The lid crease is formed by extensions of the levator aponeurosis to the dermis. However, in order for the crease to form, redundant tissue above the crease must fold over the crease. This redundant tissue is the skin above the crease and the preaponeurotic fat. This patient has a low lid crease prior to surgery. In order for me to raise the crease, I need to obliterate the connections of the levator aponeurosis to the original lid crease, followed by reestablishment of the lid crease by incorporating the levator aponeurosis into the closure. However, I also want to be careful not to disturb the preaponeurotic fat by not opening the orbital septum. She will have a conservative blepharoplasty as well as browpexy performed to increase her tarsal platform show.
For a written transcript of this video, please see below:
This is Richard Allen at the University of Iowa.
This video demonstrates an upper blepharoplasty with internal suture browpexy in a patient with a relatively low lid crease. The goal of the surgery is to increase the patient's tarsal platform show as well as elevate her eyelid crease. An upper blepharoplasty has been marked on each side as well as the area of the browpexy. The blepharoplasty markings are then incised with a 15 blade. A flap of skin and orbicularis muscle is excised with Westcott scissors. This is performed on each side. Due to the patient's relatively low lid crease, the levator/orbital septum will be disinserted from the anterior surface of the tarsus. This will obviate the connections between the levator and the dermis inferiorly. This dissection continues along the anterior surface of the tarsus to the superior border of the tarsus at the insertion of Mullers muscle. This is performed with a thermal cautery which I think is really useful for this dissection. This is performed on the opposite side. Again, the septal/levator aponeurosis confluence is disinserted from the anterior surface of the tarsus inferiorly to negate the lower lid crease. This is performed along the length of the eyelid. This proceeds superiorly until Muller's muscle is exposed. This will be incorporated into the closure of the incision. The internal suture browpexy is then performed. This can be seen in detail in another video. Dissection is carried out superiorly along the surface of the orbital septum to the superior orbital rim. A 4–0 Vicryl suture then engages the periosteum superior to the superior orbital rim. The suture then engages the brow fat at the same distance. The suture is then tied. The eyelid crease incisions are then closed with a 6–0 Prolene suture which engages the cut end of the levator/orbital septum. This is performed with interrupted sutures along the length of the eyelid. This will reestablish the connection of the levator aponeurosis and septum to the dermis but at a higher level. This will raise the patient's eyelid crease and with the browpexy will increase the tarsal platform show. At the conclusion of case, erythromycin ophthalmic ointment is placed over the incisions. The patient will return approximately one week for suture removal.
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