14. Upper blepharoplasty by means of rapid pulsed timedsurgical cutting
KEYWORDS: Upper blepharoplasty, timedsurgical cutting, Timedsurgery
Removing the skin enables us to create an eyelid that looks more youthful, while removing the palpebral fat allows the patient to open the eyes wider and more easily.
The design of the excision must be precise. The lower line is drawn immediately below the natural palpebral fold. The upper line is drawn at the border of the skin that has been visibly worn by the opening and closing movements of the eyelids.
The local anesthetic used is 2% mepivacaine or 2% lidocaine, to which ½ mg of epinephrine is added in a 10 mL vial. The epinephrine enables the operating field to be kept bloodless and is extremely useful in the event of bleeding from a larger-caliber vessel.
Local anesthesia is carried out with a 7 cm long 25 G cannula. Using a cannula prevents the formation of small hematomas and reduces ecchymoses. If the anesthetic solution is injected slowly, anesthesia is painless.
Upper blepharoplasty is considered to be the first of the anti-aging procedures that patients undergo.
After a 10-minute wait, the procedure begins.
The Timed apparatus is programmed to rapid pulsed timedsurgical cutting, Direct Cut 0.3/5.3, at 27 Watts, and a 0.08 mm diameter EM 10 White electromaniple is fitted.
The operator can choose whether to make the incision in the center of the preoperatively drawn line or at its upper or lower margin. This cutting technique enables precise millimetric excisions to be carried out in order to achieve the greatest symmetry.
In timedsurgical cutting, the depth of the incision is determined by the power of the emission.
We use the Timed apparatus for all the fine surgical procedures performed on the eyelids: from the excision of small neoformations by means of slow pulsed timedsurgical cutting, to upper and transconjunctival blepharoplasty. Owing to the characteristics of the cut and its excellent scarring, the Timed apparatus is particularly suited to use in this region.
Timedsurgical cutting enables the skin to be incised without being burnt; this is done by exploiting the characteristics of the programmable current generated by the Timed apparatus and the exclusive triangular-tipped conical electrode.
Once the skin incisions have been made in the two eyelids, the power is increased to 50 W and the EM10 White electromaniple is replaced by a 0.2 mm diameter EM10 Yellow electromaniple.
Removal of the outer angle of the diamond-shaped skin flap begins. In this small area, the excision is deeper, in order to avoid creating a so-called "dog ear".
The elasticity of the electrode enables it to cut at a speed that cannot be equaled by any human hand. Moreover, the electrode cuts without deforming the skin, as it exerts a pressure of less than 5 g, as opposed to the 1.5 kg force needed to cut with a surgical scalpel.
During cutting, the capillaries are coagulated by the current. If there is a larger vessel, it is closed by means of electro-coaptation; to do this, the operator uses the same 0.3/5.3 current and microsurgery pincers with a very fine tip, similar to those used by watchmakers.
The excision is almost always exclusively cutaneous, in order to preserve the volume of the eyelid. Indeed, a thick palpebral fold is a sign of youth.
On completion of the skin excision, the operator incises the orbital septum in order to remove the palpebral fat, which, in small orbits, impairs the correct opening of the eyelids. After incising the septum, the operator uses a fine Klemmer to grasp the fat and, by means of rapid pulsed cutting, frees it from the fasciae to which it is anchored. Timedsurgical cutting is super-selective, does not burn the tissues, and allows perfect visibility.
The operator infiltrates the fat with local anesthetic.
Removing the fat from the upper eyelids enables the patient to keep the eyes open more easily; the eyelids open wider and the eyes look larger. In this respect, upper blepharoplasty is not only an esthetic procedure; it is also functional.
Although the isolated pedunculated fat can be used to correct volume deficits of the eyelid, we very rarely do this. If there are volume deficits, we prefer to perform Adipofilling by injecting a suspension of small fragments of tissue together with the cell suspension. Adipofilling enables volume deficits to be precisely corrected, without limitations in terms of quantity or position. As the tissue fragments created by the aspiration vortex of the Adipopimer® are extremely small, they do not cause any surface alterations, even if injected through a cannula immediately beneath the thin palpebral skin.
Having removed the yellow fat, the operator checks to see if any white fat has herniated. As it has not, there is no need for further exploratory incisions, which would weaken the fascia.
The fat is now removed from the contralateral palpebral region. As always, local anesthetic is injected into the fat. The epinephrine contained in the anesthetic helps to keep the operating field bloodless and eliminates the sensation of reflex pain. It must be remembered that the feeling of pain during the removal of palpebral pouches is mainly caused by the traction applied to the fat by the operator.
The operator checks for possible herniation of the white fat.
The symmetry of the two eyelids is checked, considering that the orbits are often asymmetrical. Not only are the areas of skin excision compared, the residual areas of eyelid skin are also checked.
Spiral suturing is then carried out with a 6-0 nylon thread. The suture begins from the lateral angle of the excision. The needle passes exclusively through the skin, not through the underlying tissues.
