52
Blepharoplasty

See Chapter 3.

1. Complete lid and eye examination to determine detailed operative plan.

2. Measure position of lid crease. (If lid crease is indistinct or malpositioned, placement of supratarsal fixation sutures may be indicated.)

3. Evaluate presence and location of herniated orbital fat. (Cosmetically unacceptable fat prolapse is often located medially.)

4. Evaluate brow position. (A brow lift may be required if brow droop is present.)

5. Evaluate lid position. (A ptosis procedure may be indicated in combination with the blepharoplasty.)

6. Check corneal sensation, corneal staining, Bell phenomenon, and Schirmer test to evaluate potential impact of any postoperative lagophthalmos.

7. Perform a visual field examination to document any field cut (usually superior) secondary to dermatochalasis if required by insurance.

8. Obtain photographs in frontal and side view to document preoperative appearance.

9. Discontinue aspirin and nonsteroidal anti-inflammatory agents for 10 days before surgery. Discontinue warfarin 2–3 days preoperatively, if medically possible.

10. Query patient about bleeding tendencies. A useful screening question is asking if the patient had unusual bleeding after dental extraction. Obtain hematological evaluation if bleeding tendency is suspected.

Instrumentation

Scleral shield

Marking pen

Toothed forceps

Scalpel (e.g., #15 Bard-Parker blade)

Stevens scissors

Westcott scissors

Cautery

Needle holder

Hemostat

Sutures 6–0 Prolene or 6–0 fast absorbing plain gut

Operative Procedure

1. Mark location of desired lid crease with tissue marking pen usually at the upper border of the tarsal plate.

a. In general, use the existing lid crease because it is easier to make symmetric marks.

Note: Creases are lower in men than in women, and lower in most Asian individuals than in Caucasians.

b. The eyelid crease is ~6 mm above lashes at the lateral canthus, 7–9 mm centrally, and 5 mm nasally.

2. Ascertain upper border of planned skin resection, noting the preoperative appearance of eyelids and size of desired eyelid fold. Use one of the following methods:

a. Place lower tooth of forceps on the premarked lid crease line, pinch excess skin just enough to evert lid margin slightly. Repeat this maneuver over the full extent of the upper lid, marking upper border of skin to be resected with marking pen. (This maneuver suggests the most skin that can be removed without developing lagophthalmos) (Fig. 52.1).

b. Measure from inferior aspect of eyebrow to upper aspect of planned excision on each side. In functional blepharoplasty, it is rare to leave less than 8–10 mm from inferior brow to upper aspect of the incision. In cosmetic blepharoplasty, leaving 12–17 mm of skin is typical. Note, by inspection and palpation, the junction of thin eyelid skin and thicker skin below eyebrow; do not extend excision into the thicker skin (Fig. 52.2).

3. Extend marks medially to level of superior punctum and temporally beyond lateral canthus.

a. Lateral extent of blepharoplasty is determined by redundancy of skin beyond canthus. If skin is to be excised laterally, gently slope excision superiorly from the canthus following the normal skin crease pattern.

b. Angle upward if extending medial past punctum to avoid webbing.

4. Apply topical anesthetic.

5. Subcutaneous infiltration with a 50:50 mixture of lido-caine 2% plus 1:100,000 epinephrine and 0.75% bupivacaine.

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