The Art of Surgical Technique


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Welcome! I hope that this book will add to your success in the clinic and operating room. It is my pleasure and honor to make any contribution I can to your learning! For me, three decades of practice have been more fun than work, and even after all these years I am still learning and improving my technique. My wish is that you do the same.

This chapter serves as your introduction to some of the theoretical and practical technical aspects of actually performing surgery. A successful operation starts with planning before you enter the operating room. To be effective, you must have a plan and let the operating room team know what it is. If you are prepared, you will inspire the team to follow your leadership. You will coordinate the setup of the operating room and equipment necessary for your procedure.

To be effective, you need to know the tools of the trade and how to use them. In this chapter, we discuss different types of instruments and their general and special uses. We stress some fundamental techniques, including holding and cutting of the skin. We describe the important instruments used in retraction, hemostasis, suctioning, and suturing. In the last section, we talk about the role of the assistant, who has an underestimated and important job.

As you read this chapter and the others, look at the big picture first. I suggest that you read the chapter three times, going into more depth each time. Scan the chapter initially to get the flow of the material, and then go back and peruse the content casually. Don’t labor over the details of each section; rather, read the text several times as your abilities and interests increase, each time taking in more detail. If you are like me, you have read a text and carefully underlined passages in it, and then realized that you don’t remember a thing! There is a lot of information here. Learning happens in layers over time.

Preparation for the Operation

Firm Plan with Contingencies

When you enter the operating room, you should have a firm plan in mind. Early in your career, it is helpful to have a set of contingency plans if things don’t go as expected. As your surgical expertise increases, your need to make formal contingency plans will disappear. At the early stage, or later when you are planning a new procedure, it is helpful to write down the steps of the operation and list the necessary equipment and then bring the list to the operating room. The nursing staff will appreciate your preparation and be confident in your abilities.

You are the team leader in the operating room. Your behavior sets the stage for how the operation goes. You set the pace and the quality of the entire effort. If you are operating in a new setting, be sure to introduce yourself to the nursing staff. Discuss your plans for surgery with the team. Your preparation and willingness to include them in your plans will improve the overall effort and give the team confidence in your ability to get the job done. This approach applies to every surgeon, from new residents to experienced surgeons in practice for many years.

Room Setup

Part of your plan should be to know where the operating equipment is placed. Generally, the setup is as shown in Figure 1.1 . In most cases, the position and orientation will be the same for each procedure in a particular operating room. For example, usually the head is away from the door and away from the flow of traffic in the room. In some cases, the operated eye will be placed away from the anesthesia equipment. You, as the surgeon, will sit at the head of the bed. Your assistant will sit at the side of the bed corresponding to the operated eye. For some procedures, you may find it easier to sit at the patient’s side (e.g., for lateral tarsal strip and lateral orbitotomy procedures). Feel free to move throughout the operation and be comfortable. The nursing table is placed on the side of the operating table, opposite any anesthesia equipment and staff.

Figure 1.1

Typical operating room setup for an operation on the right eye.

Equipment Setup

For most operations, you will be in the sitting position. If you are planning to move around the patient during the operation, as in an orbital floor exploration for a blowout fracture, you may want to stand. If so, consider step stools to make the assistant and surgeon relatively the same height.

Once you have decided whether to sit or stand, you should position the operating room table. Often it is helpful to angle the head of the table away from the anesthesia equipment. Remember to consider where the operating room overhead lights are when positioning the table. Adjust your chair to an appropriate height with your feet flat on the ground. Adjust the table height so that your elbows are bent slightly more than 90 degrees. Make sure that the patient’s head is at the top edge of the operating table and the plane of the face is parallel to the floor so you will not have to lean over the patient. Take the patient’s pillow and place it under the patient’s knees.

Do your best to position the patient for the comfort of both the patient and yourself. When operating on children, your view will improve if you place a towel roll under the patient’s shoulders to hyperextend the neck, bringing the face into the same plane as the table. Older patients with neck arthritis may require a roll under the head for comfort. Markedly kyphotic patients may need a pillow under the neck and shoulders for comfort. You may have to operate standing at this patient’s side with the head of the bed elevated. In some cases, you can raise the foot of the bed so that a kyphotic patient is flatter on the table. Do your best to maintain reasonable posture. Many older surgeons have to alter or stop their surgical practices because of the neck aches and back pains that result from years of poor body mechanics. Learn to preserve your spine and neck from the beginning of your surgical career!

If you expect significant venous bleeding, as in nasal surgery, put the patient in about a 10% reverse Trendelenburg position (head up, feet down) before adjusting the table height. Once the table is at the chosen position and height, make sure that it is locked into position.