The threads of the spiral sutures of the two eyelids are knotted together above the nose. The stitches will be removed after 3-6 days.
Surgical blepharoplasty in small orbits yields a natural result. The eye looks bigger and the palpebral fold appears fuller and younger.
The skin scar left by rapid pulsed timedsurgical cutting is excellent; it is never hypertrophic, practically invisible, and of superior quality to that of any other type of cutting.
Why is upper blepharoplasty with skin excision particularly suitable for patients with small orbits?
In patients with medium-sized, and especially large, orbits, removing the skin makes the eye look sunken, like a doll's eye; this often does not correspond to the patient's appearance when young. In these patients, I frequently carry out non-surgical blepharoplasty by means of 0.5 mixed peeling; this technique of strong peeling does not involve any risk and rejuvenates the patient's look without leaving scars or surgical artifacts. Even in patients with sunken eyes and excess skin, this timedsurgical peeling technique restores the patient's youthful look, maintaining the volumes of the eyelid and the palpebral fold that is typical of youth.
How do you make the preoperative design?
A dermographic pen is used. With the patient in the supine position, the eyelid is pulled upwards; the patient opens the eyes slightly, and the line of the design is traced immediately below the angle that is formed in the eyelid. The lower line starts from the vicinity of the internal canthus, reaches the extremity of the eyelid and extends to the wrinkle, if present. The upper line starts from the medial end of the lower line and continues along the border between the skin that has been worn by the opening of the eyelid over time and the intact skin below the eyebrow. The upper line stops at the level of the external canthus. At this point, the patient is placed in a sitting position in order to complete the design of the diamond-shaped skin flap that encompasses the lateral skin excess that is visible only under the effect of gravity.
If a patient with small orbits wants to undergo blepharoplasty, do you perform non-surgical blepharoplasty with 0.5 mixed peeling?
Generally, yes, but you have to consider what the eyelids were like when the patient was young; if the eyelids were sunken, surgical blepharoplasty can be performed. If the eyelids had a fold, it is advisable to carry out 0.5 mixed peeling.
Why do you use rapid pulsed timedsurgical cutting for upper blepharoplasty? What advantages does it have?
This particular type of cutting, which uses the specific 0.3/5.3 pulsed current generated by the Timed apparatus, has several advantages: it allows perfect visibility, ensures hemostasis of the capillaries, and, unlike all cutting by means of high-frequency currents, does not burn the tissues; moreover, scarring is excellent and never hypertrophic – much better than that of the traditional surgical scalpel or the diamond scalpel. If a new EM10 White electromaniple is used, the scar is practically invisible, as in this case. Even on the mucosae, such as the vermilion border for example, the scars are practically invisible.
What device is the TIMED?
The TIMED (Technique for the Implementation of Measured Electrosurgical Data) is a programmable electrosurgical device (Patent USA, Sergio Capurro) suitable to perform more than 70 standardized interventions in the field of plastic, aesthetic and dermatological surgery. Timed has unique and exclusive operating possibilities that have been implemented and tested for around 40 years.
What do you think of the Colorado needle?
The Colorado needle has an evocative name which fascinates those colleagues who do not know Timedsurgery, who are unfamiliar with high-frequency currents, and who are unwilling to learn new techniques. To me, it is just a pointed piece of iron, like many other electrodes that we used to use at one time.
What do you prescribe in the post-operative period following upper blepharoplasty?
The patient continues antibiotic therapy and applies swabs of cold chamomile, which is prepared before the procedure.
If the patient wants to modify the shape of the eyes, what can be done?
In the patient shown here, we lifted the eyebrows and the temporal region by implanting elastic threads (Elasticum, Korpo, Italy) a few weeks later. Elastic lifting was performed through an incision of a few millimeters at the hairline. This lifting technique enables several elastic threads to be implanted through the same incision. Lifting the tail of the eyebrow makes the eye almand-shaped, modifying the patient's look.
Why do you knot the two sutures above the nose?
We prefer to avoid knotting the spiral suture in the medial corner because, if we want to remove the stitches after three days, the palpebral edema could make it more difficult.
How should the patient prepare for the blepharoplasty procedure?
Two weeks before the procedure, the patient must suspend any treatment with aspirin, anti-inflammatories, vitamin E or phytotherapy, and refrain from drinking alcoholic beverages. If the patient is a coagulation defect, this must be corrected.
The benefits of upper blepharoplasty are immediately visible, but how stable are they?
For a year, the appearance of the eyelids improves; in the following years, gravitational ptosis continues to exert its effect. However, this can be corrected by means of Adipofilling of the forehead and eyelids. Conceptually, we never operate twice on the upper eyelids, except in the rare and unforeseen event of herniation of fat. Repeat procedures are more frequent in blepharoplasty of the lower eyelids, in which we always remove all the visible fat through the conjunctiva.
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