Indications
- cosmetic purposes (to look less tired, younger, more refreshed)
- reduced visual field
- need to improve visual field for a driving licence
Differential diagnosis
- dermatochalasis, palpebral ptosis
- eyebrow ptosis
Alternative therapy
botulinum toxin, endoscopic brow lift, transconjunctival browpexy
Preoperative
- diagnosis (including good quality frontal and side pictures; visual field testing only for medical cases)
- consent form: always mention risk of postoperative scar and need for scar treatment, visual loss, asymmetry, need for revision surgery, variable results depending on anatomy
- align expectations with realistic results; identify patients with high expectations or dysmorphophobia
- +PLUS (private self-pay costs): consider offering adjuvant therapies such as upper and lower lid blepharoplasty, eyelid ptosis correction, skin resurfacing, botulinum toxin, treatments to improve skin quality
- anaesthesia: local anaesthesia plus sedation
- anticoagulation: adjust antiplatelet or anticoagulant medication if possible (stop Aspirin® 10 days before surgery; Marcoumar® INR >= 1.2 on the day of surgery; new anticoagulants (Eliquis®, Lixiana®, Xarelto® etc.): stop 2 days before, on the day of surgery and 2 days after surgery)
Preparation
- preoperatively: check that anticoagulation has been stopped, clean skin, no creams, no make-up, no skin tanning if skin lasers are planned
- 3x Tetracaine SDU® 1% eye drops (every 5 minutes)
- cleanse skin with alcohol wipes
- local anaesthetic cream on skin 30 minutes before surgery if skin lasers are planned
Surgical setup
- operating table: supine position, elevate head if needed to reduce bleeding
- surgical loupes if needed, bipolar and/or monopolar cautery, CO2 laser ready if needed
- Castroviejo-Schachar compass, anatomical Adson forceps for skin marking, surgical Adson forceps, Paufique forceps, fine toothed forceps
- Westcott scissors, Stevens scissors, Castroviejo needle holder, Desmarres eyelid retractor, surgical basin, ocular shields if CO2 laser is used
Disposables
- Hibidil® disinfecting solution, ice-cold NaCl solution
- anaesthetic solution (7.2 ml Rapidocain® 2% with epinephrine + 0.9 ml sodium bicarbonate 8.4% + 0.9 ml tranexamic acid) in 2x 5 ml syringes with a 30G needle
- sterile drape, marking pen, no. 15 scalpel blade, gloves, dental rolls for haemostasis, compresses for haemostasis, round gauze swabs
- 0.5 cm wide Steri-Strips®, lubricating gel if laser shields are needed
Sutures
- 6-0 Vicryl® for subcutaneous suture
- 6-0 Prolene® or 6-0 Ethilon® for skin
Surgical technique
Mark the desired eyebrow height in sitting position. Tetracaine eye drops. Skin disinfection. Cover with a drape exposing both eyes including the forehead region. Protect with ocular shields if needed.
Skin crease incision with a no. 15 scalpel blade. Remove the skin flap with Westcott scissors and forceps. Haemostasis with bipolar cautery. Subcutaneous suture with 6-0 Vicryl®. Skin suture with 6-0 Prolene® or 6-0 Ethilon®. Steri-Strips® over the sutures. Cold packs.
Postoperative
- elevate head, cold packs every hour, reduce physical activity
- leave Steri-Strips® on the sutures
- Tobradex® ointment before sleeping
- lubricating drops (Optava®) 4 times a day
- Prednisone 40-40-20-20 mg for 4 days p.o.
- Paracetamol 1g every 6-8 hours if needed (max 4g/day)
Follow-up
- 1 day postop: check visual acuity and bleeding
- 12-14 days postop: remove Steri-Strips® and sutures; start scar gel (Strataderm® Gel once a day on the scar for at least 3 months); avoid sun exposure for 2 months (SPF 50)
- after 4 weeks: assess result, symmetry, patient satisfaction; consider additional scar treatment if needed; inform patient that the final scarring result may take up to 6 months