If you are using an operating microscope, this is the time to make adjustments to the scope and your chair. There are several possible positions for the scope base, but the most common is off the shoulder of the patient opposite to the eye on which you are operating. Set the base of the scope to allow for the full range of the microscope’s arm. Make gross adjustments to the microscope height. Set the interpupillary distance of the microscope heads for the surgeon and the assistant. Set the focus of the microscope. If you are doing a conjunctival or canalicular procedure, set the focus of the microscope in the middle of the range. If you are doing deep orbital surgery, set the focus at the top of the focus travel so that you are able to adjust the focus with the foot pedal to see deeper tissue without repositioning the operating scope as the dissection continues into the orbit. Most procedures are performed without a wrist rest, but don’t hesitate to use one if it increases your steadiness. If you plan to drape the scope, swing the microscope arm away without altering your microscope base position and have the scrub nurse drape the scope away from the operating field. Consider using sterile handles or sterile baggies over the handles rather than draping the whole scope to save time and money. Position the microscope and cautery foot pedals in the appropriate spot underneath the head of the table. If you don’t do this, you may be surprised at how many times you start the operation and reach for the cautery pedal but find that it is not yet ready to use. Do all this before you leave to scrub.

Skin Marking and Local Anesthesia

Many oculoplastic procedures require skin marking as a guide to incision placement. Most incisions are placed in natural skin creases , such as the upper lid skin crease for ptosis and blepharoplasty operations. Other skin incisions are placed adjacent to anatomic structures so the scar will be hidden. You should mark the skin before any local anesthetic is injected. Two good choices for marking eyelid skin are available: (1) gentian violet solution and (2) the surgical marking pen. Gentian violet can be applied with the sharp end of a broken applicator used as a quill. With experience, you can draw a fine line that does not easily wash off with prepping, but this takes some experience to keep from making a mess. Usually, we use a thin-tipped surgical marker (Blephmarker 1424 Gentian Violet Twin Ultra Fine Tip Ruler Sterile, , reference 1424SR-100). Be sure to degrease the skin with an alcohol wipe before marking.

You should use a local anesthetic with epinephrine for all procedures to provide some hemostasis (due to the vasoconstriction). The most common local anesthetic mixture is 2% lidocaine with 1/100,000 epinephrine in combination with 0.5% bupivacaine. Some surgeons choose to add hyaluronidase to the mix, but I have not found this necessary. For larger scalp and face procedures, you may want to consider “tumescent” anesthesia. With this technique, a large amount of very dilute local anesthetic with epinephrine is injected into the subcutaneous tissues. This technique firms up the tissues and makes it easier to develop flaps and perform liposuction. This is not needed for periocular procedures.

Local anesthetics sting badly (if you are not feeling sympathetic, have a colleague inject 1 mL of local anesthetic into your eyelid; you will not soon forget how it feels). Two factors are thought to be responsible: (1) a difference in pH and (2) the distention of the tissues during rapid injection. To minimize the pain, try injecting a tiny amount—about 0.1 mL—into two or three places and then massage the local anesthetic into the tissues. After a few seconds, inject more anesthetic very slowly. This greatly minimizes the pain. Some surgeons buffer the local anesthetic using one part 7.5% sodium bicarbonate in nine parts 2% lidocaine with epinephrine (2 mL of bicarbonate in 20 mL of lidocaine). I have not found this worth the trouble, but many surgeons swear by it. If you operate with an anesthesiologist, using appropriate sedating agents, the patient is totally unaware of any local injections.

Remember to inject just beneath the eyelid skin. Avoid placing the needle into the muscle to prevent a hematoma, which may make intraoperative adjustments of the eyelid difficult; this is especially true with anterior ptosis correction. Avoid putting the needle in the crease at the junction of the lateral one third and medial two thirds of the eyelid. There is a vessel that, if torn, will guarantee a hematoma before you start the procedure! For an upper eyelid procedure, such as a blepharoplasty or ptosis repair, you should inject 1 to 1.5 mL of local anesthetic mix.

The topical solutions that provide anesthesia are EMLA cream and Betacaine gel. EMLA cream should be applied in a thick coating 1 to 2 hours ahead of the procedure and covered with an occlusive dressing (topical lidocaine 2.5% and prilocaine 2.5%). BLT cream (20% benzocaine, 6% lidocaine, and 4% tetracaine) is an alternative. Betacaine gel (topical lidocaine 5%, ) can be applied for 20 to 30 minutes ahead of the procedure without an occlusive dressing. These preparations provide some anesthesia but do not cause vasoconstriction, so an additional local injection with epinephrine is required for surgical procedures. Topical agents are also useful prior to Botox or filler injections and can be helpful in children. Overdosing with a systemic reaction is unlikely but possible. Most of the time, I do not use these preparations, but you might find them helpful in some situations. You may be able to avoid taking a child to the operating room for suturing if you apply topical cream before injection of any local anesthesia.

