Patient safety and satisfaction with surgical outcomes depend on complete preoperative assessment and counseling. Medical comorbidities should be optimized and elective procedures should be scheduled so as to allow for medical clearance by other specialists as needed. Incisional biopsy of potentially malignant lesions or other small eyelid biopsies may often be safely performed without cessation of anticoagulation. For more invasive, nonemergent procedures, stopping anticoagulation should be considered and discussed with the physician managing the anticoagulation. In a large, randomized, controlled trial, the continued use of aspirin increased the risk of major bleeding in the perioperative period and did not affect the risk of death or myocardial infarction.¹ The risk of thrombosis with withdrawal of anticoagulation and the need for bridging must be assessed individually for each patient.

If the decision is made to hold anticoagulation, the specific plan should be agreed upon and carefully documented with the prescribing physician. In general, warfarin is held for 4 to 5 days, and a preoperative international normalized ratio (INR) is checked with a goal of < 1.5. Aspirin is held for at least 5 to 7 days and platelet P2Y₁₂ inhibitors, such as clopidogrel, for at least 7 days. Direct thrombin and factor Xa inhibitors (e.g., apixaban and rivaroxaban) are held for 2 to 3 days. Careful history taking and cross-checking with medication lists are necessary to elicit anticoagulation use. Nearly one out of five patients may under-report use of anticoagulation, especially aspirin.² Patients should also be instructed to hold vitamins and supplements with anticoagulative properties, such as garlic, omega-3, and vitamin E. In many cases, patients may safely resume anticoagulation on the first postoperative day.

A careful ophthalmic examination should be performed on all patients undergoing periorbital reconstructive surgery. If a patient is functionally monocular, consideration should be given to not covering the seeing operative eye, or if necessary, patching for as short a period as possible during the postoperative period. Care must be taken intraoperatively to avoid damage to the eye, especially if there have been previous surgical interventions such as corneal transplants or glaucoma blebs. In trauma cases, a careful ophthalmic exam to rule out an open globe should be completed prior to addressing any periorbital or orbital injuries. In addition, the status of tetanus immunization must be assessed. If the most recent tetanus booster was more than 5 years ago, a tetanus toxoid booster should be given. In the case of a contaminated penetrating injury when the tetanus immunization status is unknown or fewer than three doses of tetanus toxoid have been administered, tetanus immune globulin is given in addition to the full vaccination series.

The infection rate for routine eyelid surgery is very low.³ Many surgeons routinely treat patients with a prophylactic course of systemic antibiotics intraoperatively or after reconstructive eyelid surgery. However, some surgeons do not routinely use systemic antibiotics. It is especially important to consider antibiotic use in cases of trauma or when
using a full- or split-thickness skin graft. In such cases, intraoperative intravenous antibiotic may be given followed by an appropriate postoperative oral antibiotic for approximately a week. The prophylactic use of topical antibiotics in the form of an ophthalmic antibiotic ointment for 1 to 2 weeks postoperatively should be considered. In addition to preventing infection, the ointment functions as an ophthalmic lubricant.

The periorbital area has a generous blood supply, with eyelids having arcades of vessels that are supplied by both the internal and external carotid arteries. For intraoperative hemostasis, consideration should be given to the use of local vasoconstrictive agents. This can be accomplished by injecting local anesthetic consisting of 1 or 2% lidocaine with 1:100,000 epinephrine. The addition of bupivacaine extends the duration of anesthesia. Including hyaluronidase in the block allows the anesthesia to diffuse farther, which is often beneficial but should be avoided in certain cases, such as levator advancement. Local anesthesia distorts tissue planes; therefore, measurement of defects or skin marking is best performed prior to this step.

In trauma cases, wounds should be irrigated with normal saline and any foreign bodies should be removed. Skin preparation with an iodine-containing solution or other antiseptic is routinely performed. If an alcohol-containing preparation is used, as may be done in cases of iodine allergy, adequate time for drying must be allowed prior to the use of cautery to reduce the fire risk in the surgical field. Chlorhexidine should never be used in the periocular region because of the risk of permanent corneal injury. Isolation of the surgical field with sterile drapes is then performed. Often the full face is prepped and exposed with drapes for periorbital surgery, to allow for monitoring of the unoperated eye, for comparison to the contralateral side for purposes of symmetry, and for patient comfort.

