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Bill Ramsdell - V9_Final2_ 11.4.16

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Transcript of Bill Ramsdell - V9_Final2_ 11.4.16

Lateral canthi
Lower Eyelid Margin
8-10 mm superior
to eyelid margin

6-8 mm superior
to eyelid margin
Asian
– highly variable, may be absent
Lid should just touch or
closely approximate the
inferior aspect of the limbus.
BLEPHAROPLASTY
COMPLICATIONS

LOWER BLEPHAROPLASTY
PROCEDURE

Monitor blood pressure
UPPER BLEPHAROPLASTY
PROCEDURE

BLEPHAROPLASTY AND BROWLIFTS
William M. Ramsdell, MD Austin, Texas
Incise orbital septum to expose fat
Develop skin muscle flap through skin and orbicularis muscle
Fat Resection vs Fat Repositioning
Infraciliary
Approach
Just below orbital rim, straighter
Superior to orbital rim, arched with highest point above lateral limbus
Brows

WHAT IS
NORMAL?
4 mm superior
to medial canthus
2 mm superior
to medial canthus
Upper Eyelids
Based upon Maxillary Anatomy
1
2
3
1-2 mm inferior to lashes
excise conservatively
excellent exposure to mobilize orbicularis muscle, +/- SOOF for canthoplasty or midface lift
scar, rounding of canthal angle
3
---------------------------------------
----------------------------------------
Scalpel,
CO2 laser, electrosurgical,
Ellman unit
Fat pad sculpting
Incise septum medially and superiorly
Not in men!
Skin to skin (only) closure
Identify 3 (usually) fat pads
place incision midway between lid margin and inferior fornix = 3-5 mm inferior to tarsal plate
“Open Sky” excision through conjunctivae and capsulopalpebral fascia
2
Expose palpebral conjunctivae
1
Transconjunctival Approach
Corneal Abrasion
treat with lubrication, patching, proparacaine, contact Ienses
Eyelid crease malposition
Lagophthalmos
secondary to over-resection of skin or vertically shortened orbital septum due to inadvertent inclusion of the septum into the skin closure
Strabismus/Diplopia
DRY EYES
Chemosis
Ptosis
secondary to edema, damage to levator aponeurosis or supratarsal fixation placed too high (limits excursion of levator muscle)
Scleral show/
Ectropion
Retrobulbar hematoma
Bleeding usually from orbicularis muscle or vessels within fat pads. Causes optic nerve compression , 90 minutes until irreparable damage occurs.
Lyse lateral canthal tendon
Stop bleeding
Control blood pressure
· clonidine
Remove all sutures
Negative Vector
Hypoplastic maxilla, globe projects beyond inferior orbital rim. Consider fat repositioning or fillers.
Fat Pad Resection
Central pad
– easiest to locate, excise first
Medial pad
– gentle traction, meticulous hemostasis
Lateral pad
- can be difficult to locate

Fat Repositioning
Canthopexy
– Suture fixation of lateral canthus to orbital periosteum.
Canthoplasty
– Excision of excess (horizontal) eyelid followed by suture fixation to orbital periosteum.

Malar Fat Pad
Levator
Aponeurosis
Periorbital
AGE-RELATED
ANATOMICAL CHANGES
Boney Changes
Lower orbital rim
and maxilla recede
Consequences
scleral show
ectropion
Soft Tissue Changes
Brow
Upper Eyelid
Lower Eyelid
Retaining ligaments lengthen

Consequences
- Inferior descent of the retroorbicularis oculi fact (ROOF) with brow ptosis

Orbital septum attenuation
Consequences
- Fat pads prolapse
Orbicularis retaining ligaments lengthen
Consequences
-
Determines shape and extent of fat pad
contributes to tear trough formation,
Mullers Muscle
Thanks for your attention!
1.5 – 2 mm
below the superior margin of the limbus
Annual Meeting · November 12, 2016 · New Orleans, Louisiana
American Society for Dermatologic Surgery
for the Dermatologic Surgeon
A.
B.
C.
D.
4
Avoid the inferior oblique muscle

5
Neutral Vector
Globe and orbital rim coincide. Either resection or repositioning.
Positive Vector
Inferior orbital rim projects beyond the globe. Fat pad excision, not repositioning.
Adjunctive Procedures For Scleral Show, Ectropion or Lower Eyelid Laxity
vertically lengthened lower eyelid
prolapse (steatoblepharon),
Tarsal plates and canthal tendons become lax
Consequences
-

Scleral show, ectropion
Levator muscle attenuation with levator aponeurosis dehiscence

Consequences
- Upper eyelid ptosis,
high eyelid crease



Advantage
Disadvantage
Trim excess skin, then close
minimum 1 cm between brow and incision line (never excise > 1/3 of upper eyelid skin)
Establish upper
incision line
History
Skin only vs skin and muscle flap excision
Medications, Hypertension, Grave’s disease, Dry eyes, Vision, Myasthenia Gravis, Personality Characteristics
Orbital Fat
Orbital Fat
Suborbicularis Oculi Fat (SOOF)
Retro-Orbicularis Oculi Fat (ROOF)
Preseptal Fat
Caution

Medial fat pad whitish and deeply located. Inferior trochlear artery present. Obtain hemostasis prior to releasing residual fat pad. Gentle traction only.
Consider ondansetron 4mg or 8 mg for nausea
Consider clonidine 0.1 mg PO – can repeat q 30 minutes prn
+/- supratarsal fixation
Establish upper eyelid crease
1
2
3
4
5
6
7
8
Anatomy
Orbital Septum
Orbital Septum
Orbicularis Oculi Muscle
Orbicularis Oculi Muscle
Superior Tarsus
Inferior Tarsus
Conjunctiva
Capsulopalpebral Fascia
1
Dissect central and medial fat pads from “pseudocapsules”, fibrous septae and inferior oblique muscle.
2
Develop fat pedicles.
3
Lyse arcus marginalis with cutting current.
4
SOOF
Fat Pads
Arcus Marginalis
Orbicularis Muscle
Develop subperiosteal vs supraperiosteal pocket.
5
Reposition fat pedicles over tear trough.
6
Percutaneous suture to hold fat in place.
Upper Eyelid Margin
Upper Eyelid Crease
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