Modified full-thickness blepharotomy
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This is Richard Allen at the University of Iowa. This video demonstrates a modified full-thickness blepharotomy for treatment of upper lid retraction secondary to thyroid eye disease. The eyelid creases are marked with a marking pen with a small blepharoplasty. The area is then infiltrated with lidocaine with epinephrine. The marks are then incised with the cutting tool of the surgeon's choice. A flap of skin and orbicularis muscle is then removed. Using a high-temperature thermal cautery, the confluence of the levator aponeurosis and orbital septum is dissected from the anterior surface of the tarsus. Dissection then continues superiorly between the levator aponeurosis and the underlying Muller's muscle. The goal here is to not expose and preaponeurotic fat. Westcott scissors could be used, but I think the thermal cautery is ideal for this dissection. The lateral horn of the levator is then lysed with the thermal cautery followed by Westcott scissors. This is important to do to relieve any temporal flare. The thermal cautery is then used to make an incision superior to the superior border of the tarsus through the Mullers muscle and underlying conjunctiva. This will expose the underlying globe. This then proceeds medially to the central portion of the eyelid. The patient is sat up and the position of the lid is inspected. It appears too high. Addition dissection is then performed medially to excise the Mullers muscle from the underlying conjunctiva. In addition, an incision is made through the conjunctival medially to leave just a small bridge of conjunctiva attached to the tarsus, usually at the level of the peak of the pupil. The height of the eyelid appears appropriate. The same procedure is performed on the other side. The full-thickness nature of the procedure is demonstrated. The eyelid incisions are then closed with a single layer of 6-0 prolene suture through the skin edges in an interrupted and running fashion. Antibiotic ointment is used three times a day over the incisions and in the eye. The patient returns in one week for suture removal.