13. Transconjunctival blepharoplasty by means of rapid pulsed timedsurgical cutting
KEYWORDS: Transconjunctival blepharoplasty with the Timed, Transconjunctival blepharoplasty with two micro-incisions, rapid pulsed timedsurgical cutting, Timed apparatus
Transconjunctival blepharoplasty eliminates adipose pouches from the lower eyelids without leaving skin scars. Adipose pouches of the lower eyelid are congenital, but become more evident with age. These pouches give the patient a tired appearance; removing them makes the patient look younger.
Transconjunctival blepharoplasty is performed by means of rapid pulsed timedsurgical cutting. A few drops of topical anesthetic are applied to the conjunctiva. After a few minutes, local anesthesia is carried out. This is done by adding 1/2 mg of epinephrine to a 10 ml vial of mepivacaine and injecting the solution through the anesthetized conjunctiva. The operation begins about 10 minutes after the local anesthesia has been administered.
The adipose pouches are removed through two horizontal incisions of about 1 cm, one lateral and one medial, which do not require stitches. The lateral incision is made in the mucosa, 3 or 4 mm from the conjunctival fornix. A 0.10 mm diameter EM 10 Green electromaniple is used, in the rapid pulsed timedsurgical cutting function at 38 Watt. A fine Klemmer is used to delicately part the tissues until the adipose pouch covered by its fascia appears. The operator's assistant keeps the surgical field dry. The operator incises the fasciae that retain the adipose pouch. With a Klemmer, the operator then grasps the adipose pouch and injects a small amount of anesthetic solution into it. The injection of local anesthetic not only eliminates the reflex pain caused by the traction of the pouch; together with timedsurgical cutting, it also contributes to making the procedure bloodless. The operator removes the adipose pouch with an EM 10 Gray electromaniple in the rapid pulsed timedsurgical cutting function at a power of 50 Watt. The fact that the procedure is bloodless is important, as good visibility is necessary so that the operator can remove all the fat that has herniated outside its natural site, the orbit.
The fat is removed selectively; this is made possible by the small size of the 0.15 mm electrode, which allows optimal visibility. The conical tips of the electromaniples are flexible and have a triangular cross-section. Timedsurgical cutting does not burn the tissues, and, because of the shape of the electrode, only the last few millimetres of the tip are active.
The operator must ensure that all the adipose pouches are removed. Particular care must be taken when the most lateral pouch is removed; if it is not removed completely, the procedure may need to be repeated.
The medial incision is now made with the EM 10 Green electromaniple at 27 Watt. A thin Klemmer is used to part the tissues until the adipose pouch appears. The fascia that retains the pouch is incised. The pouch is extracted and the anesthetic solution containing epinephrine is injected into it. The adipose pouch is removed by means of the EM 10 Gray electromaniple in the rapid pulsed timedsurgical cutting function at 50 Watt. Once the fasciae have been incised, the adipose pouch emerges from the small incision. The operator patiently removes the adipose pouches in the medial compartment. It is necessary to remove all the herniated pouches, which manifest themselves owing to the congenital weakness of the orbital septum.
A cotton-wool bud soaked in physiological solution is now used to check that the pouches have been completely removed, leaving a regular concavity. This maneuver reveals the presence of any lateral volume excess. The operator checks for excess fat by delicately pressing the upper eyelid. As mentioned above, the adipose pouches must be completely removed. The fat in the pouches, in addition to being dislocated in an anomalous position outside the orbit, has the unpleasant tendency to swell in response to the diet, for example owing to an excess of dietary salt. The operator locates the lateral pouch revealed by the above-mentioned maneuvers, and injects and removes it. The maneuver with the cotton-wool bud is repeated. A small fragment of fat is detected in the medial region.
