Full-thickness blepharotomy with debulking of medial and brow fat pads
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This is Richard Allen at the University of Iowa. This video demonstrates a levator recession via a full-thickness blepharotomy with debulking of the medial fat pad and brow fat in a patient with thyroid eye disease. A monopolar cautery is used to make an incision along a conservative blepharoplasty marking. A flap of skin and orbicularis muscle is excised with the monopolar cautery. This is performed bilaterally. A thermal cautery is then used to disinsert the confluence of the levator aponeurosis and orbital septum from the anterior surface of the tarsus. Dissection is then carried out between the underside of the levator aponeurosis and the underlying Muellers muscle. This is performed along the length of the entire eyelid. Scissors are then used to transect the lateral horn of the levator aponeurosis to relieve temporal flare. In doing this, there may be some exposure of the lateral portion of the preaponeurotic fat pad. The thermal cautery is then used make an incision along the superior border of the tarsus to release the attachments of Muellers muscle and conjunctiva. This extends from the lateral aspect of the tarsus to the center of the tarsus. In this case, the retraction is moderate and the incision does not need to extend more medially. The height of the eyelid is inspected.
The same procedure is then performed on the other side where the confluence of the levator aponeurosis and orbital septum is disinserted from the anterior surface of the tarsus with the thermal cautery. Dissection is then carried out between the levator aponeurosis and underlying Muellers muscle. This is again performed along the entire width of the eyelid. Again, the lateral horn of the levator aponeurosis is transected to relieve temporal flare. This is best performed by following the lateral portion of the levator aponeurosis to its attachment to the lateral orbital wall. The thermal cautery is then use to release the attachments of the conjunctiva and Muellers muscle from the superior border of the tarsus. This extends from the lateral aspect of the tarsus to the mid-point of the tarsus.
Attention is directed to the medial portion of the orbital septum where the medial fat pad is exposed and mobilized. The medial fat pad is then injected with lidocaine with epinephrine. The same is performed on the other side where the fat pad is identified posterior to the orbital septum and then mobilized and injected. The fat pads can then be conservatively excised with the needle tip cautery. Hemostasis is assured with the needle tip cautery. Some surgeons prefer to clamp the fat pad prior to excision.
Dissection is then carried out superiorly along the surface of the orbital septum to the superior orbital rim. At this point, the brow fat is anterior to the orbital septum and posterior to the orbicularis muscle. Dissection is then performed between the orbicularis muscle and the brow fat. The brow fat can then be debulked with the needle tip cautery. Brow fat is known to be expanded in patients with thyroid eye disease. Hemostasis is obtained with the unipolar cautery. This is performed symmetrically on both sides to debulk the brow fat.
Inspection of the height of the eyelid and the debulking of the fat pads is then performed and found to be appropriate. The incisions can then be closed in a single layer with running 6-0 prolene suture. At the conclusion of the case antibiotic ointment is placed over the incisions and in the eye three times a day. The patient will return in one week for suture removal.