Most eyelid and lacrimal operations can be performed under local anesthesia. If you choose to operate without the benefit of an anesthesiologist, you should consider intravenous (IV) sedation to minimize the patient’s anxiety. Doses of midazolam in 0.5- to 1.0-mg increments are reasonable to achieve some relaxation. I find it helpful to have a midazolam drip running (1 to 3 mg/hour) rather than give intermittent doses of the medication. Some surgeons prefer preoperative oral sedation with 2 to 10 mg of oral diazepam. Additional pain relief can be given intraoperatively using small doses of a narcotic, such as morphine (1 to 2 mg IV). Intravenous fentanyl is useful because of its short duration, but keep in mind that this is a very potent opiate narcotic and a highly abused drug. Surgical centers often do not permit the surgeon to administer this without anesthesia staff oversight. Avoid oversedation to the point that the patient has lost inhibitions and gets restless or is too sleepy to follow your instructions. A supportive attitude from you and the nursing staff (sometimes called talk-esthesia or vocal local) is helpful. I am always impressed by how many postoperative patients comment on how helpful it was to have the circulating nurse offer to hold hands during the procedure. The nurse can also alert you when the patient is feeling discomfort.

If your operating situation allows for the efficient use of monitored anesthesia care, your anesthesiologist can medicate your patient to the point at which there is no memory of any pain from the injection and often no memory of the entire operation. The downside of this is more staffing and an increased cost. The majority of my eyelid and lacrimal procedures are done with monitored anesthesia care in our practice-owned ambulatory surgery center. If you plan to ask for any intraoperative patient cooperation, such as eyelid opening for a ptosis adjustment operation, make sure that no IV midazolam is administered until you have completed the adjustment. As you would expect, working with the same anesthesia and nursing team on a regular basis increases your efficiency greatly and can make your life in the operating room much better.

Preparing and Draping the Patient

In most operating rooms, the patient can be prepped while you scrub. This gives time for the local anesthetic to take effect. A traditional povidone-iodine scrub applied in concentric rings away from the planned surgical excisions, repeated three times, provides adequate cleaning of the skin. A surgical bonnet and a drape with a single sticky edge (bar drape) across the forehead keep the patient’s hair out of the operating field. If the hairline is particularly low or close to the operating field, tape can be used to pull the hair away from the field. For most procedures for which the patient is awake, the entire face is prepped under local anesthesia. If the patient is asleep, prep both eyes whenever there is a need to obtain symmetry between the two sides or if forced duction testing may be required. A good general rule is to prep a larger area than you think you will need. Most of my patients are draped with a single split sheet (U-drape) spread over the face. It is worth considering placing a towel over any endotracheal tube before placing the U-drape so that the adhesive on the drape does not stick to the tube (and it is always a good idea not to pull the tube out when tearing the drapes off the patient!).


In the next sections of the chapter, we will discuss several types of surgical instruments. These instruments include:

  • Scalpel blades and other cutting tools

  • Scissors

  • Forceps

  • Retractors

  • Cautery tools

  • Suction implements

  • Needle holders

  • Sutures

You are undoubtedly familiar with several variations of each of these instruments. I am going to explain the instruments that I have found most useful in my practice. You may already have your own favorite tools for specific jobs, or you may choose to use the instruments that I have suggested.

Particular instruments are available in different lengths and calibers. In general, the length of the instrument is related to the depth of the surgical incision in which the instrument is used. Most of the eye instruments are only 4 inches long. These instruments are not used in deep incisions and are rarely used for incisions deeper than the eyelid. The delicate instruments used for neurosurgery are much longer, often measuring 12 inches. An example is the curved Yasargil scissors used in optic nerve sheath fenestration. These instruments are 9 inches long and have a finer tip than the familiar Westcott scissors used for eye and cardiac surgery. Ideally, for an optic nerve procedure, I use a 6-inch instrument, but none is currently available in this scissor type so I make do with the longer instrument. The caliber or strength of the instrument varies, depending on the type of tissue to be manipulated or cut. Conceptually, you want to pick the correct instrument based on length and caliber. We talk more about the individual variations of each of these instrument types later in this chapter.

Cutting the Skin

Hand Position

Once you are properly positioned at the head of the bed of a patient who has been prepped and draped, your next job is to make a skin incision. Remember you are positioned with your feet flat on the ground and your elbows at your side in flexion slightly more than 90 degrees . Hold your hands in the functional position (like holding a pencil), with your hand in slight flexion at the wrist. This improves your dexterity and strength.

