Dr Chen’s Preoperative Regimen
For cosmetic blepharoplasty, Dr Chen routinely prescribes 10mg of Valium plus one tablet of Vicodin at 60–90 minutes prior to the procedure. This allows a good period of time for the sedative and analgesic effect to take place. Patients may have been nervous and sleepless the night prior to coming in, or they may have had to travel from a distance, and most will enjoy the relaxation.
About 10 minutes before the scheduled time, he greets his patient and goes through the following check list:
- 1.
Reaffirm the physical findings previously observed and discussed with the patient.
- 2.
Reaffirm the goals of the patient for the surgery that day.
- 3.
Ask if there are any unanswered questions.
- 4.
Take photographs.
The patient is positioned on the operating table in a supine position. A soft foam cushion headrest as well as knee and back support are provided. The nursing staff attach the appropriate monitoring leads, including electrocardiographic, pulse oximetry, as well as grounding pads for monopolar cautery or a radiofrequency transmitter lead.
Intraoperative Regimen
Dr Chen uses 2% xylocaine with 1:100 000 epinephrine, mixing 10mL with 150 units of hyaluronidase, if available. He then mixes 1mL of the 2% xylocaine with 9mL of injectable saline to yield a relatively painless injection (pH balanced, diluted to 0.2% xylocaine and 1:1 000 000 epinephrine).
A dose of 0.5mL of 0.2% xylocaine is applied subcutaneously per eyelid. He then waits 2 minutes. Clinical blanching of the skin is observed. Further infiltration of about 0.75–1.5mL of 2% xylocaine (full concentration) per eyelid is then given submuscularly.
A drop of proparacaine is applied per eye for topical anesthesia of the cornea, conjunctiva, and inner surface of the eyelids. The nursing staff prepare the operative field with the appropriate disinfective soap or solutions.
Via a pre-placed butterfly, intravenous aliquots of Versed (midazolam) 0.5mg may be utilized, should further sedation be necessary. Nasal oxygen or room air may be supplied.
Surgical drapes are applied. Dr Chen uses paper drapes as well as an operculated 3M #1020 adhesive drape to minimize any potential gaseous communication between the operative field and the rest of the face under the paper drape. A drop of tetracaine is applied per eye for longer lasting effect.
A black corneo-scleral shell that conforms to the curvature of the cornea and sclera is lubricated with sterile Lacrilube ophthalmic ointment and then applied over the eye to be operated on. The procedure commences.
Ice-cold saline solution is used on the operative field.
In selected patients or those who prefer a deeper level of conscious sedation or general anesthesia, the use of an anesthesiologist may be prearranged. This category includes those patients who required cheeklift/midface repositioning, as well as a significant number of those requiring revisions.
Preoperative Regimen of Dr Khan
Most incisional cosmetic procedures are performed in an ambulatory surgery center where monitored anesthesia care is delivered by certified registered nurse anesthetists (CRNA). Patients are greeted and reassured preoperatively and the procedures are confirmed. In the preoperative holding area, supplemental oxygen is provided via nasal cannulae, pulse oximetry and cardiac telemetry are monitored and a heparin lock is placed for intravenous access. In the holding area, patients are rendered amnestic and briefly unconscious with intravenous Versed and Propofol prior to injection with local anesthetic. Usually, the local anesthetic consists of lidocaine 2% with epinephrine 1:100 000 mixed 1:1 with Marcaine 0.75%.
In the operating room, the patient is prepped and then draped with cloth towels. Metal protective eye shields and wet cloth towels are placed if CO 2 laser is to be used. Supplemental oxygen is provided via nasal cannulae, and pulse oximetry, blood pressure monitoring, and cardiac telemetry are continued. Propofol is delivered intraoperatively by the CRNA, if needed. In patients in whom deeper levels of sedation or even unconsciousness are required, supplemental oxygen is delivered to the nasopharynx via a nasal trumpet so as to maintain pO 2 levels despite respiratory depression. This technique allows CO 2 laser resurfacing to be performed without any local anesthetic or endotracheal intubation. Supplemental local anesthetic is often used intraoperatively.
