1 / 40

Ryan W. Ridley, MD Raghu S. Athre, MD Grand Rounds Presentation University of Texas Medical Branch Department of Otolary

Outline. I. IntroductionII. Aging processEyelid anatomyPatient assessmentSurgical techniquesUpper eyelidsLower eyelidsComplicationsBrief intro to Asian blepharoplasty. The Eye: Window to One's Soul. 22 ?The lamp of the body is the eye. If therefore your eye is good, your whole body wi

chung
Download Presentation

Ryan W. Ridley, MD Raghu S. Athre, MD Grand Rounds Presentation University of Texas Medical Branch Department of Otolary

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    2. Outline I. Introduction II. Aging process Eyelid anatomy Patient assessment Surgical techniques Upper eyelids Lower eyelids Complications Brief intro to Asian blepharoplasty

    3. The Eye: Window to One’s Soul 22 “The lamp of the body is the eye. If therefore your eye is good, your whole body will be full of light. 23 But if your eye is bad, your whole body will be full of darkness. If therefore the light that is in you is darkness, how great is that darkness!”(Matt 6:22-23, NKJV) Cicero (106-43 B.C.) is quoted as saying, “Ut imago est animi voltus sic indices oculi”(The face is a picture of the mind as the eyes are its interpreter)

    4. Can You Guess the Emotion? Pics of eyes only; globes w/o upper 1/3 of facial expressionPics of eyes only; globes w/o upper 1/3 of facial expression

    5. How About Now? Pics of upper 1/3 of face expressionsPics of upper 1/3 of face expressions

    6. The Aging Process Loss of collagen & elastic fibers Loss of dermal-epidermal junction Dermal/epidermal thinning Weakening/thinning of underlying muscle Sun damage (solar keratosis) Smoking Gravity effects Intrinsic Extrinsic

    7. The Aging Process Macroscopic changes. Place pic of young and old side by side split screen and label the old face with the changes.Macroscopic changes. Place pic of young and old side by side split screen and label the old face with the changes.

    8. Surface Anatomy A: Medial commissure B: Lateral commissure C: Medial canthus D: Lateral canthus E: Upper eyelid crease F: Lower lid margin G: Nasojugal fold H: sclera I: Iris J: pupil Don’t forget to show the palpebral fissure : distance btwn eyelids=9-10mmDon’t forget to show the palpebral fissure : distance btwn eyelids=9-10mm

    9. Muscular Anatomy A: Palpebral orbicularis oculi B: Orbital orbicularis oculi C: Frontalis D: Procerus E: Corrugator supercilii F: Muscles of midface G: Malar fat pad H: Suborbicularis oculi fat (SOOF) Procerus: lowers eyebrow corrugator: brings them togetherProcerus: lowers eyebrow corrugator: brings them together

    10. Orbital septum A: orbital septum B: Levator aponeurosis

    11. Septum/Muscles removed A: medial canthal tendon B: lateral canthal tendon C: Superior tarsal plate D: Inferior tarsal plate E: levator palpebrae F: Tendon of superior oblique G: Inferior oblique H: lacrimal gland I: lacrimal sac J: medial fat pad K: Superior/Inferior orbital rims

    12. Cross section of lower lid A: sclera/globe B: skin C: orbicularis oculi D: tarsus E: septum F: orbital fat G: inferior oblique H: retractors 1. capsulopalpebral fascia 2. inferior tarsus muscle I: orbital rim J: conjunctiva K: periosteum

    13. Upper lid Cross Section: Asian v. European lids Septum Skin Orbital fat Levator Tarsus Orbicularis Suborbicularis fat Subcutaneous fat *The conjoining of the orbital septum and levator aponeurosis to the orbicularis and skin occurs more inferior. This allows orbital fat to prolapse anterior/inferior obliterating the upper lid crease and yields a more full appearance.*

    14. Preoperative Assessment Medical Comorbidities should be stable Blepharoplasty is an elective procedure Social history important in addition to medical Smoking, drugs, etc. Ophthalmologic history Vision Ocular trauma Dry eye Excess tearing Lasix surgery Blepharoplasty deferred for at least 6 months

    15. Preoperative Assessment: Facial Analysis In addition to general head/neck exam, should focus exam on the following: Brow position Eyelid shape Lid position Upper lid crease Skin excess/laxity

    17. Testing lid laxity: Snap Test Lower lid is grasped and then pulled away from the globe. Lower lid is then released. Lid should quickly “snap” back into position Slow return=very conservative skin excision; possible lid tightening procedure needed.

    18. Preoperative Photodocumentation Specific views for blepharoplasty: Full face Close up lid views Frontal eyes open Frontal gaze upward Frontal eyes closed Oblique views Lateral views

    19. Upper lid surgery: marking Pt should be marked in the upright position if possible. If not, must be sure to account for gravity. Classic: horizontal line carried laterally to orbital rim. Pastorek: lateral portion of mark is placed between lateral canthus and eyebrow.

    20. Upper lid surgery: excess skin If excess skin estimation performed in supine position, must account for opposing force of scalp and forehead Grasping of skin with forceps should not cause elevation of the upper lid margin.

    21. Upper blepharoplasty technique 1. 1-2 ml of 1% lidocaine with 1:100,000 epinephrine using 30-guage needle. 2. Skin-only incision made with No. 15C blade. 3. Bishop forceps or skin hook used to grasp skin while skin is removed from underlying orbicularis using blepharoplasty scissors. 4. Appropriate amount of muscle removed w/o violation of septum 5. Septum now in view and fat compartments to be addressed are visualized. 6. Septum is incised over the fat compartments to be addressed 7. Gentle pressure on globe naturally displaces herniating fat to be removed. Meticulous hemostasis achieved using bipolar 8. Bipolar also may be used to deepen the upper lid crease 9. Wound closed using 6-0 prolene in running subcuticular fashion.