There are three tools used for cutting the skin:

  • No. 15 scalpel blade

  • Microdissection needle (Colorado needle)

  • CO 2 laser

Most of my comments not only pertain to the traditional scalpel but also to the cutting cautery needle and CO 2 laser. It is worth learning the traditional surgical techniques with the scalpel and scissors. As your skill increases, you will likely find that using the microdissection needle or laser shortens the operating time. Although some surgeons use a blade and scissors throughout all operations, I use a microdissection needle for most surgeries.

As you hold the scalpel with the pencil grip , you notice that, on the scalpel handle, there is a groove or flat area where your index finger rests. The scalpel is supported between your thumb, index finger, and middle finger ( Figure 1.2 ).

Figure 1.2

Holding the scalpel with the pencil grip. Note that the hand is in the functional position in slight flexion.

The eyelid skin is mobile. Precision cutting requires immobilization of the skin with the help of your fingers or the assistant’s fingers. Let your ring finger rest on the patient, stabilizing the skin or guiding your hand. Learn to use the ring finger on your dominant hand and the thumb and forefinger on your nondominant hand to stabilize the skin ( Figure 1.3 ). If the tissue is slippery, using a gauze pad for some traction will be helpful.

Figure 1.3

Skin stabilization. During upper eyelid blepharoplasty, the skinfold is stabilized and stretched with the surgeon’s fingers while the upper eyelid is drawn downward using a lid margin traction suture. Note that a Colorado microdissection needle* is being used for the incision. With experience, the traction suture can be eliminated and the surgeon can use fingers to stretch the skin tightly.(*The original micropoint electrocautery needle was called the Colorado needle. Other brands of true microdissection needles are now available. In this text, the terms Colorado needle and microdissection needle are used synonymously. However, this fine tungsten microtipped needle should not be confused with the older needle point monopolar cautery tool available in many operating rooms.)

It is best to start the skin incision with the tip of the scalpel blade. As you move across the incision, lay the scalpel down so that you are cutting with the curved part of a no. 15 blade. As the wound edges start to separate, observe the depth of the wound. Ideally, you want to cut the eyelid skin only and not extend the cut deep into the orbicularis. This is difficult to do but, nevertheless, worthwhile. Controlling the depth of any eyelid incision is critical. Remember that the eyelid is only slightly more than 1 mm thick at the skin crease, and you do not want to extend your incision into the cornea! You might find initially that using a corneal protector is a useful safeguard. With experience, you will probably find it easier not to use a corneal protector for scalpel cutting or cutting cautery incisions, but surgeons vary on this opinion. Adjust the pressure to maintain the proper depth of the wound. As if you were driving a car, look down the road as you pull the scalpel across the skin. All of this is happening as you or your assistant holds steady tension on the skin. Remember, tight skin is more easily and accurately cut than more mobile skin. Like most instruments for eye and eyelid surgery, the scalpel is a finger tool. As you bring your fingers toward your palm with the scalpel tip, you may need to reposition your hand and repeat the cutting process in lengths of the wound ( Figure 1.4 ). As you get more experienced, you will be able to flex your fingers and move your hand at the same time.

Figure 1.4

Flexion of the fingers with the scalpel blade followed by movement of the hand.

This is a good time to remind you about having a good body position . You should feel relaxed and at ease as you cut. Make sure your elbows remain close to your side rather than up high; having them up high converts the scalpel to an arm tool rather than a finger tool. You will be making many incisions in your life, so learn to cut away from important structures such as your fingers and the eye. Familiarize yourself with the several types of scalpel blades available.

Scalpel Blades

  • No. 11 blade: This blade has a sharp point that is good for tight angles and curves. It is a good “stabbing” knife for draining an abscess or a chalazion. It is not useful for longer incisions.

  • No. 15 blade: This is the best all-purpose scalpel blade for eyelid and facial skin; 99% of your eyelid surgery with a scalpel will be done using a no. 15 blade.

  • No. 10 blade: The no. 10 blade is shaped like a no. 15 blade except it is bigger. This blade is used primarily for thicker skin incisions. It is not used for periorbital incisions but can be helpful in facial flaps.