For in-office upper eyelid blepharoplasty, anesthetic discomfort is reduced when each eyelid is pre-injected subcutaneously with 0.75mL solution lidocaine 2% with epinephrine 1:100 000 mixed 1:1 with nonpreserved saline. This is followed by an injection of 0.75mL lidocaine 2% with epinephrine 1:100 000. The subcutaneous anesthetic bolus is then milked and manipulated to cover the entire surgical site.
Following surgery, erythromycin ophthalmic ointment may be placed on the eyes or incisions. Patients generally are recovered and discharged within 30 minutes. The eyes and incisions are not usually patched. Stitches (usually 6-0 Prolene) are usually removed 9–12 days after surgery.
Postoperative Considerations
The following is a sample of Dr McCord’s postoperative instructions for his patients:
Scars
Incisions for a blepharoplasty are made in the natural crease of the upper lid, which disguises the final thin scar so that one would have to look very closely in the mirror to determine where an incision had been made, if one can see it at all. In the lower lid, the skin incision is made as close as possible beneath the lash line, and many times extends past the corner of the eye for several millimeters if needed. These incisions leave imperceptible scars. The only area of incision that may be noticeable for a period of time is the outside corner of the eye, in the laugh line area. Some people may require a longer incision or stitch line at the outside corner of the eye in a slightly downsloping direction. This is needed so that the skin may be tensed in the proper way to get good cheekbone definition, and this is true particularly if they have extra folds in the lower cheekbone or mid cheek area. If it is necessary to carry the incision into this area, there usually occurs a small red line, which will fade with time. If one does require an incision above the eyebrow, as will be discussed with the direct brow lift, the incision line is more conspicuous but can be covered with cosmetics until the incision line fades. Although it is unusual to have to do so, dermabrasion can smooth out incision lines that are more conspicuous than one would like, if they do not smooth out on their own. Incisions behind the hairline leave no visible scars and, with the newer techniques, little if any hair loss.
It is important to understand the natural history of healing and scar formation. Tissue glue causes enough healing within a week or 10 days such that the incision is strong enough and the stitches can be removed at that time. The incision lines, however, then begin to ‘knit’. This process includes the ingrowth of many blood vessels, extracellular material, and other tissue that goes into those areas to strengthen the tissue. During this period of ‘knitting’ (5–6 weeks), the incision lines will become tight, firm, and reddened, which is the body’s response to any cut or incision. This process may not be noticeable to other people but may be noticeable to the patient, and is more a source of frustration than any discomfort. When the body finally recognizes the fact that the tissues are healed enough to suit its purpose (6–7 weeks), the extra blood vessels and cellular material will leave and the incision lines will soften, bleach, and then fade. The maximum relaxation occurs in about 4 to 5 months. During this period of time – or, for that matter, any time after – it is extremely important to avoid any sunburn or exposure to ultraviolet light in those areas, as this may aggravate and intensify the activity in the incision line.
Stitches
The stitches used are generally nylon stitches or very fine silk sutures, which are removed in 5 to 7 days. Immediately after removal of the stitches, no creams or cosmetics should be used, to avoid tiny cysts that may form along the stitch tracks. About 7–10 days must go by to allow smoothing over of the stitch holes; after this time, one may use cosmetics and cover-up creams, if desired, over the incision lines. Surgical staples or the mini screws associated with the endoscopic eyebrow–forehead lift are usually removed at 10–14 days.
Anesthesia
For the standard eyelid surgery – either upper lids or lower lids by themselves, or upper and lower lids at the same time – usually the surgery can be done with deep sedation (twilight sleep) and local anesthesia that numbs the eyelids. Most people sleep through the procedure. Dr McCord prefers general anesthesia. If one is going to have eyelid surgery combined with the mini-lift of the forehead, or a cheeklift performed with a lower lid blepharoplasty, then a very light ‘general’ anesthetic is preferred because of the length of the procedure and patient comfort. These procedures can easily be performed on an outpatient basis; however, some people may elect to spend the night after surgery in hospital, for which most hospitals will provide a special rate.
