27. Upper blepharoplasty by means of the Timed apparatus (technique and golden number)
KEYWORDS: Upper blepharoplasty, Timed, rapid pulsed cutting, golden ratio
Upper blepharoplasty is the first anti-aging procedure requested by patients. It is not a simple procedure, as many surgeons believe. However, it becomes simple if we know how to perform it and what result we want to obtain.
First, the skin flap that is to be removed must be drawn out precisely; designs that are fanciful or which do not take into account the removal of the aged palpebral skin must be avoided. Most patients want to rejuvenate their eyelids. This video demonstrates how the Timed apparatus can be used to perform the procedure.
As already mentioned, the design of the diamond-shaped skin flap is important. The future scar must always remain in the fold that will be formed when the eyes are opened. To determine the position of the new fold, the operator uses two fingers to pull the eyelid upwards. While in the supine position, the patient must look at the tip of the dermographic pen. The operator moves the tip of the pen and asks the patient to open her eyes until the palpebral fold forms; the fold is then marked with the dermographic pen. After partially drawing the lower line of the skin flap, the operator draws the upper line, which encompasses the visibly aged skin of the eyelid. Once this part of the skin flap has been drawn out, the patient is asked to sit up, so that the lateral part of the flap can be completed under the effect of gravity. The operator extends the lower line of the skin flap to a wrinkle of the crow's feet. The design encompasses the drooping lateral skin, which becomes evident when the patient is sitting. Skin excision often differs from one eye to the other. The upper line is now drawn in order to complete the design of the skin flap.
Local anesthesia is obtained by means of 2% mepivacaine or 2% lidocaine; ½ mg of epinephrine is added to the 10 mL vial. The anesthetic is injected with a 2.5 mL or 5 mL syringe and a 30G needle or a 25G cannula, as in this procedure.
The lower line of the design is always drawn while the palpebral skin is under traction and the patient's eyes are open, so that the future palpebral fold can be exactly identified. This prevents the scar from rising and becoming visible. A high scar creates an unnatural ratio between the lower portion of the eyelid and the upper portion, in which case the patient's look is not rejuvenated, but maintains its aged appearance.
The correct positioning of the palpebral scar and the complete excision of the aged skin, as in this case, achieves the maximum rejuvenation of the patient's look. But is rejuvenation of this type always desirable? Actresses, models and show business personalities may want to rejuvenate their look while maintaining the characteristics of their eyes. In this case, the position of the sulcus remains unchanged, but the amount of skin removed is less. After the procedure, a small, natural-looking palpebral fold remains. The patient looks younger mainly because of the ratio between the portions of the eyelid above and below the sulcus.
The Timed apparatus is programmed to the function of rapid pulsed cutting at 27 Watts, and a 0.08 mm diameter EM 10 White electromaniple is fitted. This conical electrode has a triangular section. When used with the specific current of the Timed apparatus, it enables us to make a skin incision that does not burn at the edges; moreover, no pressure is exerted on the tissues and there is no need for counter-traction. The operator has to decide whether the palpebral skin has to be incised along the center of the previously drawn line, or along its superior or inferior margin. In the case of the lower line and the medial portion of the upper line, the skin is normally incised along the inferior margin. In the case of the lateral line, the superior margin is incised. With the Timed apparatus, the depth of the incision is determined by the power. Incision of the skin flaps of both eyelids is carried out. Before the skin is excised, the power is increased to 50 Watt and the EM10 White electromaniple is replaced by a 0.15 mm diameter EM 10 Gray electromaniple. Removal of the skin begins from the lateral angle of the skin flap. In this small area, the excision is a few mm deeper, as to avoid creating a so-called "dog ear". Only the skin is removed; the orbicular muscle is not. The removal of muscle tissue, especially in the medial portion of the skin flap, often causes unsightly alterations of the eyelid.
Having excised the skin, the operator assesses the need to coagulate the vessels. If coagulation is necessary, this is done by means of pincers with a very fine tip, similar to those used by watchmakers, and the same program data.
The skin of the contralateral eyelid is then removed. As always, the excision is a few mm deeper at the outer angle of the skin flap. If the operator encounters a bleeding vessel, it is coagulated with the pincers and the same pulsed current. Having completed the excision, the operator coagulates a few small vessels that are not bleeding, but which might bleed during the spiral skin suturing. The operator now checks the symmetry of the residual palpebral skin from above. This involves using the right side of the brain. The operator does not compare the skin flaps that have been removed, but the skin that surrounds them. He notices that a strip of skin about 1 mm wide needs to be removed. The power is reduced to 27 Watt and the EM 10 Grey electromaniple is replaced by the EM10 White electromaniple. After removal of the small strip of excess skin, the areas are sufficiently symmetrical. The operator now removes the herniated fat from the septum orbitae. The medial excess fat is unesthetic and must be removed. This fat is identified by pressing the eyeball before the procedure begins. If the medial adipose pouches are not removed, an unsightly swelling may remain. The fat in the central portion of the eyelid hinders opening of the eye, and its removal makes the eyes appear larger. Removal is carried out on specific request by the patient or in the case of asymmetry. Moreover, if the medial fat is removed, the patient has the impression of being able to see better, as she can keep her eyes open more easily.
