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Bill Ramsdell - V4 10.26.16

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Transcript of Bill Ramsdell - V4 10.26.16

History
Medications, Hypertension, Grave’s disease, Dry eyes, Vision, Myasthenia Gravis, Personality Characteristics
Lateral canthi
Upper Eyelid Margin
Lower Eyelid Margin
8-10 mm superior
to eyelid margin

6-8 mm superior
to eyelid margin
Asian
– highly variable, may be absent
1.5 – 2 mm
below the superior margin of the limbus
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

Consider ondansetron 4mg or 8 mg for nausea
Consider clonidine 0.1 mg PO – can repeat q 30 minutes prn
Negative Vector
Fat Pad Resection
Fat Repositioning
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.

Central pad
– easiest to locate, excise first

Medial pad –
gentle traction, meticulous hemostasis

Lateral pa
d- can be difficult to locate
Dissect central and medial fat pads from “pseudocapsules”, fibrous septae and inferior oblique muscle.

Develop fat pedicles.

Lyse arcus marginalis with cutting current.

Develop subperiosteal vs supraperiosteal pocket.

Reposition fat pedicles over tear trough.

Percutaneous suture to hold fat in place.
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AFTER
BEFORE
for Scleral Show or Ectropion
Trim excess skin, then close Advantage
Incise orbital septum to expose fat
Develop skin muscle flap through skin and orbicularis muscle
Fat Resection vs Fat Repositioning
Infraciliary
Approach
Suture fixation of lateral canthus to orbital periosteum
just below orbital rim, straighter
superior to orbital rim, arched with highest point above lateral limbus
Brows

WHAT IS
NORMAL?
2 mm superior
to medial canthus
4 mm superior
to medial canthus
Upper Eyelids
Upper Eyelid Crease
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 Disadvantage – scar, rounding of canthal angle
Adjunctive Procedures
Excision of excess (horizontal) eyelid followed by suture fixation to orbital periosteum
Cantho
pexy
3
Cantho
plasty
BLEPHAROPLASTY
REPAIR & REJUVENATION

-------------------------------------
---------------------------------------
----------------------------------------
Establish upper eyelid crease = inferior incision
Establish upper
incision line
minimum 1 cm between brow and incision line
(never excise > 1/3 of upper eyelid skin)
Skin only vs skin and muscle flap excision
scalpel, CO2 laser, electrosurgical, Ellman unit
+/- supratarsal fixation
Fat pad sculpting
Incise septum medially and superiorly
Not in men!
Skin to skin (only) closure
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Avoid the inferior oblique muscle
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.
B. Lyse lateral canthal tendon
C. Stop bleeding
D. Control blood pressure - clonidine
A. Remove all sutures
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