The contralateral eye is now treated. First, the mucosa in the medial region of the conjunctiva is incised. An EM 10 Green electromaniple is used and Timed apparatus is set to rapid pulsed timedsurgical cutting at 38 Watt. The thinner the electrode, the greater its cutting effect will be; a larger electrode has a greater coagulating effect. The tissues are parted by means of a Klemmer, in order to identify the adipose pouch. After replacing the EM 10 Green electromaniple with an EM 10 Gray electromaniple, the operator increases the power to 50 Watt and incises the sheath that contains the fat. The adipose pouch can now be gripped with pincers and extracted. At the base of the fat, a few larger vessels are visible; these must be coagulated. This is done by using pincers with a very fine tip and delivering a current of the same power as that used in rapid pulsed cutting (50 Watt), but this time in the coagulation function. The pincers are the same as those used in microsurgery and are similar to those of a watchmaker.
Once hemostasis has been carried out, the adipose pouch is removed. If the patient has any feeling of discomfort, the operator injects the adipose pouch with a small amount of anesthetic solution containing epinephrine. At the beginning of the procedure, the patient has been instructed to signal any feeling of pain, even if it is tolerable. If the patient feels even the slightest pain, this means that the anesthetic has not had the proper effect. If the effect is insufficient, this means that the anesthetic does not contain enough epinephrine to ensure the vessel constriction necessary for hemostasis with pulsed timedsurgical cutting.
Drying the operating field prevents dispersion of the high-frequency current and ensures that cutting remains efficacious. Having removed the pouch, the operator again uses the Klemmer to search for herniated fat. The sheaths that retain the lobules of fat are incised, and the lobules are removed by means of rapid pulsed timedsurgical cutting. All the fat in the pouches is removed. Removal is highly selective. The last fragment of fat in the compartment is removed.
The operator now replaces the EM 10 Gray electromaniple with the thinner EM 10 Green electromaniple and reduces the power to 38 Watt. The conjunctiva is incised and a thin Klemmer is used to spread the tissues until the lateral adipose pouch is exposed. In blepharoplasty, we always remove all the herniated fat; in this way, the skin adapts to a concave surface, and excision or mixed peeling are rarely necessary.
The adipose pouch is now clearly visible. The fascia that covers it is incised. The pouch can be grasped with the Klemmer. A small amount of anesthetic solution containing epinephrine is injected.
The EM 10 Green electromaniple is replaced by the larger EM 10 Gray, and the power is increased to 50 Watt. The fat removed is collected so that it can be compared with that removed from the contralateral eyelid. The operator now closes the eyelid and presses slightly on the eyeball, in order to squeeze out the residual fat. The patient reports feeling pain in the upper eyelid. This is a reflex pain, as mentioned above. The operator injects the anaesthetic solution.
Particular care must be taken when removing the most lateral adipose pouches. Now, the fat that is extracted by means of the Klemmer displays the features of deep fat; it is smooth and less lobular. This deep fat must also be removed. The operator now continues to remove the pouches. The procedure is almost over, but the most important part remains to be done: the operator must check that the pouches have been completely removed.
To check that the pouches have been completely removed, the operator wipes a cotton-wool bud over the eyelid. If the pouches have been completely removed, the bud will leave a uniform furrow. In the present case, this maneuver reveals a slight swelling in the central region; this requires further investigation.
The Klemmer is used to explore the eyelid through the medial conjunctival incision, but no pouch can be seen. The operator then approaches through the lateral incision. The tissues are delicately shifted with the Klemmer. This search is meticulous, but the pouch is finally found. This last pouch is also removed.
Now the amount of fat from each of the two eyelids is compared. The adipose pouches removed are equivalent.
The transconjunctival blepharoplasty procedure is now over. No stitches are necessary. A cold mask is applied for about 30 minutes. At home, the patient will apply cold chamomile.
The result of transconjunctival blepharoplasty by means of rapid pulsed timedsurgical cutting is optimal and rejuvenates the patient's face in a natural way.
Capurro S. (2018): Transconjunctival blepharoplasty by means of rapid pulsed timedsurgical cutting. CRPUB Medical Video Journal. Timedsurgery section. www.crpub.org
What advantages does rapid pulsed timedsurgical cutting have over laser therapy or the scalpel?
