I treat only about 10 percent of my patients with dermatochalasis (excess skin) and herniated orbital fat of the upper eyelid by performing an upper eyelid blepharoplasty with skin or skin-muscle resection alone. In 90 percent of patients I perform a skin and orbicularis oculi muscle resection with or without fat removal, but with reconstruction of the eyelid crease.
The skin-muscle resection with crease reconstruction allows less skin to be removed and thereby decreases lagophthalmos (incomplete eyelid closure), which is especially important in patients with low basic tear secretion. Also, I find that most patients with upper eyelid dermatochalasis have ill-defined eyelid creases and eyelash ptosis (inversion of lashes), and reconstructing the creases helps these problems also. This approach also allows for resection of orbicularis muscle, which might be redundant if skin is removed alone. Finally, it provides access for other procedures, such as redepositing a lacrimal gland, performing an internal brow lift, and performing levator aponeurosis resection-ptosis surgery.
Allen M. Putterman
Preparation for surgery
The patient's entire face is prepared with povidone-iodine (Betadine) soap and paint. The patient is draped so that the entire face is exposed. Topical tetracaine is applied over each eye. A scleral contact lens is placed over the eye and under the eyelids.
Surgical technique
A line is drawn with a methylene blue marking pen, beginning at the lateral canthus and extending in a horizontal direction of approximately 1 cm. This line marks the site of the lower lateral canthal incision. The site of the predetermined eyelid crease is then marked. When the surgeon is drawing the eyelid crease marks, the eyebrow must be elevated to reduce the excess upper eyelid skin fold and to make the upper eyelid skin taut and the lashes slightly everted. If this is not done, the crease may result in being much higher than desired because the skin is usually loose before it is marked.
The temporal, central, and nasal crease sites are marked by placing a millimeter ruler so that the zero line is at the eyelid margin. The distances above the eyelid margin can then be viewed and marked with a specially designed marking instrument. In women, the temporal mark usually is placed 10 mm above the upper eyelid margin; the central mark, 11 mm above the margin; and the nasal mark, 9 mm above the margin. In men, the marks are usually 9 mm temporally, 10 mm centrally, and 8 mm nasally.
The temporal, central, and nasal marks are then connected and are extended with a line, which begins at the punctum and ends at the lateral canthus. The line sweeps laterally approximately 1 cm temporal to the lateral canthus in a slightly upward direction. There should be at least 5 mm of skin between this line and the line placed for the lower lateral incision.
A smooth forceps is used to grasp the crease line at the center of the eyelid with one blade. The other blade is used to pinch upper eyelid skin at various positions until, when the forceps is closed, all the redundant upper eyelid skin is eliminated and there is no eversion of the lashes and no lifting of the eyelid from its apposition to the lower eyelid margin.
Once this position is determined, a dot is made with the marking pen at the top blade of the forceps. Similar marks are made nasally and temporally after the amounts of extra skin are determined in these positions. The three superior dots are connected and joined with the nasal and temporal ends of the eyelid crease line. The opposite eyelid is marked in the same manner. To ensure symmetry, the surgeon then compares the measurements of the eyelid crease and the amount of skin to be excised temporally, nasally, and centrally in the two eyelids.
Several milliliters of 2 percent lidocainc (Xylocaine) with epinephrine is injected subcutaneously in the areas of the marked ellipse as well as between the upper eyelid margin and eyelid crease across the eyelid.
A No. 15 Bard-Parker blade is used to make an incision through skin at the marked lines. A 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superficial tarsus at the center of the upper eyelid just above the eyelid margin. Approximately 12.5 cm of suture is left on each arm, and a knot is tied at this end. The traction suture is used to pull the upper eyelid straight downward while a toothed forceps is used to grasp the upper eyelid centrally just above the crease incision and to pull upward and outward.
A blunt Westcott scissors is used to make a buttonhole incision in orbicularis muscle and to sever central orbicularis muscle at the skin crease level. With the scissors directed superiorly and inward, the orbicularis muscle can be penetrated and the sub-orbicularis space entered without injury to the levator aponeurosis and other important eyelid structures. This maneuver is possible because the orbicularis muscle is firmly attached to skin, whereas the orbital septum, levator aponeurosis, Muller's muscle, and conjunctiva stay deep surrounding the globe.
The orbicularis muscle is then undermined temporally and nasally at the site of the eyelid crease while the surgeon keeps the eyelid in the same position with the traction suture and forceps. The orbicularis muscle is severed along the incision site of the eyelid skin crease with the use of a disposable cautery, a Colorado needle, a sapphire-tipped scalpel neo-dymium: YAG (Nd: YAG), or a carbon dioxide (C02) ultrapulse laser. Each instrument coagulates blood vessels as it cuts through tissues.
When this has been accomplished, the surgeon should be able to view the levator aponeurosis. At times, orbital septum is in the way and must be identified with the use of a forceps. The orbicularis muscle at the superior skin incision site is then severed with a disposable cautery, Colorado needle, or the Nd: YAG or C02 ultrapulse laser. Thereby, an ellipse of skin and orbicularis muscle is excised with simulta¬neous cauterization of blood vessels.
Isolation and excision of orbital fat
The septum is pulled upward and outward. Then the Westcott scissors, a disposable cautery, Colorado needle, or Nd: YAG or C02 ultrapulse laser is used to penetrate orbital septum and suborbicularis tissue just beneath the orbital septal rim until herniated orbital fat is visible.
The orbital septum and suborbicularis fascia are opened from the nasal to temporal aspect of the eyelid; when this is accomplished, the surgeon should see nasal, central, and, at times, central-temporal herni¬ated orbital fat pads. Usually, the nasal fat is white, whereas the central and central-temporal fat is yellow and very loose. Bleeding is controlled with the cautery.
The capsule over the nasal fat pad is then penetrated with Westcott scissors. The eye is pushed on through the upper eyelid, and the nasal fat that herniates upon gentle pressure applied to the eye is grasped with a straight forceps. With a No. 15 Bard-Parker blade, the surgeon severs the fat along the hemostat. Cotton-tipped applicators are placed under the hemostat, and a Bovie cautery is applied to the hemostat to coagulate any vessels within the fat pad. A forceps is used to grasp the fat beneath the hemostat as the hemostat is released. This gives the surgeon a chance to inspect the fat stump for any residual bleeding before it is allowed to retract into the orbit. An alternative is to remove the herniated orbital fat with a laser.
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