    22. Upper Blepharoplasty Demonstration

    23. Lower Lid Techniques 3 basic approaches Transcutaneous skin flap Most conservative technique=most limited results Best for patients with little/no fat excess and no orbicularis oculi muscle laxity Transcutaneous skin-muscle flap Most popular technique Ideal for patients exhibiting fat pseudoherniation, lid laxity, skin redundancy, and orbicularis oculi hypertrophy Incision through muscle=bleeding, bruising, scar contracture Risk of ectropion Transconjunctival approach Ideal for patients whose primary issue is fat pseudoherniation in the absence of skin laxity/excess or orbicularis oculi hypertrophy

    24. Transcutaneous skin flap technique Patient is marked in upright position 2-3mm skin pinch along subciliary margin Skin-only incision made parallel and 1-2mm below lid margin. May extend 1-1.5cm laterally in a crow’s foot rhytid Careful dissection between skin and muscle (meticulous hemostasis) Once desired amount of skin elevation complete, skin flap is retracted superiorly over lid margin and conservatively resected. Lateral extension closed with interrupted 6-0 prolene. Remaining subcilliary incision closed with running subcuticular absorbable suture.

    25. Transconjunctival Technique 1.Place Desmarres retractor inside lower lid and gently displace inferiorly. At the same time, gentle pressure on globe confirms locations of fat compartments 2. Incision made using needle tipped bovie in conjunctiva 1-2 mm below inferior tarsal border. Incision length depends on number of fat compartments to be addressed. 3. Grasp lower edge of incision with Bishop forceps and place retraction suture in midline of conjunctival wound edge. 4. Combination of blepharoplasty scissors and cotton tipped applicators may be used to dissect in submuscular plane to the orbital rim. 5. The septum and fat compartments can now be seen and addressed as needed. 6. Meticulous hemostasis throughout procedure (especially fat removal) using bipolar. 7. Incision d/n need to be closed.

    26. Transcutaneous skin-muscle flap technique 1.Patient is marked as in the skin-only technique,however, special attention is paid to the fat compartments to be addressed. 2. Injection of local anesthesia, placement of eye shields. 3. No. 15C blade used to make skin incision as in skin flap technique. 4. Orbicularis fibers are penetrated laterally and bluntly dissected from lateral to medial from the underlying septum. Meticulous hemostasis must be achieved. 5. Elevate a skin flap of 5-7mm off of the pretarsal orbicularis oculi. 6. Use blepharoplasty scissors to cut through the orbicularis oculi 5-7mm from lid margin. This will connect the skin and muscle flaps. 7. Orbital septum is now exposed and opened over the fat compartments to be addressed. Gentle pressure on the globe will naturally deliver the amount of fat that needs to be removed. Always be conservative. Hemostasis is important during this step. 8. Wound edge is redraped to assess skin excess. Excess skin is conservatively excised. Occassionally, 2-3mm of muscle need to be removed to aid in edge-to-edge approximation. 9. Wound reapproximated as in the skin flap technique.

    27. Lower lid blepharoplasty demonstration

    28. Before & After (Intraoperative)

    29. Before & After

    30. Postoperative Care Patient should be checked for bleeding, gross visual acuity, extraocular movements Head elevation and cool compresses to the eyes for 48hrs No strenuous activity Avoidance of ASA, NSAIDS, herbal supplements x 1 week Petroleum-based antibiotic ointment to incisions BID-TID Sutures removed in 5-7 days post-op

    31. Complications Hematoma Small: managed conservatively Large/expanding: exploration; possible emergency interventions (0.04%) Lateral canthotomy/cantholysis IV mannitol + steroids Corneal injury Preventative measures are best Chemosis May last several days-6weeks Always resolves; reassure patient Steroid eye drops may be needed Lid malposition, lagophthalmos, ectropion Conservative tx: gentle massage, steroid injections Lid tightening procedure if conservative measures fail. If too much skin was resected, will need STSG placement to lid If cicatrical scar formation occurred in conjunctiva, may need a mucosal graft placed in conjunctival fornix.

    32. Complications

    33. A Brief Word on Asian Blepharoplasty Indications The absence of a supratarsal crease Motivation of the patient to create a supratarsal crease 3 major approaches Full incision method More permanent fixation results Longer downtime Limited incision method Eventual fold loss over time Suture-based techniques Fastest technique, little downtime Potential for fold loss

    34. Asian blepharoplasty: crease configurations Inside fold: termination of the fold lateral to epicanthus. Crease converges toward epicanthus Outside fold: Parallel crease orientation with medial aspect ending medial to epicanthus.

    35. Technique Lam, 2007 1. Desired crease is marked . 2. Injection of local anesthesia 3. Incision through skin to orbicularis oculi 4. Incision carried through muscle and the skin island is removed. 5. Orbital septum is identified laterally and orbital fat exposed. 6. Orbital fat retracted to reveal levator aponeurosis.

    36. Technique (cont’d) 7. Remaining orbital septum is cauterized with bipolar and cut to reveal entire length of levator aponeurosis. 8. Very little, if any post septal fat is removed 9. Three levator-to-skin fixation sutures placed using 5-0 nylon. Desired eyelash eversion is achieved 10. Skin closed using running 7-0 nylon

    37. Asian blepharoplasty: Postoperative course

    38. Postoperative Results A= preopertive B= 3 months postop C=1 year postop

    39. Closing thoughts Be conservative, conservative, conservative! Meticulous hemostasis during the procedure is key to avoiding postoperative complications Careful preoperative patient assessment to ensure the best surgical option is chosen

More Related