A laser beam burns the tissues and is difficult to control. Palpebral surgery can certainly be performed with the scalpel and scissors, but we prefer rapid pulsed cutting. This type of cutting does not burn the tissues, is hemostatic, does not deform the tissues, allows extreme precision, and offers perfect visibility; in addition, in comparison with incisions made with a scalpel, healing times are halved. Moreover, when used on the mucosa, for example on the vermilion border, pulsed timedsurgical cutting does not leave visible scars. However, the greatest advantage of performing transconjunctival blepharoplasty by means of rapid pulsed timedsurgical cutting is that it is extremely selective and scantly invasive. For us, preserving the integrity of the tissues is very important in every procedure! Indeed, it is irrational to perform transconjunctival blepharoplasty by dissecting the whole area, as is done in blepharoplasty through an external incision, an approach that we abandoned decades ago! In the procedure demonstrated here, the adipose pouches were isolated and removed selectively, without damaging the surrounding tissues.
What are the features of the electromaniples used?
The EM10 electromaniples have a flexible tip, which is conical in shape and has a triangular cross-section. These electromaniples come in different sizes (EM10 White 0.08 mm, EM10 Green 0.10 mm, EM10 Gray 0.15 mm, EM10 Yellow 0.20 mm, EM10 Black 0.30 mm; the EM15 has a 1.5 mm cylindrical tip) and are used in the numerous (over 70) standardized Timedsurgery procedures.
In the lower eyelid, are the adipose pouches completely removed?
Yes. A feature of the adipose pouches of the eyelids is that they retain water and swell in response to the amount of sodium in the diet or to dietary intolerance. If there is little subcutaneous tissue in the region, we can perform Adipofilling, which is able to correct the lachrymal sulcus and rings under the eyes and enhance the malar region.
Some surgeons say that adipose pouches of the lower eyelid should not be completely removed. What is your view?
Congenital weakness of the orbital septum allows the retrobulbar adipose tissue to herniate through to the surface. The adipose pouches therefore occupy an anatomically anomalous position. This is a sufficient reason to remove them. Moreover, the complete removal of the adipose pouches, in addition to eliminating the swelling of the eyelids, creates a hollow that distends the skin. This is very useful in transconjunctival blepharoplasty, in which the skin is almost never removed. If we wished to be a bit malicious, we might say that removing all the pouches during lower blepharoplasty requires a degree of patience that not everyone has.
We know that you remove adipose pouches from the lower eyelids only by means of transconjunctival blepharoplasty. Why is this?
I believe it is important to remove these pouches completely, without causing scarring of the skin or muscles. In this way, we avoid those frequent surgical artefacts, rounded eyes and an altered appearance. Very rarely, and mainly in cases of asymmetry, we remove a small strip of skin a few months after transconjunctival blepharoplasty. Complete removal of the pouches restores the natural introflexion of the eyelids that is typical of youth and distends the skin. If the patient has unsightly festoons, we carry out timedsurgical mixed peeling, which smooths the skin and eliminates crow's feet, even if they are deep.
Finally, it should be borne in mind that transconjunctival blepharoplasty should be performed at a young age, as adipose pouches of the lower eyelids are congenital and familial.
What advice would you give to someone who wants to begin performing these procedures?
Thorough anamnesis and careful preparation. Measure the patient's pressure before the procedure and reduce it if necessary. Use the doses of epinephrine indicated and inject the adipose pouches as the operation proceeds. Epinephrine can also be used to control more persistent bleeding. You need to be resolute in order to remove all the adipose pouches, which is the aim of the procedure.
Finally, you must avoid the ample dissection used in traditional transconjunctival blepharoplasty procedures, as this needlessly damages the tissues.
Is the post-operative course painful?
No, there is no pain.
What do you think of the Colorado needle?
A piece of iron.
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