Indications
- increase visual field
- cosmetic purposes (to look less tired, improve asymmetry)
Differential diagnosis
- upper eyelid dermatochalasis/pseudoptosis/brow ptosis
Alternative therapy
none/botulinum toxin in the orbicularis oculi for mild cases
Preoperative
- diagnosis (including good quality frontal, side and up-gaze pictures, neuro-ophthalmological examination, phenylephrine test if required)
- consent form: always mention risk of asymmetry and contour abnormalities, need for revision surgery, variable results depending on anatomy, eyelid retraction, visual loss
- 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 eyelid blepharoplasty, brow ptosis surgery, 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
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 (several sizes), Putterman clamp if conjunctivomullerectomy, 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 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
- 4-0 silk traction suture for transconjunctival approach
- 6-0 Vicryl® or 6-0 Prolene® for surgery on the aponeurosis
- 6-0 Prolene® for skin if needed
Surgical technique
Mark the skin with marking pen. Tetracaine eye drops. Skin disinfection. Cover with a drape exposing both eyes including eyebrows. Protect with ocular shields if needed.
Transcutaneous approach (levator advancement or resection): skin crease incision with a blade, excise skin if planned, dissection of the anterior tarsus, opening of the orbital septum, dissection of the levator aponeurosis, careful haemostasis, advancement or resection of the aponeurosis, fixation on the anterior tarsus with 6-0 Vicryl® or 6-0 Prolene®. Check height and contour. Skin closure with 6-0 Prolene®.
Transconjunctival approach (conjunctivomullerectomy): 4-0 silk traction suture, evert the eyelid over a Desmarres retractor. Mark the desired resection, insert the Putterman clamp, suture through conjunctiva and Muller's muscle with 6-0 Vicryl® or 6-0 Prolene®, conjunctivomullerectomy. Knot the suture, check eyelid height.
Postoperative
- elevate head, cold packs every hour, reduce physical activity
- Tobradex® eye drops 3 times a day if transconjunctival approach
- Tobradex® ointment before sleeping
- lubricating eye drops 4 times a day
- Prednisone 40-40-20-20mg for 4 days p.o.
- Paracetamol 1g every 6-8 hours if needed (max 4g/day)
Follow-up
- 1 day postop: check visual acuity, pupillary reaction, IOP and signs of bleeding
- 7 days postop: remove sutures; start scar gel if needed (Strataderm® Gel once a day on the scar for at least 3 months); avoid sun exposure for 2 months (SPF 50)
- 2-3 weeks postop: assess height and contour, start stretching exercises if needed
- after 3 months: assess result, symmetry, oedema, patient satisfaction
