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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “So we're going to remove this little bit of fat. See all those soles? So you can see when I push on the globe a little bit you see the fat bulging there. So this puffiness right here is due to fat coming forward and then she has a little bit of excess skin that will be better if you just pull up a little bit. If we pull this up too much it won't stay up. What will happen is it will pull the lid away from the eyeball like that or pull it down like that and that's no good. So we want to be careful about how much of this loose skin we take and basically we never want to try to do a face lift by lifting up and then expect the lower eyelid to hold it. It will pull down and that's not going to be good. So we'll take that excess skin here and the fat from the inner fat and that would be the blepharoplasty. You can see the fat bulging right here that we identified before. The skin is a little blanched because I've injected her. I'm going to make a little incision in the sub ciliary fold here. This little fold just under the lash so we can get access to that fat pad and also remove a little bit of the medial fat. Okay Sarah, can I have a pickup and I'll take the caudery and put the caudery down to oh 20. Down to 20 and then the other one down to 20 also and you can see how thin the skin is in the and I'll pick it up here very gently.
So now we're through the obicularis muscle. That was the layer we just cauderized through. You can see a little bit of the muscle right here. This layer right here is the muscle and then we'll see the this layer right here is called the septum orbitalis. It's a fibrous layer that holds that fat in and in her case it's bulging a little bit. As you can see that's the fat that's bulging in. Once I cauterize through that the fat will bulge right out and present itself to us. And that's the medial or most inward fat pad. And then you have a little smooth retractor that vein retractor or desmarr. So, here's the medial fat pad. Sarah just come back here. Yeah, that'll be good. Let's just leave that. You're doing great. Now this fat can also be repositioned. Basically, repurposing it rather than removing it in some cases. But in this case, we're just going to remove that fat. There you go.
I'll take the Q-tip. Just make sure there's no bleeding there which doesn't look like there is. Now a little push on the globe to make sure we have everything we want which I believe we do. It's a little bit of the middle fat pad. And you can't see it but right here is where the infra orbital rim is of the globe. And that is this little bone that you can feel. So now I've taken the fat out and I've got a little excess skin so we'll take that excess skin out and I'll take a scissor for that. And I want to make sure that I don't take that Can you have my six out of the cell? Yes. And we're going to close this with some interrupted six out silk sutures. We'll come out in about three to five days. On the note? No. A little longer. Longer. That's it. Good. I might make those a little bit shorter but it's easier. If they're a little on the longer side we'll come taking them out. Same thing on the opposite side. And if you'll hand me a 15 blade. So, if I put a little pressure on the globe you can see the fat bulging here, that medial fat pad. And we'll make a little sub ciliary incision again. And what we're looking at is the orbicularis oculi muscle. There you go. And what we're going to do is cauterize a little here. So, we have less bleeding from the edges of the muscle and we're going to elevate a skin muscle flap so there'll be muscle and skin just hold steady there. That'll be skin and muscle. Good. Now lift a little bit with your hook. That's it. And you can see the fat pad again coming in to view nicely for us. That's great. And there's the fat pad bulging very nicely through the septum orbitale. If I put a little pressure again on the globe you can see it's bulging even a little bit more. So, what we're going to do, go ahead and swap it. We're going to make a little hole in that septum. Perfect. There's the fat pad we're after. You can enter that now. And let our fat come out. I'll take a few tips please. And we're just going to tease this guy out so that we don't tear any of these fine blood vessels hopefully. And that way we'll have less bleeding and therefore less postoperative swelling and bruising. So there's our medial fat pad. I don't know if you noticed but the color of the fat pad is slightly different depending on which one it is. In the lower there are three fat pads, a medial, a lateral, and a middle. That's my little present to you. And they all have a slightly different character of fat and as a consequence the color fat is slightly different. There's a lot of different kinds of fat tissue. There are different kinds of fat cells present. This is more middle fat pad here. There we go. I've done it. And I think that's about it. We'll just do a little check. And again, right here is the orbital rim that you can't really see very well but Sarah and I can feel it. That's that little bit of fat. You can see bulging preoperatively off to this side here. It's more prominent on this side so I'm going to go ahead and remove it. Great. Now let's just take a look here. Very nice and no bleeding. Here's our orbital rim. Here is our pubicularis muscle. I'm going to show you next right here this beefy tissue that's muscle. That's a thin muscle that orbits around the eye so we call it obicularis. It's a thin muscle. I went through the septum. That's this layer and got the fat. Now I'm going to remove a little bit of our skin and muscle and sew everything up. That will be our lower blep. So now Patel is going to drape this over so I can get an idea of what's the proper amount of skin to remove. I'll take the scissor next. And as I told you preoperatively I'm going to be conservative about how much skin I remove here because we don't want to be in a position where the lower lid is being pulled down. Here you can see the cut edge of the muscles bleeding a little bit. Sarah if you'd swap that with your Q-tip. Okey doke. And now the six of silk and we are ready to close. So here's a quiz question. When we sleep our eye rolls back to protect the cornea. So if a patient has a situation where the eye doesn't close all the way then the globe will rotate back automatically when the patient is asleep to protect the cornea from drying out and we do that naturally and that has a name. Does anybody know what the name of that phenomena is and what we can do if the patient doesn't have that ability to have their eye roll back. Caitlin, do you remember what that's called? Do you remember what that's called when the eye rotates rolls back when you're sleeping?”
Caitlin: “I don't recall.”
Dr. Joel Aronowitz: “Strabismus would be wrong. It's an eye related thing that's when the there's a muscle problem. So stay tuned we'll tell you. Very nice and I appreciate how careful and thoughtful Sarah's being in cutting my sutures and that makes me not worry which is great. So the skin of the eyelid is one of the thinnest skin areas of skin in the body and especially as we age it gets thinner. Beautiful. Okay so we're done with the blepharoplasty. You can see my 6-0 silk sutures here. I've removed some skin a little bit of muscle and I've removed that excess fat immediately here. It was a little bit laterally as well same thing over here and now we are going to put on a nice dressing put some cool saline soaked sponges on the eyes to reduce her chance of getting bruising postoperatively give her instructions before she goes home and we'll arrange for a follow-up these stitches in somewhere three to five days.”
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