  • Beaver blades ( ): The no. 66 Beaver blade (376600) is a special-purpose right-angled blade. Its primary use is for making cuts in tight spaces. It is especially useful for nasal mucosal incisions in dacryocystorhinostomy procedures. Angled keratomes designed for anterior segment surgery work in a similar fashion ( Figure 1.5 ). Other useful blades are the no. 64 blade (376400 rounded tip, sharp on one side) and the no. 76 blade (376700, a mini no. 15 blade), both of which are useful for the delicate shaving of tissue off the sclera or cornea. The needle blade 375910 is good when you need to make a microincision. Beaver handles come in a variety of lengths, the most common being 10 cm. Longer-length handles (13 and 15.5 cm) are useful for deep orbitotomies or craniotomies.

    Figure 1.5

    Surgical cutting instruments. ( A ) Colorado microdissection needles. Blue needle is shorter (preferred); red needle is longer. ( B ) Beaver blades 376400, 376600, 376700, 375910. ( C ) ( Top down ) scalpel blades no. 15, no. 11, and no. 10.

Other Cutting Tools

Two other useful cutting tools are available for eyelid surgery: the microdissection needle and the CO 2 laser. The microdissection needle has been my choice for most periocular surgical procedures in recent years. This unipolar cautery device does an excellent job of cutting and cauterizing the thin eyelid tissues. The needle is made of tungsten and has an extremely fine tip. Tissue in contact with the tip is vaporized. Getting used to this instrument takes some practice. Cutting the tissue should be done with superficial light passing over the tissue in a “painting” motion and the needle slightly angled as if you are using a paintbrush. If you find that carbon is building up on the tip of the instrument, you are moving too fast, cutting too deep, or have the power turned up too high. The trick of using this tool is cutting only at the very tip so that there is little thermal damage to the surrounding tissues. You learn that “pulling” the layers of tissue apart is essential for this tool and gives a very clean dissection with little collateral damage to the adjacent tissues. Using a “blend” mode setting on the cautery machine provides cutting and cautery. Try this for the dissection of an upper eyelid blepharoplasty skin muscle flap. Once you get used to this “bloodless” field, you will have trouble going back to scissors. You should use a smoke evacuator to eliminate the hazardous smoke produced by this tool. The patient requires grounding, as with the use of any unipolar cautery equipment. The use of this unipolar cutting tool is sometimes limited to tissues anterior to the orbital septum, because the electric current is carried into the orbit and causes pain for many patients under local anesthesia. The tip works on the dry eyelid skin but works best on tissues deep to the skin. For this reason, some surgeons prefer using a blade for the initial skin incision because the edges of the wound are cleaner. They switch to the needle for any deeper work. You may find the Colorado needle with a foot pedal useful, but I prefer the hand switch on the cautery handle itself. Several companies make a microdissection needle (e.g., Stryker makes the Colorado microdissection needle, , and Medtronic makes the Valleylab tungsten microsurgical needle E1650, ). The shortest-length needle is the easiest to work with on periocular tissues. The quality and price vary from manufacturer to manufacturer.

The CO 2 laser is also a useful tool for cutting eyelid skin. Like the microdissection needle, tissues are vaporized, with excellent cautery of capillaries and small veins. The UltraPulse CO 2 laser was introduced years ago and remains a workhorse in my practice. The current model is the UltraPulse Encore made by Lumenis ( ). These lasers remain the gold standard for laser incisional and resurfacing work. As when using a microdissection needle, large vessels are often cut with the laser rather than cauterized, so you need a bipolar cautery tool on the operating room table, as well. Both of these cutting and cauterizing tools can shorten operating times considerably. If you have a CO 2 laser available, you should try it as a cutting tool. You must emphasize the pulling apart of the tissues with your forceps, even to a greater degree than with a microdissection needle. There is no touch or feel involved in the cutting. It is all visual, so technique is very important. Once you learn it, you love it. Patients have less discomfort with the CO 2 laser than with the Colorado microdissection needle. Some precautions are necessary. You need sandblasted instruments to prevent reflection of the laser energy. Metal corneal shields are a must. Surgeons and staff must wear protective goggles. Smoke evacuation is necessary. Care with oxygen and the use of wet drapes are important to prevent fire. Most procedures in this text use the microdissection needle, but I suggest you try the laser, especially for upper blepharoplasty. The skills that you learn using the microdissection needle and the laser are complementary; learning to use one helps you with the other.

Placement of Skin Incisions

Most skin incisions are hidden in natural creases or wrinkle lines ( Figure 1.6 ). The upper lid skin crease is a natural place to make incisions in the upper lid. The upper lid skin crease is often carried laterally into a laugh line. If you are not familiar with the wrinkle lines of a certain area, ask the patient to contract the facial muscles in that area. Seeing the wrinkles and folds in the skin shows you where to place your incisions. You can anticipate these lines. The natural skin creases occur perpendicular to the direction of the muscle fibers causing the creases. By contracting your frontalis muscle you are able to see the furrows of the forehead perpendicular to the frontalis muscle fibers.