Thin eyelid skin necessitates the use of fine suture and precision instruments. There are a multitude of specialized instruments available. A basic periorbital set is discussed in this section (▶ Fig. 2.1). Locking, fine-tipped needle holders, such as Castroviejo needle holders are ideal for control and manipulation of fine suture and needles. Fine-tipped toothed forceps such as Bishop-Harmon forceps or 0.5 mm Castroviejo forceps work well for gentle handling of eyelid tissue. Sharp dissection in the periorbital area is often performed with fine spring handle scissors, such as Westcott scissors. Blunt dissection may be performed with larger scissors such as Stevens tenotomy scissors or a fine hemostat. Eversion of the eyelid can be easily performed with the use of a Desmarres retractor and a traction suture placed in the eyelid margin. When elevating a skin flap, a fine skin hook may be used to prevent crush injury to the flap edges.

Punctal dilators, lacrimal probes, and lacrimal irrigation cannulas are used for evaluation of the lacrimal drainage apparatus. Stenting of the lacrimal drainage system may be performed with monocanalicular or bicanalicular silicone stents. Monocanalicular stents are seated in the punctum with a flange that fits tightly within the natural punctum. Bicanalicular stents pass through the upper and lower canaliculi and are secured in the nose forming a loop.

When possible, it is advantageous to have cautery available, as the periorbital area is quite vascular. Hand-held battery-operated hot-wire cautery units are useful for controlling minor
bleeding and may also be used as a cutting or dissecting tool. Small vessel bleeding may be controlled with high-frequency unipolar or bipolar electrocautery. Significant arterial bleeding from larger vessels may rarely require ligation with silk ties. Caution should be exercised to reduce fire risk when using cautery. Supplemental oxygen and blowing air should be turned off prior to using cautery, and flammable substances such as dry gauze sponges, cotton-tipped applicators, or paper drapes should not come in contact with the tip of the cautery unit. When the source of bleeding is diffuse, topical methods of hemostasis may be used. Applying firm, uninterrupted pressure to the wound will frequently stop the bleeding. However, this is not advisable in cases where the blood may track post-septal into the orbit and result in compartment syndrome. Cotton pledgets soaked in local anesthetic with epinephrine can be applied to the bleeding surface. If bleeding persists, thrombin-soaked compressed sponges may be packed into the wound.

Suture should be selected after consideration of the desired duration of suture within the tissue and concern about inflammatory reaction, absorption, and susceptibility to microbial colonization of the various available suture materials. Braided suture handles easily with low memory and holds knots well, but is more susceptible to bacterial colonization. Nonabsorbable sutures are more resistant to hydrolysis and as a result they are often less inflammatory. When there is concern for hypertrophic scarring, it is best to use a minimally tissuereactive suture, such as polypropylene or nylon, for skin closure.

There is a range of reactivity and elasticity among nonabsorbable sutures (▶ Table 2.1). Nonabsorbable skin sutures are typically removed at 1 week after placement, when wound healing is adequate. Sutures in the eyelid margin are often left in place for 2 weeks to ensure adequate strength and wound healing.

Absorbable sutures obviate the need for subsequent suture removal which occasionally causes discomfort and are a good choice in young children or when there is uncertainty over a patient’s reliability to return for follow-up. The wound is temporarily supported by absorbable sutures while tissue remodeling and healing occur. The suture is broken down by enzymatic degradation. The tensile strength of the suture is diminished long before the suture material is
completely absent from the body. There are many absorbable sutures available with a range of tissue durations and tendencies to incite inflammation (▶ Table 2.1).

Selection of the size (diameter) of the suture filament is dictated by the thickness of the tissue. Thin eyelid skin can be approximated with fine suture, such as 6-0. Thicker glabellar, brow, or cheek skin can be closed with larger suture, such as 4-0 or 5-0. Finer 7-0 suture may be used in the eyelid margin or at the eyelash line.

When suturing, it is important to select the appropriate needle. Reverse cutting or cutting needles pass most easily and atraumatically though tissue. Spatulated needles allow the creation of partial thickness lamellar passes through dense tissue, such as tarsus or sclera, while minimizing the risk of full-thickness penetration of these tissues (▶ Fig. 2.2). The degree of curvature of the needle also impacts its utility. Moderately curved needles, with 1/4th circle or 3/8th circle curvature, are commonly used to suture skin or tarsus. More highly curved semicircular needles are useful for locations with limited working space or for buried sutures (▶ Fig. 2.3).