Indication
- cosmetic purposes (to look less tired, younger, more refreshed)
Differential diagnosis
- fat prolapse / excess skin / festoons / post-filler oedema
Alternative therapy
none
Preoperative
- diagnosis (including good quality frontal, side and upward-gaze pictures)
- consent form: always mention risk of bleeding-related visual loss, asymmetry, need for revision surgery, variable results depending on anatomy, eyelid retraction, double vision, postoperative scar and need for scar treatment
- align expectations with realistic results; identify patients with high expectations or dysmorphophobia
- +PLUS (self-pay service): consider offering adjuvant therapies such as upper eyelid surgery, skin resurfacing, botulinum toxin, treatments to improve skin quality
- anaesthesia: local anaesthesia plus sedation, or general anaesthesia in sensitive patients
- 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)
- if transconjunctival approach: 2x Alphagan eye drops, 10 minutes apart
- 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/surgical Adson forceps, Paufique forceps, fine toothed forceps
- Westcott scissors, Stevens scissors, Castroviejo needle holder, Desmarres eyelid retractor (several sizes), surgical basin, ocular shields if CO2 laser is used
Disposables
- Hibidil® 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 500mg) in 2x 5 ml syringes with a 30G needle
- sterile drape
- marking pen
- no. 15 blade (not if +PLUS)
- sterile gloves
- Steri-Strips 0.5 cm wide
- dental rolls and compresses for haemostasis, round swabs
- +PLUS: silicone bolsters if fat transposition is performed
- +PLUS: lubricating gel if laser shields are needed
Sutures
- 6-0 Vicryl for conjunctival traction
- 5-0 Prolene for canthopexy and fat transposition if needed
- 6-0 Prolene for skin if needed
Surgical technique
Marking of the skin and fat pads with a marking pen. Tetracaine eye drops. Skin disinfection. Cover with a drape exposing both eyes including the malar region. Protect with ocular shields if needed.
Transconjunctival approach: conjunctival incision with monopolar cautery, traction suture for the conjunctiva and lower lid retractors, dissect down to the inferior orbital rim, open the septum and remove the fat pads (medial, central and lateral); transpose the medial and central pad if needed with 5-0 Prolene knotted over a silicone bolster. Canthopexy with 5-0 Prolene if required. Check haemostasis. Pinch blepharoplasty if needed. Reposition the eyelid. Skin suture with 6-0 Prolene if pinch was performed.
Transcutaneous approach: subciliary skin incision with a no.15 blade. Dissect the skin from the orbicularis muscle over the tarsal area, then deepen the dissection plane to the septum. Open the septum and expose the fat pads. Excise fat with careful haemostasis. If fat transposition is needed, use 5-0 Prolene sutures tied over bolsters. Canthopexy with 5-0 Prolene. Reposition the eyelid. Conservatively assess excess skin and remove accordingly. Skin suture with 6-0 Prolene.
Tobradex ointment, cold packs.
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)
- after 4-6 weeks: assess result, symmetry, oedema, patient satisfaction; inform patient that final results may take 3-6 months to be achieved
