Drill hole midface lift
This is Richard Allen at the University of Iowa. This video demonstrates a subperiosteal midface lift using drill holes through the inferior orbital rim. A lateral canthotomy and inferior cantholysis are performed. 4-0 Silk sutures are then placed through the lower eyelid at the level of the meibomian gland orifices in order to provide traction during the case. A transconjunctival incision is then made with the monopolar cautery inferior to the inferior border of the tarsus extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. 4-0 silk sutures are placed through the cut end of the conjunctiva and lower lid retractors in order to provide traction. A malleable retractor and Desmarres retractor are then used to expose the inferior orbital rim. The needle tip cautery is then used to incise the periosteum of the inferior orbital rim. A freer periosteal elevator is then used to elevate the periosteum from the face of the maxilla and zygoma. This dissection is carried out inferiorly to the level of the gingival buccal sulcus. It is also carried out medial to the infraorbital neurovascular bundle. A drill with a 1 mm bit is then used to make three holes through the inferior orbital rim. The first hole is made medial to the level of the infraorbital neurovascular bundle. The second hole is made lateral to the bundle. The malleable retractor is used to protect the globe. The final hole is made at the lateral portion of the inferior orbital rim. Stab incisions are then made with the 15 blade at the same horizontal level of the drill holes but more inferior in order to attain appropriate lift. A 3-0 nylon suture is then placed in the subperiosteal plane to exit out the stab incision. The suture is then turned around to be placed through the stab incision to the subperiosteal space. Each of the three sutures is placed in the same manner. The suture is then placed through the drill holes. This is placed by backing the sutures through the holes since the needle is too big to go through the holes. The suture is then tied to attain elevation of the midface. Each of the sutures is placed in the exact same manner – backing the suture through the drill hole and then tying it in order to attain elevation of the midface. Again, backing the suture through the hole and then tying. This completes the mid face elevation. This patient also had significant ectropion. Therefore, inverting sutures will be placed. This is performed with 5-0 vicryl sutures which are placed through the skin and orbicularis muscle approximately 1 cm inferior to the inferior border of the tarsus. The suture then engages the inferior border of the tarsus and is then placed back through the orbicularis muscle and skin. Three such sutures are placed along the length of the lid. Again, the suture is placed through the skin and orbicularis muscle, then engages the inferior border of the tarsus, followed by placement through the orbicularis and skin. The conjunctiva is then reapproximated to the inferior border of the tarsus with 7-0 vicryl sutures in an interrupted fashion. The lateral cantholysis is then repaired by performing a lateral tarsal strip. The strip is sutured to the lateral orbital rim at the level of Whitnal’s tubercle. Prior to tying the suture, the lateral portion of the upper tarsus is denuded at the mucocutaneous junction and sutured to the strip with 5-0 vicryl suture. This provides additional lateral support. The mersilene suture is then tied. The inverting sutures are then tied over bolsters in order to get subtle inversion of the eyelid. The canthotomy incision is then closed with the 7-0 vicryl suture. Antibiotic ointment is placed over the repair and the patient will return in one week for removal of the bolsters.