Doctor: His, I've marked the lid crease at about probably 8 to 9 millimeters above the lid margin which corresponds to his own lid crease. And I usually try to keep it around here. If it's really low, I'll move it up. If it's really high, I'll move it down. And then with Green forceps we get out how much extra skin we can take out. So I'll do an incision with a 15 blade. And I'm gonna remove his skin muscle flap with a Bovie. You can do this with scissors. You can do it as either a skin muscle flap or as just a skin flap. However recent [inaudible 00:01:00] are, a journal article said that, cosmetically, it didn't seem to make any difference whether or not you took out your Orbicularus or left it in place. [inaudible 00:01:13] like to see our anatomy here today, it's gonna be a lot a easier if we took it out, so we can go ahead and do it as a skin muscle flap. And then just cauterize, stopping the bleeding with either a Bovie or bipolar. OK. So now what we wanna do is open up the septum along the length of the wound. And if you push down on the globe frequently, you can see the fat starting to bulge through. If you don't, you can feel your orbital [inaudible 00:01:52] just below that, which would be about here.

You usually use the Bovie to do this. You can also use scissors. Now I start to see the fat. And what we'll do is you can follow up all of your fat along here. We'll do it this way. Now I know from pre-up that he has a very large medial fat pad and we see that there. Now, we don't wanna be taking out any of the central fat pad, because that would give us a hollowing, deep [inaudible 00:03:11] and possibly even an A frame appearance to the lid. I still have have quite a bit of Orbicularis here, so I'll just trim this a little bit. And we're gonna take out some of this medial fat pad. He has so much that what I'm gonna do is take it out with Westcott scissors. This is a very sensitive fat bad, though, so you do need to inject it with some local or they will start to jump around on you when you to excise it. You could do this with your Bovie. You can do it with high temp handheld cautery. And there's really little risk of seeing any hollowing medial, medially here, when you take this out, so...and what we have here, if you can see, the [inaudible 00:04:31] Aponeurosis attaching to the Levator.

And what I'm gonna do is excise a portion of the Orbicularis and deep Aponeurosis right on top of the tarsus. Got that little rectangle here. OK. So here's my Tarsus. Deep here would be my Muller's muscle. Here's my Aponeurosis. And the what we have here are the distal fibers of Aponeurosis that run right along the entire surface of the Tarsus, right under your Orbicularis. So what I wanna do is take this and attach it to these residual distal fibers, effectively shortening the Aponeurosis, advancing the Levator, and correcting Arthrosis. And I'll do that with two six sutures. They'll come through. And I also will take a bite of the subcutaneous tissue here. This helps to reform the lid crease. It also helps flip the lashes back up. So if someone has a bit of Lash Ptosis, it helps to bring the lashes back up to their normal position. Put some of the [inaudible 00:06:40] tissue there. Now, to check for symmetry, what we'll do is, in a minute, have the patient open his lids. You can also check to see what we call "The Gap" that they have, which is usually the lid is gonna be open a little bit and you'll see a little bit of inferior cornea, inferior clara, which will go away after a few days. The other thing we can do is to measure the distance from our Aponeurosis up to the lid crease. And assuming you've made the lid crease the same on both sides, you can just measure that distance and it should be the same from one side to the other. So what we'll do is we'll take the lights off and ask him to open his eyes. Senor, abre los ojos mira para aqui. El farolito. And I just want to make sure...

Patient: [inaudible 00:07:55]

Doctor: You okay? Great.

Patient: [inaudible 00:07:58] great.

Doctor: OK. And what I do is make sure that they're equal, which they are. OK. Ojo puede cerrar. Puede cerrar los ojos [inaudible 00:08:06]. And now what I'll do is just close up the skin on this side. With a 6-0 plain suture. I put one suture in centrally. What that does is just sort of establishes the orientation of the wound so as you're going along you stay, will end up correctly. I like to do 6-0 plain because it does dissolve. Cut. But you can use 6-0 prolene, you can use 6-0 nylon, you can do [inaudible 00:08:48], if you'd like. [inaudible 00:09:56] skin bites. And they'll just use ice compress just for two or three days. And usually the bruising and swelling is pretty minimal.

Ptosis Repair Surgery: Operating Room Cam

Dr. John Martin walks us through a typical ptosis repair surgery, in which he repairs a sagging eyelid.