The yellow fat is freed from the fasciae that cover it, and is removed. The white fat is then removed. This fat must be removed carefully and not in depth, owing to the presence of the angular vessels of the nose. In blepharoplasty procedures, it is always advisable to keep some pure epinephrine on hand, which can be placed in the cavity in the event of sudden bleeding. The residual fat is removed. The adipose pouches removed from the two eyelids are compared.
Spiral 5-0 suturing begins at the lateral extremity of the skin flap. On reaching the medial extremity, the operator does not knot the thread, but leaves the end free; this will be knotted to the spiral suture thread from the contralateral eyelid. The patient must be warned not to pull the thread, which passes above the nose. For a few days after the procedure, the patient's eyes will remain a few mm open. On returning home, the patient will need to apply compresses of cold chamomile. The stitches are removed after 4 – 6 days. The lateral knots are cut off and the thread is slid out with the aid of a “micro-hook” – a needle that has been blunted on a hard surface. Fine-tipped scissors can also be used. With regard to the suturing thread, in procedures involving more evident rejuvenation it may be preferable to use a rapidly absorbable 5-0 thread.
The result of the blepharoplasty is natural. One of the main objectives of esthetic surgery has been achieved: rejuvenation without artifacts.
After 4 - 6 days, the removal of the spiral suture. The incision remains in the eyelid sulcus. The restoration of the golden ratio between the mobile portion of the eyelid and the fixed one rejuvenates the gaze without artifacts
Capurro S. (2022): Upper blepharoplasty by means of the Timed apparatus (technique and golden number.) Timedsurgery section. https://www.crpub.org
Normally, the lower line is drawn in a wrinkle that is already present in the eyelid. Is that wrong?
Yes, it's wrong. The wrinkle indicates the site of folding of the aged eyelid, not that of the fold that will be formed after excision of the skin. Removing the skin flap creates upward traction and the scar could become visible. Moreover, the altered ratio between the inferior and superior portions of the eyelid may create a visual artifact. The proportions between these two small anatomical areas must for us follow the golden number. If fat is removed, the operator must carefully evaluate where the septum orbitae incision is made, with the golden proportion the cut must be very close to the upper skin margin.
So most blepharoplasty procedures are wrong?
Some, yes. Surgeons have to assess their results. Upper blepharoplasty is not a simple operation.
Some surgeons raise the incision laterally. What do you think of that?
In that case, the incision becomes visible. Therefore, it must not be done. In addition, we have to be careful not to extend the incision to the nasal skin, as this could lead to the formation of skin folds. The preoperative design must be drawn before anesthesia is carried out.
To achieve the maximum rejuvenating effect, does all the aged skin have to be removed?
Yes, if very evident rejuvenation is desired. In the upper portion of the eyelid, at least 1 cm of skin must be preserved. Removing the palpebral skin lowers the eyebrows slightly. This is a desirable effect, as the eyebrows rise with aging.
Is all the aged or wrinkled skin always removed?
Not always. In some patients, for example actresses, it may be more appropriate to perform partial removal of the skin, so as not to modify the patient's look too much.
How important is symmetry?
Symmetry is always important in esthetic surgery. The Timed apparatus enables us to carry out millimetric skin excisions in order to achieve symmetry.
Many operators remove some of the orbicular muscle. What you think of that?
We stopped removing orbicular muscle tissue years ago. With the Timed apparatus, it was extremely easy for us to remove orbicular muscle tissue. We even used to sculpt a flap in the outer portion of the muscle, which was then rolled like a cigarette, to enhance the volume of the eyelid. Today, however, the volume of the eyelid is provided by the orbicular muscle, which is compacted by the skin excision and, if this is not sufficient, by means of Adipofilling, which utilizes a suspension of adipose and stromal cells.
Some surgeons carry out intradermal suturing. Why do you advise spiral suturing?
It is difficult to perform intradermal suturing in the thin palpebral skin. If all the aged skin is removed, the incision may widen. Spiral suturing is preferable.
What can you say about epinephrine?
In this type of surgery, it is extraordinarily important. As well as the ½ mg of epinephrine that is added to the 10 ml of local anesthetic, it is advisable to keep some pure epinephrine handy, so as to stop any sudden bleeding. It should be borne in mind that hematomas are more serious in upper blepharoplasty than in transconjunctival blepharoplasty. Hematomas in this region can be emptied by means of epinephrine, cotton buds and an 18 G cannula.
What else can be done to rejuvenate aged eyelids?
There are many possibilities. The first procedure I would do is transconjunctival blepharoplasty, eliminating all the adipose pouches from the lower eyelid. Then I would perform elastic canthopexy to correct drooping of the eyelids. Next, I would eliminate roughness of the lower eyelid by means of mixed peeling. Subsequently, I would enhance the volume of the malar region and correct any volume deficits by means of cellular Adipofilling. Finally, I would carry out upper blepharoplasty. After the elastic canthopexy, the lateral skin fold of the upper eyelid becomes more evident and has to be removed.
No comments yet