What to expect immediately after surgery
Accentuated appearance
It is normal in the lower lid to have an accentuated tightness in the outside corners, giving an upslant appearance, in the immediate postoperative period and for a while thereafter (usually 3–4 weeks). This is necessary because of the need to strengthen the lower lid tendon to prevent a pulling down of the lower lid in the swollen period after surgery. This appearance is temporary, but is necessary to prevent the complication of scleral show (excessive white showing under the eye).
Bruising and swelling
There is great variation among individuals with regards to bruising and swelling. It is very rare for a person to get no bruising or swelling at all. Most people will have a puffy and purplish appearance to the eyelids. With the ‘standard amount’ of bruising and swelling usually seen, most people are presentable for public appearances (with make-up) in 10–14 days.
It is very important for patients to avoid all medications containing aspirin, aspirin-like medications, or any true blood thinners before surgery and for a week after surgery. It is also important to have their blood pressure controlled, in that if the blood pressure is elevated at the time of surgery, they will most certainly bruise more. The most important thing to do to reduce postoperative bruising and swelling is to use ice compresses continuously for the first 48 hours after surgery and as much as possible thereafter. On no occasion should heat compresses be applied to the eyelids during this period. Sometimes, before and after surgery, special medications are given, such as low-dose cortisone, to help prevent the tissue reacting so much to the surgery.
Eye lubrication and blurred vision
Our main concern for the health of the eye is the prevention of ‘dry spots’ that can occur after surgery. Because there will be some ‘tightness’ of the eyelids following surgery, we require the patient to apply lubricants to his or her eyes, particularly at nighttime, to avoid any dryness or symptoms of dryness. All tear production is examined before surgery; however, in some rare situations, a person may be required to use lubricating drops after surgery to allow his or her eyes to be comfortable. Immediately after surgery, we prefer the use of ointments, which are much more effective at preventing dry spots; however, most people do not like them because they do blur the vision. This extra lubrication is needed right after the operation for protection of the eye from dry spots and chemosis. To reduce postoperative chemosis, we apply a 6-0 nylon tarsorrhaphy suture through the upper and lower tarsal plates 1mm lateral to temporal limbus prior to completion of the case. After the stitches are removed, one can, in most cases, switch to artificial teardrops, which do not blur the vision.
Physical activity
The first 2 days are completely devoted to ice compresses and head elevation and remaining quiet. Walking around and sedentary activity can take place following the first 2 days until suture removal. The ice compresses can be used intermittently during this period (usually 30 minutes, four to five times a day). It would be possible to drive a car during this period if there was a definite need; however, the vision will be very blurred from the use of the ointment and the stiffness of the eyelids. There should be no exercise (aerobics, jogging, etc.) the first week. In the second week, no exercise should occur that places a strain on the incisions; however, some walking and stretching can be done.
Only after the first 2 weeks should exercise that raises the heart rate be undertaken. The ‘extra blood’ that may be pumped through the operated area might cause swelling. If this occurs, then the patient should stop and apply ice to the area.
Common patient worries
The two things that generally concern people the most immediately after surgery are:
- ▪
body image; and
- ▪
blurred vision.
Body image
Most people have a puffy and purplish look to their eyelids immediately after surgery. There will also be the overly tight or very tense look in the corners of their eyes if they have had lower lid surgery. This appearance can cause initial ‘patient remorse’ since they may not have seen themselves with this appearance unless they have had previous surgery. This is, of course, the normal appearance following this type of surgery, and, with time, the puffiness and bruising will go away and their eyelid contours will resume to the desired appearance.
Blurred vision
Immediately after surgery, the patients’ vision will be blurred to the point that they will not be able to read very well. The reasons are that their eyelids, which are basically windshield wipers, will be stiff for a period of time and will not be able to wipe (their cornea) properly. Also, they will be using lubricating ointment in their eyes to prevent dry spots, which will add to the blurring.
It is very important that the patient’s family or those who will be caring for the patient after surgery know and expect these changes so they will not have concern.
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