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Experience breeds improvement in these specialized procedures, notes surgeon
Four oculoplastics procedures have been refined from approaches used previously, relates one surgeon.
By Lynda Charters; Reviewed by Allen M. Putterman, MD
Chicago-With experience comes improvements in surgical procedures, relates one ophthalmologist.
Allen M. Putterman, MD, discussed how his approaches to four oculoplastics procedures have been refined from approaches he used previously. He is professor of ophthalmology and co-chief, Oculoplastic Surgery, University of Illinois College of Medicine, Chicago.
Dr. Putterman’s previous approach was either to remove all the lower eyelid herniated fat using an internal approach through the conjunctiva or reposition all the fat. In the latter case, he would remove the temporal fat, make an incision through the periosteum at the nasal half of the periorbital rim, and dissect the periosteum by 1 cm inferior to the rim.
This was followed by isolation of the nasal and central fat pads and passing of a 4-0 Prolene suture through the distal nasal fat pad, under periosteum, exiting through the skin under the hollowed area of the inferior orbital rim, and passing of a second suture through the central fat and out the skin. All of the nasal and central fat was placed in a pocket.
“This procedure worked well for patients with bagginess of the lower lid and inferior orbital rim hollowing,” he said.
He now titrates the fat repositioning. The nasal fat is divided into two pedicles, one of which is removed and the same is done with the central fat pad.
“Instead of repositioning the entire nasal and central fat pad, I titrate and remove part of the central and nasal fat, and reposition the other parts,” Dr. Putterman said.
With this approach, he can achieve an adequate result, decrease the fat in the lower lids, and avoid bulging of the fat in the hollow areas.
In Dr. Putterman’s previous procedure, he used an orbicularis flap to treat lower eyelid dermatochalasis and cheek bags. He started with a skin/muscle flap and attached the outer inferior orbicularis muscle to periosteum using 5-0 Dexon or 4-0 Prolene sutures. An alternative approach is to reposition or remove fat from an internal approach, remove a triangle of skin and muscle laterally, and attach the orbicularis flap to periosteum to decrease wrinkling of the lower eyelid skin.
He still performs this procedure, but in most cases uses a combined orbicularis plication-lateral canthal tendon pexy. An incision (~1 to 1.5 cm) is made laterally from the lateral canthus through skin and undermined from orbicularis muscle. A 5-0 Prolene suture is passed through the lateral canthal tendon internally to externally and through the periosteum of the lateral orbital wall internally to externally to tighten horizontally the lateral canthal tendon and the lower eyelid skin.
The 5-0 Prolene suture is passed through periosteum over the lateral canthal area and then internally to externally through the orbicularis muscle and externally to internally, which secures the muscle to periosteum, Dr. Putterman said.
“This is helpful to decrease wrinkling of the lower eyelid,” he said.
For ptosis associated with external ophthalmoplegia and myasthenia gravis, among other diseases, Dr. Putterman would excise the skin of the upper eyelid, which facilitates the patients’ opening of the eyelids by raising their brows.
He identifies surgical candidates by paper-clipping the skin of the upper eyelid. The upper eyelid blepharoplasty is performed, skin and muscle are removed, and the skin is closed.
To simplify the procedure, he designed a clamp to replace the paper clip.
“The clamp is easier to apply and is more comfortable than the paper clip,” he said (Figure 1). “If the patients can open the upper eyelids by raising their brows, they are considered candidates for the blepharoplasty.”
Previously a conjunctivodacryocystorhinostomy osteum was formed and a bypass tube was placed using instruments that were not specific to the procedure. Dr. Putterman used an 18-gauge needle or a spinal needle to form the track, and a Graefe-type knife, Henderson trephine, or scissors to form the osteum. Finally, a Bowman probe was used to measure the medial canthal-nasal septal distance.
In addition, each instrument had to be removed before insertion of the next one, making it difficult to identify the track made by the previous instrument before the next is inserted.
Dr. Putterman designed three new instruments specific to the procedure, i.e., a track needle, trephine to create the osteum, and modified Bowman-type probe with measuring marks (Figure 2).
“This method prevents having to withdraw and re-insert multiple instruments and shortens the procedure time,” he said. “It also avoids the difficulty of finding the track made by one instrument before re-inserting the next instrument.
Allen M. Putterman, MD
Dr. Putterman has no financial interest in the subject matter. This article is adapted from Dr. Putterman’s presentation during Oculofacial Plastic Surgery 2012 at the annual meeting of the American Academy of Ophthalmology.