1. Introduction

2. Surgical Approach

a. Incision with No. 15 Blade

b. Excision with Surgical Scissors

c. Examine Wound Edges for Cholesterol Plaques

d. Hemostasis with Cautery

e. Closure with Running 6-0 Plain Gut Suture

3. Left Upper Eyelid Blepharoplasty

c. Hemostasis with Cautery

d. Deeper Excision of Cholesterol Plaques

4. Right Upper Eyelid Blepharoplasty

Upper blepharoplasty is one of the most commonly performed oculoplastic procedures. It is aimed at correcting the involutional changes of the upper eyelids, characterized by loose, excess eyelid skin (dermatochalasis) and preaponeurotic fat herniation (steatoblepharon) as well as some cases of ptosis. These conditions could result in functional symptoms, such as reduced visual fields, as well as cosmetic concerns and perceived body dysmorphia. In this case, the patient underwent upper blepharoplasty for cosmetic improvement and to remove xanthomatous lesions. This article discusses and demonstrates the preoperative assessment of the patient, the preparation, the surgical technique, and possible complications.

<h4>CHAPTER 1</h4>

<p>Hello, my name's Dr. John Lee.
I'm the oculoplastic and reconstructive surgeon
for Boston Vision.
I want to introduce a video today
where we're going to perform a blepharoplasty surgery
on both upper eyelids.
It can be done for either cosmetic or for medical reasons.
Initially, when we see the patient on the day of surgery,
we will see if they have any questions.
If they don't, we will proceed
to mark their upper eyelids using a surgical marker.
And at this stage is when we decide how much skin to remove
and how to shape that excision of skin.
Once that skin is marked,
we do something called a pinch test,
where we take a set of dull forceps
and we bring the edges of those marked ellipses together
to ensure that we don't remove too much skin.
Once we're happy with the shape, and position,
and size of that ellipse, we will anesthetize that area
with 2% lidocaine and epinephrine
on a very thin 32 gauge needle.
We'll have the patient sit for about 15 or 20 minutes.
While that's working, we come into the operating room.
We'll get them prepped and draped.
The initial incision is done with a 15 blade,
and the ellipse is then simply excised
with Westcott scissors.
The resulting wound bed is then cauterized
with high temperature cautery
to control any bleeding blood vessels,
and then the wound is then simply closed.
In my technique,
I use a running suture using a 6-0 plain gut.
And once that's all done, we will proceed to the other side
and complete the procedure,
try to maintain as much symmetry as possible.</p>

<h4>CHAPTER 2</h4>

<p>So she's having a bilateral,
cosmetic upper lid blepharoplasty.
The surgical techniques are very similar
to a medical upper lid blepharoplasty.
The one additional twist we're gonna do for her is
we're gonna excise these xanthelasma plaques right here.
I've done my best to incorporate that
into a normal blepharoplasty ellipse.
We will have some close plaque remnants
right at the edge of that.
And we'll probably have some there as well.
In fact, some of the cholesterol plaques are
outside of our intended incision.
Patient knows that
we will prioritize getting a good incision
as opposed to taking out every plaque.</p>

<h4>CHAPTER 3</h4>

<p>So the first incision will be along the lid crease.
This is a 15 blade.
The patient has already been anesthetized
with lidocaine with epinephrine.</p>

<p>And we'll complete the excision of the ellipse
with Westcott scissors.
So here, we're removing an ellipse of skin.
The tissue just underneath it is the orbicularis.
And in the thin spots,
we will see some of the preaponeurotic fat.</p>

<p>So I look at the wound edges here
to see if there's any cholesterol plaque there.
I don't see any.
I think we got it all there.
Excellent.</p>

<p>And you can see some of the yellow, the preaponeurotic fat.
And we're using high temperature cautery
just to control some of these blood vessels.
She isn't bleeding very much at all.
Okay.</p>

<p>And we simply close the wound with a running suture.
I use 6-0 plain gut.
Goal is to approximate the edges,
make them right next to one another without any tension.
Ideally, you want the wound edges to be everted,
meaning that the under surfaces are touching one another.
That promotes the best healing
and the least objectionable scar.
Dab on that side.
Okay, follow.
And at the end of the suture line,
I'd like to create a loop and use that to tie off.
Okay, we'll go to the other side.</p>

<h4>CHAPTER 4</h4>

<p>And we'll do essentially the same procedure.
Let's double check our ellipse here.
Yeah, so I can see there's a portion
of the xanthelasma plaque
that will fall outside of our ellipse.
But if I do aim to take that,
I think that'll be too much skin removal nasally,
which will give her cosmetic problems
and even potentially problems with lagophthalmos.</p>

<p>Again, Westcott scissors to remove the skin ellipse.</p>

<p>Not much bleeding.
Do some more excision deeper of these cholesterol plaques.
These are visible
as these chalkish colored areas right there.
Some smaller plaques right at the nasal part of the wound.
Cautery, please.
Can you get me the cautery?
Hmm?
Cautery.
Okay.</p>

<p>And just as on the other side, a 6-0 plain gut to close.
I'm gonna leave the loop
to make that the other end of the knot.
And you are all done.</p>


Watch this full-length, narrated occuoloplastic video of a bilateral blepharoplasty for upper eyelids performed by Dr. John Lee at Boston Vision.

DOI
Publication Date	2023/12/01
Article ID	400
Production ID	0400
Volume	2023
Issue	400
https://doi.org/10.24296/jomi/400

Blepharoplasty for Bilateral Upper Eyelids

Procedure Outline

Table of Contents

1. Pre-op Steps

2. Surgery

3. Post-op Care