Lower eyelid blepharoplasty with direct festoon excision
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This is Richard Allen at the University of Iowa.
This video demonstrates a lower lid blepharoplasty with direct excision of festoons.
4-0 Silk sutures are place through the lower lids. The patient will have a pinch of skin removed laterally to improve fine winkles. A 15 blade followed Westcott scissors are used to excise the skin only.
The festoons have been marked preoperatively. A 15 blade is used to make an incision through the skin and underlying subcutaneous fat. There are multiple different ways to address festoons; direct excision can give an adequate result in the right patient. The needle tip cautery is used to excise a flap of skin and underlying subcutaneous fat. Undermining is then performed in the subcutaneous plane. This will allow closure of the incision without any tension on the lower lid. The same is performed on the other side, where the area of the skin that is involved with the festoon is excised. The goal here more than anything else is to ablate the space between the skin and subcutaneous fat so that no more fluid can accumulate.
An upper eyelid blepharoplasty is then performed by making an incision along the blepharoplasty markings with the needle tip cautery. A flap of skin and orbicularis are removed. The same is done on the opposite side. A direct browplasty will be performed in the standard fashion by making an incision through the skin and underlying subcutaneous fat with the 15 blade. The tissue is then excised with the needle tip cautery. The same is performed on the other side.
Attention is then redirected to the lower eyelids. Due to the significant lower lid laxity, a lateral tarsal strip will be performed. A lateral canthotomy and inferior cantholysis are performed. The strip is then fashioned by dissecting between the anterior and posterior lamella. The mucocutaneous junction is then excised. The posterior surface of the strip is scraped, and the strip is then shortened. The strip is engaged with a 4-0 Mersilene suture. The suture then engages the lateral orbital rim at the level of Whitnall’s tubercle and is tied, thus tightening the lower eyelid. The same is performed on the opposite side.
The festoon incisions are then closed with a combination of interrupted and running 6-0 Prolene sutures. This results in a good scar without significant tension on the lower lids. The same is performed on the other side. The skin pinch incisions are closed with interrupted 5-0 fast absorbing sutures.
The blepharoplasty incisions and direct browplasty incisions are closed in the standard fashion. At the conclusion of the case, the patient will use antibiotic ointment over the incisions three times per day and follow up in approximately one week for suture removal.