Figure 1.6

Facial incisions are typically hidden in natural skin creases or placed next to anatomic structures for camouflage. A , Upper lid crease incision extended into lateral canthal laugh line for lateral orbitotomy. B , Traditional Stallard–Wright lateral orbitotomy incision (rarely used). C , Modified Berke lateral canthotomy incision. D , Transcaruncular incision. E , Frontoethmoidal (Lynch) incision (rarely used). F , Upper lid crease incision. G , Vertical lid split incision. H , Subciliary incision. I , Transconjunctival incision for medial orbitotomy. J , Inferior transconjunctival incision. K , Gingival upper buccal incision. L , Forehead furrow incision. M , Suprabrow incision. N , Pretrichial incision. O , Transcoronal forehead incision. P , Endoscopic browplasty incisions.

Other skin incisions can be camouflaged by placing them near anatomic structures such as the eyelashes or eyebrow. Adults generally have no lower lid skin crease. Skin incisions in the lower lid are usually placed 2 to 3 mm inferior to the lower lid lashes (subciliary incision). This incision can also be carried laterally into a laugh line. Similarly, an eyebrow incision can be hidden by placing it adjacent to the upper or lower margin of the eyebrow hairs . Incisions can be placed within the brow itself but can cause permanent visible scarring as a result of the loss of cilia roots. Other examples of camouflaging scars near facial structures include pretrichial hairline incisions, preauricular skin incisions, and incisions along the alae of the nose. Older-style incisions such as the Stallard-Wright lateral orbitotomy incision and the Lynch incision have been largely replaced by incisions that leave a better scar.

Anxiety and Tremor

Every surgeon has a tremor to some degree or another. This tremor is worse when you are anxious, are tired, or have drunk too much coffee. If you find that your tremor is bothersome, try to eliminate these factors. I occasionally hear of a resident who takes a beta-blocker before performing an operation. This can serve as a confidence booster but is likely not necessary once you learn to relax during surgery, although I do know experienced surgeons that feel their hands become “silkier” when they have taken a beta-blocker. A big part of being anxious when learning surgery is the feeling that you will look bad to your teacher or others observing. Consequently, you get more nervous and your tremor increases. Don’t forget, everyone in the operating room is on your side, doing everything they can to help you do your best for your patient. If you are feeling a little shaky, you might want to explain to your mentor that you are nervous. Usually, this confession will bring some deserved empathy, and your tremor will settle down a bit. Take a few deep breaths. Make sure that your chair and the table height are appropriate. Try to relax your forearms and loosen your grip on the instruments. If this does not work, consider a wrist rest. I have yet to see a student who had a tremor that kept him or her from being a successful surgeon.


  • Remember to have a plan when you enter the operating room. Let the staff know what the plan is. Know how the room is set up. Know the instruments. Your preparedness inspires confidence and sets the pace for the operation.

  • You must have a plan for the operation and some contingencies if things don’t go as planned. You would be surprised how many residents come to the operating room expecting to be “shown” what to do. As a resident, the more you prepare before entering the operating room, the more you will get to do and the faster you will learn.

  • Get the patient, operating table, your stool, and your body in a comfortable position before starting. Have all the equipment prepared before you make a skin incision.

  • Why should you mark the skin and inject the local anesthetic before scrubbing?

  • Do you need to write down the names of the special instruments, sutures, or equipment you will be using?

  • Let the operating room nurses know what you are planning, especially if you anticipate any change from the routine.

  • Practice stabilizing and cutting the skin on pieces of chicken at home. It is not the perfect model, but it can be helpful. Practice everything you can at home, including cutting, suturing, and tying. Operating room time is very valuable.

  • Learn to be comfortable and relaxed in the operating room. As a surgeon, it is your home and workplace for a big part of your career.

Cutting Tissue with Scissors

How do scissors cut?

Scissors cut by the shearing action of the blades crossing so close together that tissue between the blades is separated in a controlled fashion. The majority of skin incisions, especially on thicker skin, should not be made with scissors, because of this crushing action of the scissors blades. Some surgeons do, however, use scissors to cut the thin skin of the eyelid. Most surgeons reserve scissors for the dissection of deeper tissue planes.

Types of Scissors

In the Storz instrument catalog ( , now a part of Bausch and Lomb), there are more than 50 pages showing over 200 types of scissors. For a view of ENT and plastic surgery instruments check out . I hope that after reading the next several paragraphs you can make a sensible choice in selecting the right scissors for the surgical step you are doing. Scissors vary in the following characteristics:

  • Length

  • Caliber

  • Tip sharpness

  • Blade design

  • Cutting motion

Let’s look at each of these characteristics briefly.

