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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “ Welcome back to the Aranowitz channel, everyone. Today, I have an interesting surgery to show you: a blepharoplasty. This is eyelid surgery. It's done typically for cosmetic reasons but also can be done because there's so much upper eyelid skin hanging over; it's hooding and obstructing vision, especially in the upper outer quadrant. So, this is going to be removing the excess skin and then removing or pushing back into the orbital preceptal region, the periorbital fat. So, this is on the upper and lower eyelid. I hope you enjoy the surgery and learn a little bit of the anatomy, and I'll catch up with you on the back end after the surgery. So now we're going to mark the upper lid. You can see as I'm rolling that excess skin up above the eyelid how much excess there is and also how much extra adipose tissue or fat there is. And now, what I'm doing is marking a crescentic shape of skin that's going to be removed from the upper eyelid. I want to have the lower part of the incision that you see marked on the patient's right at the tarsal fold. That's the fold that's at the top of the kind of cartilaginous plate called the tarsus. Now I'm testing, and the next thing I'm going to do is inject a little local anesthetic. This will numb up the area so that when the patient wakes up, she's not having any pain, and also, this will decrease the amount of bleeding that we encounter because there's epinephrine in the local.
So, the next step is going to be to remove the skin from the upper eyelid the way I've marked it, and you can remove some of the muscle at the same time. The orbicularis oculi muscle, this is a flat muscle that encircles the eye, and the portion over the upper lid, some of it can be removed to give a little more definition and remove some of the bulk; in this case, I'm not removing any muscle, however. So, taking the skin off just below the ender surface of the skin in the loose connective tissue layer.
And some surgeons do this with a scissor; some surgeons do this with a knife, or even a cautery. It really doesn't matter how you remove it, as long as the correct amount of skin is removed.
So now we're going from medial to lateral, and that little bit of skin is removed. Then the next step will be to tease out the preceptal fat, and I've made a little opening in the septum orbitale, that's the layer that is holding back the fat pad, and here's the fat pad being delivered from the wound, and I'm cauterizing it as we go, so that we can minimize the bleeding from that fat pad.
And there's that medial fat pad. Okay, now the next step will be to remove the fat from the medial. I've done that; now I'm going to repair the skin and, to begin with, I'm going to put a suture right in the middle so I can make sure that I get the edges lined properly. And that suture is a very fine suture; you can barely see it in the video. This is usually a 6-0 proline suture. So now, after I've sutured the opposite side, I'm going to do the identical procedure on the upper eyelid of the opposite eye, the patient's left eye, and here you can see me incising the skin to be removed along the outline I've made at the beginning of the surgery. I've marked that and checked my markings; now I'm going to remove that skin from the lateral toward the medial.
There's a little more bleeding encountered here than I normally encounter, but that's always going to happen when you're making a video.
You'll notice the patient has a permanent makeup tattooed on her upper eyelid. This is pretty common nowadays, and if you're having this procedure, you always want to point that out to your surgeon. If you're the surgeon, you want to make note of it.
It's not that the tattoo pigment causes any problems, but you don't want to end up with the tattoo pigment, the makeup, in the wrong place. So, in this case, it doesn't really affect the skin I'm removing in any way. Now we've removed the skin, and with a little pressure, I can cause the fat to bulge and that'll help me to express that fat from the upper eyelid.
In the upper eyelid, there are two fat pads, one medial toward the nose and one in the middle. Here's the middle fat pad being delivered. You notice this is more yellow-colored fat and it's being delivered from the upper eyelid, and I'm going to tease this away from the surrounding tissue and also cauterize it as I remove it.
Now I'm going to sew the skin closed, and I'm going to put just a couple of interrupted sutures so that I am sure that I have the skin closed properly.
I've aligned the top and bottom where it needs to be, and it isn't moved to the left or the right. You can see again there, the patient's tattooed permanent makeup on the upper eyelid, and this upper lid stitch is done with a 6-0 proline, typically, and then I'm going to place a subcuticular stitch that can be pulled out at about five days to seven days and that usually heals up very nicely with minimal amount of pain, and because it's placed under the skin, there are no suture marks left and the scar becomes very inconspicuous, hidden in what's called the tarsal fold, or that the fold of the upper eyelid that we have, most of us have. Not everyone has a tarsal fold, of course, but if the patient does have a tarsal fold, I want to try to place that incision line in that fold so it hides nicely.
And this is just a tedious procedure to sew, but we want to do a nice job sewing, obviously, because this is the scar the patient's going to have for the rest of her life, so we want to take care to do the sewing properly and now I'm checking to make sure that that stitch will pull out easily when she comes in post-operatively for her visit, and I'm just tying a little knot on the outside to hold it so it doesn't slip out.
Well, I hope you enjoyed watching the blepharoplasty. Some people find it a little unnerving to see surgery around the eye, but I hope that wasn't the case for you. I hope you enjoyed it. Just to review, we have the eyelid skin, the structures that raise and lower the eyelid are going to be a little bit lower than where we were. What you saw was skin, a little bit of loose connective tissue below the skin, the flat round muscle that encircles the eye, called the orbicularis muscle, and you saw the septum orbitale, that's the thin layer that holds this kind of fat back in around the globe that pads the globe or the eyeball, and you saw me remove that excess fat. You saw me remove the excess skin, a little bit of the muscle, and then sew everything up, and this will heal very rapidly. And as soon as we have some post-op pictures to show you the before and after, we'll share those with you too. So, till then, put your comments below. Any ideas for additional videos you'd like to see, or things I haven't made very clear in the explanation, please ask, and I'll try to do a video explaining it for you.
Okay, and till then, I hope you have a great day, and we'll be here operating in Aronowitz land."
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