Continuing to describe the Asian blepharoplasty technique used by the author, this chapter looks at the handling of the middle layer structures of the eyelid once the preaponeurotic (middle) space has been reached. The chapter will take the procedure up to closure of the eyelid crease. Figure 9-1 shows the cleared preaponeurotic plane being readied for construction of the eyelid crease.
Following Opening of the Orbital Septum
Rotation of Myocutaneous Strip Away From Underlying Levator Aponeurosis and Preaponeurotic Fat Pad, Hinging It Along Superior Tarsal Border
A Blair’s retractor is used to retract the opened upper incision (skin and orbicularis) ( Figure 9-2A ); Westcott scissors are used to separate the preaponeurotic fat beneath it from the orbicularis in front and levator below it. This central preaponeurotic fat pad is often adherent by fascial attachment to its underlying levator muscle fibers ( Figure 9-2B ).
The fat should be repositioned and allowed to fill in the space between the levator and anterior aspect of the superior orbital rim (the supratarsal sulcus).
In Figure 9-3 the skin–muscle flap is being retracted in the upper portion of this photograph using a Blair retractor along the upper incision line (surgeon’s view from the head of the table). Pristine levator muscle with fine blood vessels can be seen running vertically over the levator, as well as within the preaponeurotic fat pad (vessels running horizontally here).
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After separating the initial fine adhesions of fat from the overlying orbicularis, it is often safer to use moist cotton tip applicators to separate fat from the underlying aponeurosis.
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No attempt is made to remove fat pads unless the fat is grossly interfering with crease formation along the superior tarsal border. A Wetfield bipolar cautery may be used to reduce it if it is potentially hindering the construction of a good crease due to its presence directly over the superior tarsal border.
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Avoid pointing the scissors posteriorly towards the levator as you elevate the myocutaneous flap.
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After the myocutaneous flap has been elevated, avoid cutting any fat that may be intertwined on the underbelly of the myocutaneous strip; this may cause bleeding of the intra-fat blood vessels, as well as unintended reduction in the volume of preaponeurotic fat left behind.
Partial Excision of PreaponeuroticFat ( Figure 9-4 )
Occasionally in patients with very full upper lids, significant fat is seen centrally or plastered low down on to the aponeurosis. This may interfere with any attempt to form a crease. In these patients, instead of partial shrinkage with bipolar cautery, one may opt to excise a small fraction of the preaponeurotic fat seen within the surgical field.
A bipolar cautery is used to treat any prominent blood vessels first, then cutting monopolar cautery is used to cut the fat pad 2–3 mm at a time; then the bipolar cautery applications are repeated. It may take two to three repetitions before this step is completed.
If an older patient with dermatochalasis and obliteration of the crease shows even a very minimal concavity in the supratarsal sulcus, one should not remove any fat as this will worsen the hollowness and result in multiple redundant folds superior to where one would want the crease to be. Instead of excision of the fat, one should reposit it above.
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Extra care and time is allotted to this step of reduction of fat pads, if elected. Hemorrhage from undetected bleeders following transection of the intra-fat vessels may lead to serious consequences, including orbital hematoma and blindness.
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A prolapsed lacrimal gland may look like a fat lobule. It must be recognized and needs to be re-anchored to a point behind the superior lateral orbital rim.
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It is important to clearly identify the nasal fat pad and central preaponeurotic fat pad from the lacrimal gland lobule.
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Transection of the lacrimal gland may lead to varying degree of dry eye.
The Second Vector: Excision of Myocutaneous Flap (Skin, Orbicularis, Inferior Remnants of Septum) along Superior Tarsal Border ( Figure 9-5 )
This is carried out by grasping the lateral end of the myocutaneous flap of the right upper lid (or medial end of the left upper lid myocutaneous flap) with the instrument in your left hand, then using the monopolar needle tip on cutting mode to cut along a plane between the orbicularis within the flap and the superior tarsal border/aponeurotic junction.
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When the myocutaneous flap is incised, the orbicularis muscle will bleed. As one proceeds, one should control each new bleeder with bipolar cautery as soon as it arises, rather than cutting off the whole strip first before coming back to control a group of bleeders. In my view, it seems to decrease postoperative edema and hematoma formation.
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There is a tendency to go too shallow over the medial starting point of the left upper lid during this phase of the excision of the myocutaneous strip, leaving behind too much orbicularis. An inadequately anchored crease over the medial one-third of the lid may result from this subtle oversight.
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