Scissors Length

Choose scissors of the proper length for the depth of the wound in which you are working. Most of the instruments on the eye tray are 4 inches long. This size goes with the scale and depth of the usual ocular procedures. Longer instruments would be less steady and bump into the microscope. You will use many 4-inch instruments in oculoplastic surgery. Plastic surgery instruments are usually 6 inches long and fit the normal hand size better, for instance, a Metzenbaum scissors. In most cases, the longer neurosurgical instruments are not useful. For orbit surgery, on occasion, you may use a longer neurosurgical scissors for the particular tip rather than the length (Yasargil scissors).

Scissors Caliber

In general, thicker scissors blades are used for tougher tissues. This is fairly intuitive. You would not use a delicate Westcott scissors to cut through the thick dermis of the cheek. Similarly, you would not use the tough Mayo scissors to cut eyelid skin. Remember it is the blade tip size, not the length of the instrument, that you should consider for the delicacy of the tissue you want to cut. Many longer delicate instruments are also available.

Scissors Tips

The tip of a pair of scissors may be blunt or sharp. Blunt-tipped scissors are usually used for dissection in tissue planes. Sharp scissors are used to cut through tough tissues such as scar tissue. A sharp-tipped Westcott scissors works better than a blunt-tipped Westcott scissors to open an eyelid cyst. Facelift scissors have slightly sharpened rounded tips to facilitate flap dissection in the subcutaneous plane.

Scissors Blade Design

Scissors blades are straight or curved ( Figure 1.7 ). Most straight scissors are used for cutting sutures and bandages and are sometimes called suture scissors. It is easier to cut a straight line with straight scissors than with curved scissors, and vice versa. Remember to use the curve of the scissors blade to your advantage (the curve of the scissors should follow the curve of the eyelid crease, for example). Curved scissors are useful for tissue dissections. The curved angle of the blade lifts the tissue planes apart as the tip cuts the reflected tissue, which is placed on stretch. The curve of a scissors blade is easy to palpate through tissues. You will learn to protect tissues against the convex surface of the curve. An example of this technique is separating the levator aponeurosis muscle from the underlying Müller’s muscle. As the two layers are pulled apart , fine tissue bands are seen stretching between the tissue planes (learning to “pull” the layers apart is the most important surgical technical tip I can give you; more on this later). The convex surface of the scissors can slide up the fibrous bands and rest against the aponeurosis. Cutting can be performed without buttonholing the aponeurosis ( Figure 1.8 ). This technique is useful for separating any tissue planes. Another good example is separating Müller’s muscle from the conjunctiva.

Figure 1.7

Blades of the straight Mayo scissors compared with those of the curved Stevens tenotomy scissors. Notice that the length and caliber of the scissors are also different.

Figure 1.8

Dissection of levator aponeurosis from Müller’s muscle using curved Westcott scissors. Note how pulling the tissues apart creates bands of tissue that are easy to see and cut. The convex side of the scissors blades should be against the tissue that is the strongest, in this case, the aponeurosis.

Scissors Cutting Motion

Scissors are composed of opposing blades held together by a central pin. Most scissors close and open with opposite hand motions, stabilized by one or more fingers in the ring holes (often called ring scissors). You can control the force when opening the blades, as well as the force when closing the blades, with your hands. This allows you to use the scissors tips as a dissecting tool as you spread open the tissue planes by opening the scissors. Spring scissors open with the recoil of a spring mechanism in the handle of the scissors. Westcott scissors are an example of this type. These scissors are generally used for fine tissues where minimal hand motion is important (finger tools). The spring action determines the force of the opening of the blades. Stevens tenotomy scissors are ring scissors with slender curved blades; they are common 4-inch scissors used frequently in ophthalmic procedures (see Figure 1.7 ). Iris scissors are a type of delicate, sharp-tipped ring scissors designed with short blades that are either curved or straight. Although the usage is technically incorrect, the term iris scissors has almost become generic and has been applied to any pair of straight scissors used as suture cutting scissors.

Westcott scissors can be used as a spreading tool useful for separating delicate layers, for example, separating the conjunctiva from Tenon’s capsule, orbital septum from orbicularis muscle, Müller’s muscle from levator aponeurosis, conjunctiva from lower eyelid retractors, or any adjacent delicate tissues from each other. Remember that dissection is more about pulling layers apart and using the convex side of the blades to tease the tissues away from each other than it is about cutting the tissues.

