2 Fundamental Principles and Techniques of Ophthalmic Plastic Surgery
Summary
Surgical outcomes are impacted by the combined effects of preoperative assessment, surgical planning, surgical technique, and patient-specific factors that influence healing. The first three components are modifiable. Careful preoperative evaluation and comprehensive patient counseling allows the surgeon to optimally plan and appropriately set patient expectations. Attention to anatomy, technical knowledge, and experience minimize intraoperative complications. Good tissue handling affects tissue healing and the quality of histopathology specimens. Attention to detail in each step of this process will promote good outcomes and patient satisfaction.
2.1 Preoperative Assessment and Discussion
A comprehensive preoperative examination and assessment is essential for surgical planning. In addition, the surgeon should counsel the patient about the proposed procedure, address the patient’s concerns, and set reasonable expectations. The patient’s other medical comorbidities should be optimized. Elective procedures are often best delayed in the setting of urgent health issues.
2.1.1 Essential Components of Preoperative Assessment
Periorbital and complete ophthalmic examination.
For trauma cases:
Careful ophthalmic examination to rule out an open globe or foreign body.
Consider CT imaging of orbits if indicated as well as B-scan ultrasound of the globe if poor view of the posterior pole.
Tetanus booster and/or tetanus immune globulin as indicated.
Documentation via medical record and photography.
Discussion of goals and expectations.
2.1.2 Anticoagulation
Stopping anticoagulation is important for patient safety. The primary concern is development of a retrobulbar hemorrhage with the possibility of subsequent optic neuropathy due to orbital compartment syndrome. Exceptions to this policy include obtaining biopsies of potentially malignant neoplasms or other small preseptal lesions, which should not be delayed. Patients are prescribed anticoagulation for a myriad of reasons and durations; thus, communication with the prescribing physician is important to ensure patient safety on stopping these medications. Anticoagulation is typically resumed on the first postoperative day. Suggested cessation schedules are as follows: warfarin for 3 to 5 days (preoperative international normalized ratio goal < 1.5), aspirin for a minimum of 5 to 7 days, platelet P2Y12 inhibitors for a minimum of 7 days, direct thrombin or factor Xa inhibitors for 2 to 3 days, and nonsteroidal anti-inflammatory drugs for a minimum of 7 days. Other supplements with anticoagulative properties are held for 1 to 2 weeks.
2.2 Perioperative Antibiotics
The infection rate for routine eyelid surgery is very low, likely due to the abundant vascular supply to the ocular adnexa. 1 As a result, systemic antibiotics intraoperatively or postoperatively are not routinely used by all surgeons. However, many surgeons prescribe antibiotic prophylaxis for their patients, and perioperative antibiotics are strongly recommended in cases of trauma, foreign body implantation, or tissue grafting. When using systemic antibiotics for prophylaxis, intraoperative cefazolin is often adequate with an appropriate postoperative oral antibiotic for 5 to 7 days. Topical ophthalmic antibiotic ointment is routinely prescribed for 1 to 2 weeks postoperatively for both infection prevention and wound and ocular surface lubrication.
2.3 Local Anesthesia and Surgical Site Preparation
Local anesthesia is used for both its anesthetic and vasoconstrictive effects. Thus, even for cases under general anesthesia, lidocaine with 1:100,000 epinephrine is infiltrated into the surgical site, allowing 10 to 15 minutes for vasoconstriction prior to making the incision. Bupivacaine can be included to extend the duration of anesthesia. The addition of hyaluronidase allows the local anesthetic effect to diffuse more widely through tissue, therefore requiring less anesthesia. Surgical markings are best performed before infiltrating and distorting the tissue with local anesthesia.
Standard preoperative site preparation includes cleaning the skin with an iodine-based solution or another antiseptic. Care should be taken to avoid the use of flammable prep solutions such as alcohol because of the risk of intraoperative fire if the surrounding drapes remain saturated. Sterile drapes are then used to define the surgical field. Many surgeons leave the full face in the sterile field. Placement of corneoscleral shells is important to protect the eye from inadvertent damage. In cases of trauma, contaminated wounds are irrigated and foreign bodies removed.
2.4 Instruments
The thin skin of the periorbita requires the use of fine suture and precision instruments (Fig. 2‑1). The basic periorbital instruments include the following:
Precision blades (#15 and #11 Bard-Parker blades) and blade handles.
Locking, fine-tipped needle holders (Castroviejo).
Fine-tipped toothed forceps (Bishop-Harmon or Castroviejo).
Fine spring handle scissors (Westcott).
Dissection instruments (Stevens tenotomy scissors, hemostat).
Eyelid eversion instruments (Desmarres retractor).
Fine skin hooks.
Fig. 2.1 Standard periorbital surgery instruments. From left to right: Number 15 Bard-Parker blade on blade handle, Castroviejo needle holder, Adson forceps, 0.5 mm Castroviejo forceps, Bishop-Harmon forceps, straight iris scissors, curved Stevens tenotomy scissors, Westcott scissors, skin retractor, Desmarres retractor, fine hemostat. Superiorly: lacrimal irrigation cannula, punctal dilator, lacrimal probe.
Orbit and lacrimal surgery require the addition of a variety of tools including a fine suction tip, malleable orbital retractors of various sizes, a periosteal elevator, curved retractors, and orbital retractors (Fig. 2‑2). The set for lacrimal surgery, such as dacryocystorhinostomy, includes lacrimal stents, lacrimal probe, punctal dilator, nasal speculum, and bone rongeurs (Fig. 2‑3).
There are numerous options for cautery. Disposable battery-operated hot-wire cautery units are simple, inexpensive, and do not require grounding the patient. High-frequency monopolar (Bovie) electrocautery requires that the patient be grounded and cannot be used if the patient has metal implants or a pacemaker. Bipolar electrocautery transmits current only between the tips of the instrument; thus, it may be used when monopolar is unsafe. Fine jeweler-tipped handpieces are available for bipolar electrocautery. Fire risk exists for all forms of cautery, especially for monopolar cautery or battery-operated cautery; hence, supplemental oxygen must be turned off and flammable materials held at a distance.
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