OPERATIONS PERFORMED:
1. Bilateral external levator palpebrae superioris aponeurosis resection, upper eyelid, both eyes.
2. Bilateral upper eyelid blepharoplasty with correction of lateral entropion.
3. Bilateral medial canthal and inner upper and lower lid Ellman radiofrequency unit eyelash ablation, both eyes.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating room table. Previously, both upper eyelids had been defatted with an alcohol pad. A lower lid crease incision line was fashioned to define the lower lid crease in the previously, now obliterated lower lid crease. In addition, the pinch technique was used to define the amount of excessive dermatochalasis weighing both upper eyelids down. An ellipse was fashioned with the gentian violet marking pen outlining this ellipse, both eyes. The patient received appropriate preoperative monitoring and sedation, and a solution of 2% lidocaine with 1:200,000 epinephrine was instilled subcutaneously across the length and breadth in the pretarsal space of both the right upper lid and left upper lid. The superior dermatochalasis was not infiltrated to avoid akinesia of the levator muscle. The anesthetic agent was massaged into place. The surgeon performed a surgical scrub. The patient was prepped and draped in the usual sterile fashion for ophthalmic surgery.
A hard corneoscleral shield was placed before the cornea of the right eye after a series of 0.5% topical tetracaine drops were applied. A #15 Bard-Parker blade was used to incise the previously demarcated gentian violet lower lid crease incision line. Sharp Westcott scissors was used to elevate a cutaneous flap inferiorly. A strip of pretarsal orbicularis muscle was resected at the level of the posterior orbicularis fascia, exposing the superior portion of the tarsal plate. Hemostasis was achieved for the entire case with direct digital pressure, packing, and Bovie cautery. The levator aponeurosis was next isolated by asking the patient to look up and look down.
The orbital septum was incised through the breadth of the eyelid, and the pre-aponeurotic fat was retracted as the levator aponeurosis was isolated. The patient was asked to look up and look down to expose the entire portion of the levator aponeurosis. The levator was then further isolated posteriorly and anastomosed to the tarsal plate 2 mm inferior to the superior tarsal border. A temporary knot was placed in the double-armed 6-0 silk suture. The patient was sat up on the table and the appropriate lid level was observed after adjustment of the suture. The patient was returned to the supine position and additional nasal and temporal sutures of 6-0 black silk were placed anastomosing the cut advanced edge of levator aponeurosis to the superior portion of the tarsal plate. The patient was asked to look up and look down, and the appropriate lid contour was noted.
Attention was directed to the dermatochalasis of the right upper lid. Additional infiltration of 2% lidocaine with 1:200,000 epinephrine had been delivered across the length and breadth of the elliptical segment of the excessive dermatochalasis, as well as overlapping segments of redundant orbital septum and orbital fat. The hard corneoscleral shield had been replaced after a series of 0.5% topical tetracaine drops had been applied. A #15 Bard-Parker blade was used to incise the previously demarcated ellipse of excessive dermatochalasis weighing the upper lid down. Hemostasis was achieved again with direct digital pressure and Bovie cautery. Clearance of the dermatochalasis was now noted. There was minimal lagophthalmos noted as well, signifying appropriate resection without over-resection. The wound was then closed with a series of interrupted 6-0 black nylon sutures anastomosing the superior myocutaneous with the inferior pretarsal cutaneous flap. Additional closure was achieved with a running 6-0 fast-absorbing plain suture. In order to define a dynamic crease the running 6-0 plain anastomosed the superior myocutaneous with the cut edge of the levator to the inferior cutaneous flap. The lid level and contour were noted to be appropriate and attention was directed to the left upper eyelid.
A hard corneoscleral shield was placed before the cornea of the left eye after a series of 0.5% topical tetracaine drops were applied. A #15 Bard-Parker blade was used to incise the previously demarcated gentian violet lower lid crease incision line. Sharp Westcott scissors was used to elevate a cutaneous flap inferiorly. A strip of pretarsal orbicularis muscle was resected at the level of the posterior orbicularis fascia, exposing the superior portion of the tarsal plate. Hemostasis was achieved the entire case with direct digital pressure, packing, and Bovie cautery. The levator aponeurosis was next isolated by asking the patient to look up and look down.
The orbital septum was incised through the breadth of the eyelid, and the pre-aponeurotic fat was retracted as the levator aponeurosis was isolated. The patient was asked to look up and look down to expose the entire portion of the levator aponeurosis. The levator was then further isolated posteriorly and anastomosed to the tarsal plate 2 mm inferior to the superior tarsal border. A temporary knot was placed in the double-armed 6-0 silk suture. The patient was sat up on the table and the appropriate lid level was observed after adjustment of the suture. The patient was returned to the supine position and additional nasal and temporal sutures of 6-0 black silk were placed anastomosing the cut advanced edge of levator aponeurosis to the superior portion of the tarsal plate. The patient was asked to look up and look down, and the appropriate lid contour was noted.
Attention was directed to the dermatochalasis of the left upper lid. Additional infiltration of 2% lidocaine with 1:200,000 epinephrine had been delivered across the length and breadth of the elliptical segment of the excessive dermatochalasis, as well as overlapping segments of redundant orbital septum and orbital fat. The hard corneoscleral shield had been replaced after a series of 0.5% topical tetracaine drops had been applied. A #15 Bard-Parker blade was used to incise the previously demarcated ellipse of excessive dermatochalasis weighing the upper lid down.
Hemostasis was achieved again with direct digital pressure and Bovie cautery. Clearance of the dermatochalasis was now noted. There was minimal lagophthalmos noted as well, signifying appropriate resection without over-resection. The wound was then closed with a series of interrupted 6-0 black nylon sutures anastomosing the superior myocutaneous with the inferior pretarsal cutaneous flap. Additional closure was achieved with a running 6-0 fast-absorbing plain suture. In order to define a dynamic crease the running 6-0 plain anastomosed the superior myocutaneous with the cut edge of the levator to the inferior cutaneous flap. The lid level and contour were noted to be appropriate.
The hard corneoscleral shields were repositioned, both eyes, after additional 0.5% topical tetracaine drops had been applied. The Ellman radiofrequency unit was tuned to a power of 1.5 and placed in a full coagulation mode. Each of the aberrant lashes was then treated with the Ellman radiofrequency unit with short bursts of energy delivered to the lash bulb root. These were ablated medially and laterally in the inner, upper and lower lid with resolution of the aberrancy. Both corneoscleral shields were removed after a series of additional 0.5% topical tetracaine drops had been applied. The lid level and contour of both upper lids were noted to be adequate. Both eyes were dressed with Maxitrol ointment. The patient tolerated the procedure well and was removed to the recovery room in stable condition.