Scissors cut by a shearing action. Most ring scissors are designed as right-handed cutting tools. Imagine holding a pair of scissors in your hand. Push your thumb away from the palm and pull your fingers toward your palm. This action squeezes the blades of the scissors more tightly together, increasing the cutting power. You may recall doing this as a child playing with dull scissors. You quickly learn that squeezing the blades together increases the cutting power. Try doing this with your left hand; there is much less shearing action. This is why left-handed children (and techs and surgeons, as well) sometimes have trouble cutting with right-handed scissors. Try squeezing the blades together the next time you use a pair of scissors. Compare cutting sutures or tissues with your left hand instead of your right hand; you will appreciate the difference.

Cutting With Scissors (You Learned this as a Child)

Spring scissors, or Westcott scissors, are held as finger tools, like a pencil. As with any scissors, you should gently squeeze the blades together in a continuous action. As the scissors cut, watch the tissue separate . Avoid clicking or snipping the scissors closed in one quick motion (close the scissors like you may have been taught to slowly squeeze the trigger of a gun or a camera shutter release button). Quick motions do not allow you to evaluate the depth or length of the scissors’ cut as you proceed. Observing how the tissues spread apart as you cut them is the very best way to stay in the correct surgical plane.

If you watch less-skilled surgeons or nurses cut your sutures you see that they often snip away at them. This type of cutting is too inaccurate for tissues.

As you proceed with cutting tissue, do not close the blades completely to the tips. You lose your place in the wound if you close the scissors. Again, remember when you first learned to use scissors as a child. Initially, every time you cut a piece of paper, you would close the scissors blades completely. It was difficult to make a straight, continuous smooth line. You had to start over each time you cut. As you learned to use the scissors better, you found that you could more effectively cut a continuous line by closing the scissors halfway to two thirds of the way and then advancing the blades forward. This is the same technique that you should use in cutting tissue. As the blades cut approximately halfway closed, push the blade forward in the same plane and cut again . Do not cut with the full closure of the blade until the end of the incision.

Remember when cutting with curved scissors to position the curve of the scissors along the curve of the incision. Many of the incisions that you make, such as the skin crease incision, are curved.

When using a ring scissors, rest your middle finger in one ring and your thumb in, or on, the other ring . Use this grip with the index finger providing three-point fixation of the scissors ( Figure 1.9 ). These larger scissors are useful as a finger-and-hand tool. You will find a comfortable thumb and finger position, often not totally within the ring. The same cutting motion that is described above should be used with this type of scissors. You might want to practice this technique on a piece of paper to make sure that you have the idea. You may be using scissors in more than one way already. Dr. Edgerton’s book nicely describes the function of scissors. Scissors can be used for cutting sutures and tissue, functioning as shearing cutters. Scissors can be used to spread open planes as push cutters ( Figure 1.10 ). Planes may be dissected using lateral sweeps or pull wedges. Small vessels may be squeezed closed with the shearing action of scissors. Palpation of the curved blade of scissors can be used to help guide a deep tissue dissection.


  • Compare two types of scissors that you may be familiar with: straight Mayo scissors and Stevens tenotomy scissors (see Figure 1.7 ). Mayo scissors come in many variations, so look at the scissors pictured. This variation is almost 7 inches long and has thick straight blades with fairly pointed tips. The Stevens scissors are just over 4 inches long and have thinner curved blades with blunt tips. Which scissors would be best for cutting sutures in a deep abdominal wound? The Mayo scissors, of course. The straight, thick, pointed blades are not well suited for tissue plane dissection. The shorter, curved, blunt-tipped blades of the Stevens scissors are ideally suited for the tissue plane dissection of the relatively superficial layers of the eyelid.

  • Think of which layers of the eye or eyelid would be appropriate for Westcott scissors. Would you choose sharp or blunt Westcott scissors for a conjunctival peritomy? The soft conjunctival and episcleral tissues would tear if sharp-tipped scissors were used.

  • Remind yourself how to cut tissue using a plain piece of paper. Draw a straight and a curved line. Try cutting the line in “snips.” Now try cutting the line with smooth continuous strokes, not closing the blades completely. Which is easier, more accurate, and faster? Cut the straight line with a curved scissors. Cut the curved line with the curved scissors using the curve of the blades with the curve of the line. Now cut the curved line with the scissors blades turned against the curve. You should be getting the idea that learning how to use your tools correctly produces a better and faster result.

Figure 1.9

Holding scissors. Left , Ring scissors (a finger-and-hand tool). Right , Westcott scissors, the most common spring scissors used in eyelid surgery (a finger tool).

Mar 21, 2021 | Posted by in OPHTHALMOLOGY | Comments Off on The Art of Surgical Technique

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