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>> Dr. Lamperti: This is Seattle facial plastic surgeon, Dr. Thomas Lamperti. Today I'm going
to show you how to fix drooping upper eyelids using a conservative, skin-excision only blepharoplasty
technique.
Before we begin with the surgical procedure itself let’s take a look at our patient.
You can see that the patient is an older gentleman. He was referred to me by his optometrist to
see if I could help improve the upper visual field blockage problems that he was having
due to his redundant eyelid skin. You can see how his right upper eyelid is worse than
his left. We’ll just cut to the chase now and show our 3 month after result. You can
see how the patient now has much improved upper eyelid show. At the same time note how
we haven’t feminized the patient’s appearance as that’s certainly something I want to
avoid in male patients of any age.
Ok, now let’s move on to the surgery itself. The first step is to make the skin incision
markings. If the upper eyelid crease is at an appropriate height above the eyelid margin
I start by outlining this crease. The crease is usually about 8 to 10 millimeters above
the eyelid margin. It’s important to properly carry the incision out laterally as this is
typically where the skin excess is the most severe. We’ll do this step right now.
Now I’ll use forceps to gently grasp the excess skin in order to mark the upper limb
of the planned incision line. I start over the mid-pupillary line and then move to the
area where I want to maximally treat the lateral hooding. Next, I simply connect the dots,
tapering the incision lines to each end point of the lower incision limb.
Now that I’ve marked the left eye I’ll now move over to repeat the process on the
right eye. You may notice that I’m not just simply measuring how much intervening skin
I’m removing on the left and doing the identical pattern on the right. I find that by repeating
the skin pinching method more symmetrical results are possible as this better takes
into account patients’ pre-existing asymmetries. You can also see how I gently retract the
patient’s eyebrow upward as I mark to help to temporarily tighten the skin as I mark
the skin.
You may also notice that when grasping the excess lid skin I’m taking enough skin such
that I just barely elevate the eyelid margin. Of course, I always err on removing a bit
too little skin rather than too much as we can always remove a minor amount of excess
skin in the office down the road if needed.
The next step is to inject the local numbing medication. We’ll speed up the video for
this part. You can see that we’re using 1% lidocaine with epinephrine. I do this step
both with patients asleep under deeper anesthesia, like this patient, and with patients having
the surgery awake in my office procedure room. This patient opted to have surgery under deeper
anesthesia, but it’s actually very common to perform this exact upper eyelid surgery
awake. Beside numbing the skin the other benefit of the injection is the epinephrine, or adrenaline,
component as this acts to shrink down blood vessels which helps make the surgical field
less oozy. Another benefit of the injection is that it hydro-dissects the eyelid skin
we want to remove away from the underlying muscle which we won’t be removing.
Ok, after numbing both eyelids we’ll go back to the left eyelid and begin the actual
surgery. I have my surgical assistant help with providing skin retraction. I’ll first
make the incisions with a scalpel. Then, I use scissor dissection to carefully remove
the excess skin from the underlying orbicularis oculi, or eyelid muscle. During this dissection
I’ll use electrical cautery to seal up any blood oozing as well. I’m now using the
scissors to carefully dissect the skin away from the muscle. You can see how the previously
injected numbing medication has already helped to accentuate this plane.
Once again you can see the importance of skin counter-retraction. We’ll then set aside
the removed skin and continue drying any oozing blood. I also find that applying cautery along
the lower skin margin helps to sharpen and tighten the pre-tarsal eyelid skin just above
the lash line.
The last step is obviously to close the wound with sutures. I start by placing a few interrupted
6-0 vicryl sutures to help approximate the wound edges and to provide some extra support
to the subsequent running suture. This small vicryl suture is dissolvable but I usually
trim out any remaining knots myself a few weeks after surgery. Next, I’ll continue
the wound closure using a 6-0 fast gut suture. I’ll also use a 6-0 prolene suture instead.
The fast gut suture normally dissolves on its own whereas the prolene must be removed
about 1 week after surgery.
This eyelid suture line normally heals quite well. Over the main part of the eye itself
it obviously hides in the pre-existing crease. Even laterally the way I design the incision
line it normally hides very nicely in the crows foot line area.
Now that I’ve closed the left eyelid incision we’ll now repeat the entire process on the
right eyelid. We’ll start with the excision of the excess skin as we previously marked.
Some patients ask me whether I’d recommend removing any underlying eyelid muscle or fat
during surgery. I don’t typically remove any of the underlying muscle, even in purely
cosmetic cases, as I’m trying to avoid an overly skeletonized postoperative look. Similarly,
I infrequently remove any upper eyelid fat as well. In patients with very prominent medial
fat pads I do address that fat pocket by conservatively removing excess fat from that area.
As I see it most people didn’t have overly sculpted upper eyelids when they were in their
teens or twenties and I don’t see any reason to aim toward that goal now. In fact a large
trend when it comes to rejuvenating the face involves replacing lost facial volume. This
may involve facial fat grafting or fat transfer or the use of dermal fillers such as restylane,
juvederm or radiesse.
I find that by leaving the underlying orbicularis oculi muscle alone during blepharoplasty surgery
I’m able to better maintain, or even enhance, a natural, full upper eyelid. There can be
an improved eyelid contour related to the fact that with closure of the blepharoplasty
incision I’m able to plicate or fold the muscle on itself. In essence we’re using
the patient’s own muscle as a filler.
Now we’ll once again start the incision closure with the 6-0 vicryl suture. We’ll
skip ahead now to the 6-0 fast gut suture placement.
And now we’ll finish up with the last bit of suturing. Lastly we’ll apply some ointment
to the suture line before having the anesthesiologist wake up the patient and bringing him to the
recovery room.
Thanks for watching. If you enjoyed this video please check out the other surgery videos
on my Youtube channel to learn more about facial plastic surgery.
www.drlamperti.com