Upper eyelid surgery or blepharoplasty is when skin, muscle and sometimes fat is removed from the eyelid. S. Larry Schlesinger, MD, FACS, a board certified plastic surgeon in Honolulu, Hawaii, invites us into the operating room to demonstrate this common surgery and what it’s really like.
So, today we are going to be doing an upper lid blepharoplasty and one of the things that we’ve noticed that everybody has known for a long time is that there’s a big eye and a small eye and the reason for that is usually the orbits are not symmetrical therefore the eyes, the eyelids etcetera are not symmetrical. And this young lady she has a highbrow and a lowbrow.
The distance from her eyelashes to the double break is normally in Caucasians ten millimeters, so that’s almost eleven there. And medially over towards the nose, take as much skin as you need but don’t take any extra skin because this tends to not have a lot of extra skin. And then laterally, since it hangs down lower laterally, we take a little extra skin more than we would medially.
Ok, now we’re going to inject with xylocaine with epinephrine 1-200,000. We have a great anesthesiologist in the room so she feels none of this, she’s fast asleep. So, we’re supposed to give about ten minutes for the epinephrine to take effect.
And we’re going to be taking out skin and some orbicularis muscle, that muscle that closes the eyelid. And because we’re taking out some and we’re paralyzing it initially as we do the surgery it won’t close very well and then it’s going to start closing better and better.
This is the time back in the day when the surgeon would go out and smoke a cigar or a cigarette to allow the epinephrine to start working. We now know that cigars and cigarettes are not good for you and furthermore my wife would kill me if I did that so, I don’t smoke. So we just wait.
Good right there. We put a little tension on it, then we cut along the blue line we have marked. More pull. Now we’re taking off the upper eyelid skin and since the muscle in fact and the skin come from the same element, when we’re taking off skin we also take off some muscle. Not all of it but some of it since it’s the same element and ultimately you need some to close it but not a ton…there we go.
So, what we’ve done on this side is remove the excess upper eyelid skin very carefully. Now we’re hyphercating right along the break. Some people take out all this muscle, some people just take out some of the muscle but if you hyphercate right along the edge here what you can get is really good indentation at the double break. It gives you a more defined double break. Ok, so that’s one.
Now we’ll take the excess tissue from this upper eyelid. Notice her eye opened up more because we paralyzed the muscle that closes the eyelid. Ok, pull that down. Again we’re taking all the skin and some of the muscle with us. Again, this is the muscle that surrounds the eye both upper and lower called the orbicularis oculi muscle. Again, we are hyphercating or burning with a hot electrical instrument which then stops bleeding. It also improves our crease. Right here the crease in the eye is called the double break.
So, there are three compartments for fat in the lower lid but only two in the upper lid. One here and one here. And pre-operatively we pushed on this and we found there was not enough fat to make it useful to take it out. We used to take out fat from the middle compartment but we found when we did that, unfortunately, it led to a hollowing of the eye. So, we don’t take out as much fat as we used to.
Alright, now that we’ve got the skin and muscle out we’re not going to remove any fat. Now we just sew it up. We sew it in two layers, we sew a running in a dermal layer that kind of lines things up and then we sew it with an interrupted layer that does a fine tuning of the skin. We’ll even tack the tissue that elevates the skin. I can prove it by doing this so that shows that the levator palpebrae superiorous is not affected by what we’ve done.
And now we put some interrupted stitches as needed along the suture line to just make the skin match evenly. And the eye looks very open right now. And back in the day, the nurses used to ask if the eye would ever close and the answer is yes because we measured it very carefully. And so we know exactly how much to take out. One side down, one to go.
Boy, this young lady has beautiful eyes and now we’ve uncovered them. They’re green, a pretty shade of green. And now we’re able to see them better because the excess skin on the eyelid is gone. Now we’ll pull this just a little bit to prove to ourselves that it will pull through which it did. Ok, take the hemostat off. That lays down better.