Journal of Surgery

Indtroduction

Upper eyelid blepharoplasty was first performed in the 10 and 11^th centuries [1]. The main complaint was the problem with vision due to impairment of the eyelid function. As a cosmetic procedure, upper blepharoplasty was performed in the beginning of the 20^th century. It wasn’t until the 1950s that the traditional techniques of upper lid blepharoplasty that still remain today began to emerge [2]. Nowadays, upper lid blepharoplasty has become a common cosmetic procedure. The procedure is safe and it is performed by doctors in many specialties, and gives high satisfaction regarding the rejuvenation of the periorbital area. It is the surgeon’s responsabilty to identify the patient’s expectations and to determine whether they can be met or not. The initial consultation may be the most important part of the surgeon-patient relationship. Take a complete medical history, history of ophthalmic diseases, use of systemic or topical medications, drug reactions is an important part in the consultation [3]. Most patients complain of “droopy eyelids” which leads to either dull appearance or looking older than their age. Dermatochalasis mostly results from the normal physiological aging process occurring in the periorbital area and males are more predisposed to it [4].

Surgical Technique

For the marking I prefer the patient to be in supine position. A marker is used to define lid creases from directly above the punctum medially to the lateral canthus. The natural lid crease is often adequate, but sometimes it is necessary to correct the position of the lid creases [5]. The first drawing point is medially 5-7 mm above the medial commissure, in the center a small point is made 9-11 mm above the border of the lid in the middle of the pupillary line, laterally another point is placed that is 8-10 mm above the canthal angle lateral [3,6]. The fourth point is placed between 12 and 15 mm, with one tip placed in the lateral commissure and the other directed superolaterally [6]. This technique helps to perform bilateral symmetrical incisions.

I recently only use the mid pupillary point and the rest is free drawing. The lid crease mark then continues laterally to address any lateral’’ hooding”. Continuing laterally to the lateral canthus, the drawing should slope slightly upward and outward, preferably in a skin crease [7]. The extension of the skin drawing laterally depends on the amount of excess skin to be removed, but it generally extends 3-10 mm. After the marking the pinch test is performed. The eyelid should not remain open during the pinch test because more skin may be removed. This procedure can be performed in the office with local anesthesia or potentiated with venous anesthesia for more patient comfort. The use of 1 cc 30-gauge syringe allows for a very slow infusion and precise placement of the local anesthetic [8]. In general, 1-4 cc of local anesthetic per eyelid is adequate. The initial injection is placed superficially to the skin of the eyelid to facilitate dissection and induce vasoconstriction. Additional local anesthetic is injected into the fat pouch or lacrimal gland (or both) if these tissues are to be reduced or repositioned. After betadine washing of the surgical area, the next step is the skin incision which is done with a blade nr 15, once the incision is complete, a flap of skin is removed with scissors laterally-medially. Accurate hemostasis is necessary at this stage of the operation. Preserving all or part of the orbicularis muscle will decrease the potential for lagophthalmos (incomplete or defective eye closure) and dry eye [9]. Depending on whether it was discussed in the consultation about the presence of fat pads that burden the eye, they will be corrected during the blepharoplasty. The incision is made through the orbicularis muscle and the orbital septum with scissors, the medial or nasal fat bags are removed, which is paler in color and more vascularized than the rest, and by applying light pressure to the eyeball and rarely targeting to remove the central fat bag. The underlying levator aponeurosis is protected by opening the septum as high as possible because the levator and septum separate there and the septum moves superiorly [10]. The levator aponeurosis can be modified if ptosis of the levator muscle is assessed to be present. The fat pads are removed through “clamping-cutting-cauterization”. The fat is gently teased out by opening the septum with forceps or applying gentle pressure to the globe. The fat is tightened with a clamp and excised over the clamp with scissors; and then the base cauterized. This technique continues until the right amount of fat is removed.

Careful removal of fat is recommended when necessary, especially medial fat pouches, to avoid a sulcus deformity [11]. The septum should not be sutured. Subcuticular closure with prolene 6.0 are used , this technique facilitates suture removal by pulling on one end. After surgery, the patient should be instructed to place cold ice packs on the eyelids for about 15 minutes every hour during the day for 2 days [12]. The patient should not engage in any strenuous activity or weight lifting and should sleep with his/her head elevated. Sutures are removed after 7-8 days by first removing the steri-strip and then pulling one end of the suture until the entire suture is free. The eyelids heal very quickly and leave behind a good scar, many surgeons leave the sutures for 3-5 days and the wound is closed [13]. We choose the 7 day approach as we have had several cases of wound opening on the 6th day. After suture removal, patients are instructed to avoid rubbing the eyelids as this may result in wound dehiscence (Figures 1-9).

Figure 1: Preoperative marking of the patient.

Figure 2: Local anesthetic injected in the upper eyelid.

Figure 3: The flap of skin is removed with scissor.

Figure 4: Fine hemostasis with bipolar electrocautery.

Figure 5: Subcuticular suture of the skin with prolen 6.0.

Figure 6: Clamping of herniated nasal fat pad before cutting and cauterizing.

Figure 7: Results 2 weeks after upper eyelid blepharoplasty.

Figure 8: Results 2weeks after upper eyelid blepharoplasty in a 63 year-old female in a 59 year-old female.