Maximal eyelid surgery with a single external blepharoplasty incision
This is Richard Allen at the University of Iowa. This video demonstrates a blepharoplasty with a trans-blepharoplasty browpexy, canthopexy, and Muller muscle-conjunctival resection (MMCR). The blepharoplasty is marked and a needle tip cautery is used to make an incision along the blepharoplasty marking. A flap of skin and orbicularis muscle is removed. The medial fat pad is exposed and mobilized. The fat pad usually needs to be anesthetized due to the pain during its excision. The same is then performed on the other side. The fat pad is mobilized and anesthetized and each side is then conservatively excised. I don't feel the need clamp fat in these areas. I think careful excision of the fat can be performed without clamping it. Dissection is then carried out superiorly along the surface of the orbital septum to the superior rim. Dissection is then carried out superior to the superior orbital rim in a pre-periosteal fashion with the Freer periosteal elevator. The area is measured above the superior orbital rim which is usually about 12 millimeters. The spot is then engaged with a 4–0 Vicryl suture. The same measurement is then made from the superior skin edge to the brow fat pad. This area is then engaged with the 4–0 Vicryl suture. The suture is then tied which results in placement of the upper blepharoplasty incision edge at the superior orbital rim.
A trans-blepharoplasty canthopexy will then be performed. This is performed with a 4–0 Prolene suture which is placed through the blepharoplasty incision laterally to exit out the lateral canthus at the level of the tarsus of the lower lid. The suture is then replaced and directed posteriorly where it engages the periosteum of the superior lateral orbital rim. The suture is then retrieved. Tightening the suture will result in tightening of both the upper and lower lid. The sutures are left untied at this point. The browpexy is then performed on the opposite side. The brows appear to be in good position. The trans-blepharoplasty canthopexy is then performed on the opposite side. Again the suture enters at the blepharoplasty incision and exits out the lateral canthus at the level of the tarsus of the lower lid. The suture then reenters adjacent to the exit point. The suture is directed posteriorly to engage the lateral canthal tendon which then engages the periosteum of the superior lateral orbital rim. The suture is then retrieved. Again the suture will be left untied to facilitate performance of the MMCR.
Attention is then redirected to the upper lids where the MMCR will be performed. 4-0 silk sutures are placed through the upper lids at the level of the tarsus. The amount of conjunctival resection is marked with the needle point cautery. Forceps fixate the markings followed by placement of the Putterman clamp. A 6-0 chromic suture is then placed in a mattress fashion along the edge of the Putterman clamp. I don't place these sutures trans-blepharoplasty just due to the fact that I had some problems with bleeding when I placed the suture through the blepharoplasty incision. Therefore, I will place this with the knot at the conjunctiva. Often I place a contact lens postoperatively to prevent any irritation. Realistically, with the knot laterally, usually it does not cause much irritation. The same is performed on the other side with the MMCR. Attention is then directed to the canthopexy sutures which are tied. This is performed on each side. The blepharoplasty incisions will then be closed with interrupted and running 6–0 Prolene suture. At the conclusion of the case, the patient will use erythromycin ophthalmic ointment 3 times a day for a week. The patient will follow-up in approximately 1 week for suture removal and reevaluation.
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