscular sac. After the treatment of the fat cushions, the muscle flap is strengthened by sewing its lateral end to the periosteum of the eye socket with Vicril 5/0 thread and comparing the pretarsal muscular margins with several nodular sutures from the chromated catgut 5/0. The skin is closed as described above.

[1], [2], [3]