Indication
- cosmetic purposes (to look less tired, younger, more refreshed)
- reduced visual field
- need to improve visual field for a driving licence
Differential diagnosis
- palpebral ptosis, pseudoptosis
- eyebrow ptosis
Alternative therapy
none
Preoperative
- diagnosis (including good quality frontal and side pictures; visual field testing only for medical cases)
- consent form: always mention risk of bleeding-related visual loss, asymmetry, need for revision surgery, variable results depending on anatomy, postoperative scar and need for scar treatment
- align expectations with realistic results; identify patients with high expectations or dysmorphophobia
- +PLUS: consider offering adjuvant therapies such as brow lift, eyelid ptosis correction, lower lid blepharoplasty, 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/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 blade, gloves, 0.5 cm wide Steri-Strips®
- dental rolls and compresses for haemostasis, round gauze swabs, lubricating gel if laser shields are needed
Sutures
Surgical technique
Tetracaine eye drops. Skin disinfection. Cover with a drape exposing both eyes including eyebrows. Protect with ocular shields if needed. Mark the skin flap with a marking pen, ensuring lid closure is maintained.
Skin crease incision with a no.15 blade. Remove the skin flap with Westcott scissors and forceps. Haemostasis with bipolar cautery. Open the septum in the medial portion and remove the medial fat pad.
Haemostasis with bipolar cautery. Skin suture with 6-0 Prolene®. Tobradex® ointment. Steri-Strips® over the sutures. Cold packs.
Postoperative
- elevate head, cold packs every hour, reduce physical activity
- Tobradex® ointment before sleeping
- lubricating drops (Optava®) 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 and bleeding
- 7 days postop: remove Steri-Strips® and 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, patient satisfaction; consider scar treatment if needed; inform patient that the final result may take up to 3 months
