Surgery Spotlight: Blepharoplasty with Fat Injection: Part II-Surgery Spotlight: Blepharoplasty with Fat Injection: Part II

Surgery Spotlight: Blepharoplasty with Fat Injection: Part II

Video Transcription

Prior to making my incision, I always put the lid on traction-counter-traction between the medial and lateral canthus.  I lightly score my line.  And I save the medial-most and lateral-most parts of the incision for last.  And then I ask my assistant to hold some counter-traction on the forehead brow.  part of the removal I like to do with a scissor. I think it creates a nice, natural, sharper edge.  Okay, so now we've got our excision. We're looking at muscle underneath.  And so what I do is I like to divide the preorbital portion of the orbicularis, which is right here.  And then I remove this whole triangle. And what that does is this creates both a lateral brow elevation, but it also helps to avoid postoperative crow's feet.  That's kind of my so-called the surgical Botox effect.  Which is significant. You can see that there's some underlying suborbicularis fat.  And then in her case, as you could see preoperatively, she had a bit of ptosis.  So instead of doing formal ptosis surgery, what I'm going to do is I'm going to remove a two millimeter strip of preceptor orbicularis. And I found that that is very, very effective  at correcting very mild or subclinical cases of blepharoptosis.  while preserving the majority of the muscle, which we can see here. And then we can also do an assessment to make sure that the underlying aponeurosis is intact,  so I get to visualize that. She does have a bit of septal fat excess, but the majority of it is suborbicularis, as you can see here. So, again, as we know with the aging process,  we don't want to skeletonize the eye, because that will, in turn, age the eye. So we want to preserve this relative fullness that we have under the brow.  And at the same time, in her case, I want to do a little bit of an evaluation to make sure that we're not dealing with lacrimal glanctosis, which I'm just assessing right now,  see no signs of it. This is the brow. Septum is intact. This is septal fat, but, again, not significant excess. And so I'll do just a little bit of diathermy on the septum itself.  That creates just enough of a cicatricial response. All right, Chris, you can look up. And you can see how now we're left with structures that will auto-augment.  So this residual muscle will invaginate like so. You can see here that this tissue is then allowed to invaginate. And you get the fullness that we want along the brow,  which is rejuvenating. And at the same time, we've removed the excess. And so it's a vest over pant phenomenon here. Now for the closure, I incorporate the muscle.  But I think it's important to note that for the muscle portion of the closure, skin muscle portion of the closure, that I'm not including the leading edge,  but rather incorporating the edge immediately underneath my skin line, suture line.  And also making significant progress.  And really with the closure, assuming the excision has been well placed, the skin should almost want to come together.  That is done, and just for contrast, you can see the difference. We had just an ever so slight effacement of the eyelash line, which in her case has been augmented.  And we'll move on to the other side. I think the most difficult part of doing eyelid surgery for someone who's just starting out is really making a judgment as to how much is enough  and when too much is going to lead to complications. I think that is the hardest part. And so there are little pointers that I've found useful.  For the upper eyelid, typically I look at the tarsal height, so it's a very simple maneuver to evert the eyelid, the upper eyelid, and measure the height of the tarsus.  And in general, that's going to be the relative height of the supratarsal crease. So then once you've got that line marked, then you find the lower border of the brow,  the inferior border of the brow, and you have to look carefully because many women in particular will tweeze their eyebrows, so you have to look for that transition,  typically with magnification. And so once you find that point, you typically don't want to remove more than half the amount of skin between those two structures,  otherwise you run the risk of removing too much skin, which in turn can lead to lag of thalamus or an inability to close the eye.  For the lower eyelid, less is always going to be more. In many cases for the lower eyelid, I remove not a single millimeter of skin. I think it's critical for the lower eyelid.  Once you've removed just a millimeter too much of skin, you have a significant risk of ectropion or lid retraction, which is very difficult to correct.  In general, my personal opinion is for the lower eyelid to proceed or to address lower eyelid concerns from a transconjunctival approach.  I think that this is an approach that will, by definition, have a lower risk of lid malposition because, one, you're actually dividing the lower lid retractor,  the capsule palpebral fascia. Number two, you're manipulating the orbicularis very little, if any. And three, you're naturally able to gain access  to all the relevant anatomy, and if you felt it necessary, you can do a little pinch skin excision to complete skin removal if you felt that it was indicated.

Video Summary

The speaker describes a meticulous surgical technique for eyelid correction, emphasizing traction-counter-traction and precise incisions. They prioritize preserving key structures, using scissors for natural edges, and assessing for conditions like ptosis without invasive surgery. Their approach minimizes complications, like crow's feet and aging appearance, achieving a "surgical Botox effect." They discuss balancing skin removal to avoid complications like lagophthalmos or ectropion, particularly in lower eyelids. The speaker advocates a transconjunctival approach for the lower eyelid to reduce risk. Overall, the focus is on careful assessment and conservative action to enhance aesthetics while maintaining functionality.

Asset Caption

Julius W. Few, MD demonstrates a bilateral upper blepharoplasty with fat injection to the mid-face and lower third of the face. Part 2 of 3 includes incision, excision, removal of muscle and suturing.

Surgeon Julius W. Few, MD

Disclosure Julius W. Few, MD has nothing to disclose. All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

Surgical Videos

Surgery Spotlight

Aesthetic

Julius W. Few MD; Memben

eyelid correction

surgical technique

transconjunctival approach

ptosis assessment

surgical Botox effect