The lower lid transconjunctival blepharoplasty short.
The orbital fat prolapse in the lower eyelid is the most frequent reason for patients to request a lesser bleph.
Only in very rear of the skin resection is necessary and therefore lower eyelid transconjunctival I prefer an approach rather than a transcutaneous.
Besides, in transconjunctival blephs no visible scar, so: no sutures must be placed (or removed!) And muscle orbicular not be incised.
For this reason, the risk for postoperative ectropium and / or scleral show is only minimal.
In fact not only the excessive skin resection can cause ectropium. Even a simple incision in the orbicularis and orbital septum alone can cause retraction and ectropium or postoperative scleral show!
Moreover, an incision into the tarsal conjunctiva is highly vascular, can take significant bleeding, especially in patients with a short lower eyelid and undeep impasse where no ore fat pockets easily accessible.
My technique of transconjunctival blephs of the lower lid, try to address all these aspects.
Anesthesia:
When doing the surgery under local anesthesia with an injection begins deep subcutaneous injection of Xylocaine 2% with epinephrine.
Then, the lower eyelid is everted with a retractor Desmarres and subsequently
Xylocaine 2% with epinephrine is injected subconjunctival.
The purpose of this injection is subconjunctival Quadriple:
– Additional anesthesia.
– Vasoconstriction due to epinephrine.
– Hydrodissection of the conjunctiva and retractor muscles.
– Wetting of tissues with the injection to facilitate incision anaesthetique radiosurgery.
Therefore, also in patients under general anesthesia, always inject 2% xylocaine subconjunctival with epinephrine.
Although theoretically, the surgery can be performed both with local and general anesthesia,
I prefer the second: the incision transconjunctival seems to be more stressful for a lot of patients.
This may have caused blood pressure to rise thus causing more bleeding.
An intervention with general anesthesia, they are not only safer bus is also more comfortable for the surgeon and patient!
Moreover, in accordance with the anesthesiologist in blood pressure can be minimized during general anesthesia.
Surgical technique:
Eyelid is everted lower lid retractor Desmarres wit.
Additional 2% lidocaine with epinephrine is injected subconjunctival and as shallow as possible from the nose to another temporary.
Thanks to both stretch the lower lid retractor with the lid and the effect of epinephrine almost bloodless area has been created to reduce further bleeding during surgery.
The stretching of the lid also facilitates the incision of the cap layer by layer.
All surgery radiosurgery is performed with incisions unit.Indeed Ellman Radiosurgery performed with presureless and therefore more enjoyable and causes less bleeding. Moreover, the spread lateral thermal effects is much smaller than the laser.
For the incision of the conjunctiva in radiosurgery using a relatively thick electrode with the unit in the cut / coagulate mode that gives a 50% cut and 50% of coagulation.
The thicker the electrode that is used for skin incisions gives a clotting additional incision to bleed hardly at all.
Looking at the ships or bleeders that can be grasped with forceps and coagulated by touching the forceps with the electrode and the activation of the unit shortly.
The conjunctival incision is very superficial, parallel to the bottom border of the tarsus but few millimeters lower.
The cut conjunctiva is lifted with tweezers and then a similar incision is made through the retractor muscles and then the orbital septum.
The lid retractor is removed. Pushing lightly on the world, now fat prolapse.
Because the septum is a structure of multiple layers, sometimes additional membranes should be cut the fat pockets before leaving orbit.
For maximum dilation of the wound, a wound hook with rounded edges on the side of the skull and a clamp on the caudal side is used.
With the unit in the cut / coagulate the resection of fat directly without the use of a clamp is possible.
It is important to reduce very slowly to have a maximum coagulation effect.
The thicker blood vessels, when they meet, can be coagulated before cutting, in the same manner as described for the conjunctival incision.
We must be careful to excise only the fat pure. In effect, the inferior oblique muscle lies between the nasal fat pad and central and should not be harmed!
Resection of the fat has to be very conservative: the lower eyelid bags are not caused by excess fat, but only by a prolapse of anatomical fat pockets.
Furthermore, the orbital fat diminishes with age and we must be careful not to cause a "sunken eyes"!
We are looking for an ideal technique for bloodless dissection of the fat to a new location and setting, without any particular need for fat.
At the end of surgery, review the wound bleeding. With a clamp on the lid strip to loosen up the adhesions final.
I do not suture the conjunctiva at all, but just put some antibiotic ointment.
Tranexamin is administered intervenously and a cooling pad is placed on the eye.
An outpatient check up is done after 6 days.
At this point, it is not unusual to see some edema.
The skin may be moderately rough. If wrinkles persist, a superficial peel can be performed after a month.
Only in very rare cases a (conservative) excision of skin is necessary.
This can be combined with a suspension of muscle orbicularis to the periosteum of the superior temporal border of the orbit.
Dr. Peter Raus
About the Author:
Dr.Peter Raus is a Belgian Oculoplastic Surgeon who was trained in Belgium, Spain, Egypt and the US. He is the head of the Mirò Centre for eyelid surgery
Article Source: ArticlesBase.com – Transconjunctival Blepharoplasty of the Lower Eyelid
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