Excess upper eyelid tissue and/or herniated orbital fat can be excised for functional or aesthetic reasons. In the former the excess tissues abut or overhang the lash margin, thus interfering with visual function. Significant coincidental brow ptosis must be repaired or it will be worsened by blepharoplasty.
The incision is marked with the patient sitting up. A line is drawn along the skin crease starting above the superior punctum extending to the lateral canthus and then sloping upwards 1-1-5cm from the lateral canthus in a natural skin crease (Figure 8.4). The skin above this area is pinched vertically using fine tooth forceps, the lower jaw of which is positioned on the marked line such that excess skin is eliminated and the lids
just touch with passive lid closure. The position of the superior jaw of the forceps is marked. This method of marking is repeated nasally and temporally and the marks joined with similar preparation of the other eyelid remembering to aim for a symmetric post operative appearance. If local infiltrative anaesthesia is used it is injected at this stage.
The skin is incised with a scalpel along the marked line and excised from the underlying orbicularis. A strip of orbicularis may be removed if the muscle is felt to be bulky or significant skin excision has been undertaken. Orbital fat excision is undertaken if appropriate. Excess upper lid fat is usually confined to the central and medial areas of the eyelid. An apparent lateral protrusion is invariably a prolapsed lacrimal gland which should not be excised but rather repositioned using plicating sutures between the anterior gland capsule and supraorbital rim. Fat prolapse is facilitated by incision through the orbicularis and underlying fat capsule; gentle pressure on the globe via the lower lid enhances fat prolapse. It is essential that the fat is handled carefully and gently to avoid unnecessary traction on posterior orbital fat and associated blood vessels. The excess fat to be removed is clamped and excised with cautery to the excision stump. Meticulous care is necessary throughout with particular regard to haemostasis.
If excess medial canthal skin is present then this is excised by extension of the medial incision superiorly with excision of redundant overlying skin. It is not necessary to close either orbital septum or the deeper layers of the eyelid. The skin is sutured with an over and over 6/0 Prolene centrally reinforced with individual sutures at the medial and lateral angulation, which are removed four to five days post operatively.
To minimise post operative bruising and facilitate healing, ice-packs are applied for 24 hours post operatively. The vision is checked hourly for the first four hours post operatively. The patient is advised to report sudden orbital pain or loss of vision immediately.
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