Pearls and Pitfalls in Cosmetic

Oculoplastic Surgery

Pearls and Pitfalls in Cosmetic

Oculoplastic Surgery

Edited by

Morris E. Hartstein, MD, FACSClinical Associate Professor, Saint Louis University, Department of Ophthalmology and Division of Plastic and Reconstructive Surgery,

St. Louis, Missouri

John B. Holds, MD, FACSClinical Professor, Saint Louis University, Departments of

Ophthalmology and Otolaryngology-Head and Neck Surgery,St. Louis, Missouri

Guy G. Massry, MDDirector, Ophthalmic Plastic and Reconstructive Surgery. American

Eye Institute, Cedars Sinai Medical Center, Los Angeles, CA, Spalding Dr. Cosmetic Surgery and Dermatology, Beverly Hills,

California, Davidorf Eye Group, West Hills, California

Morris E. Hartstein, MD, FACS John B. Holds, MD, FACSClinical Associate Professor Clinical ProfessorSaint Louis University Saint Louis UniversityDepartment of Ophthalmology Departments of Ophthalmology and Division of Plastic and Otolaryngology-Head and and Reconstructive Surgery Neck SurgerySt. Louis, MO St. Louis, MOUSA USA

Guy G. Massry, MDDirector, Ophthalmic Pastic and Reconstructive SurgeryAmerican Eye InstituteCedars Sinai Medical CenterLos Angeles, CASpalding Dr. Cosmetic Surgery and DermatologyBeverly Hills, CADavidorf Eye GroupWestHills, CAUSA

Library of Congress Control Number: 2007937487

ISBN: 978-0-387-25389-3 e-ISBN: 978-0-387-25389-3

Printed on acid-free paper.

2008 Springer Science+Business Media, LLC.All rights reserved. This work may not be translated or copied in whole or in part withoutthe written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection withreviews or scholarly analysis. Use in connection with any form of information storage andretrieval, electronic adaptation, computer software, or by similar or dissimilar methodol-ogy now known or hereafter developed is forbidden.The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as tofiwhether or not they are subject to proprietary rights.While the advice and information in this book are believed to be true and accurate at thedate of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes nowarranty, express or implied, with respect to the material contained herein.

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v

Foreword

Learning oculofacial surgery is a lot like learning to dance. In the begin-ning, the dance student is consumed with where to put his or her feet. For these new students (or for the rhythmically challenged), dancing ischaracterized by the struggle to step their feet in imaginary numbered shoeprints, 1234, and they barely hear the music. In surgery, thebeginning surgeon is preoccupied with steps as well. Their focus is onthe mechanical process. Proscribed steps create the paradigm for per-forming the surgery.

With time, the dance student moves on to the next stage. He does nothave to think as much about where he is putting his feet, and can start to listen to the music and feel the rhythm. The advanced surgeon begins to internalize the steps of surgery so that instead of a preoccupation with the next maneuver, she can start to individualize the surgery to the patient and employ flexibilty in the face of unique problems.fl

The master dancer makes no conscious effort to move his feet; his feetmove him. He does not concentrate on rhythm; the rhythm of the music becomes part of him. Freed from the intellectual exercise of dancing andfrom the technical requirements of keeping time, he is free to break from the restraints of the proscribed steps and invent a new dance as he goesalong.

The master surgeon enjoys a similar freedom. The focus is not on maneuvers and, in fact, the surgeon might be temporarily taken abackif asked to explain the mechanical details of what he is doing. Instead, the thought process is conceptual. The surgeon is visualizing a result, is sensitive to the nuances of the patients individual anatomy, and is always making adjustments to address the unique requirements presented bythe case at hand. By approaching the operation conceptually, and having effortless command of anatomy and technique, the master surgeon isfreed from the constraints of proscribed operations, and is able to inventnew surgeries.

In this book, a high octane collection of master surgeons provide awork that refl ects the scope of ophthalmic plastic surgery. There is mate-flrial here for every type of student. The beginner will appreciate step-by-step instructions and clear anatomic diagrams. The advanced surgeon

will be drawn to the delightful tricks and peals that are sprinkled liberally throughout the text. The master surgeon (and the aspiring master) will recognize that they are seeking the same thing that the authors areseeking, and they will be stimulated to continue to search for better treatments and surgeries. The obvious hard work that went into the preparation of this book will pay off handsomely when its readers improve their ability to take care of their patients, and particularly when they are inspired to continue their own journey toward mastery of our discipline.

Robert Alan Goldberg, MDKaren and Frank Daby Professor of Ophthalmology

David Geffen School of Medicine at UCLAChief, Orbital and Ophthalmic Plastic Surgery Division

Jules Stein Eye Institute

vi Foreword

vii

Preface

The goal of this book is to help surgeons perform more effi cient, produc-fitive, and successful surgeries. By sharing our varied experiences, acquired through years of practice, we hope this book will provide insights thatcan enhance surgical outcomes. In compiling this text, we solicited con-tributions from experts in cosmetic oculoplastic surgery, as well as sur-geons from other related fi elds, such as facial plastic surgery, plasticfisurgery, and dermatology. The book is divided into 12 parts, which coverthe spectrum of oculofacial procedures. Each section is divided into concise chapters focusing on just one aspect of a given procedure. Within these short chapters, each contributor offers tips on how to achieveoptimal results. For example, the section on upper lid blepharoplasty issubdivided as follows:

Preoperative evaluation Incision planning Procedure pearls Adjunctive procedures Wound closure and postoperative care

There are also multiple presentations on the same aspect of a procedureto provide different points of view and approaches. We greatly appreci-ate the various experts, who have shared their experiences.

Acknowledgments

Roberta D. Sengelmann and Brent R. Moody served as section chiefsfor Part IX, Skin Rejuvenation.

Tamara R. Fountain served as section chief for Part XII, Functional LidMalpositions, Sections 12, Ptosis.

We would like to thank Jan Heizer and Chris Kleber, Saint Louis Uni-versity Department of Ophthamology, for their assistance in preparingthis book.

Morris E. Hartstein, MD, FACSJohn B. Holds, MD, FACS

Guy G. Massry, MD

ix

Contents

Foreword by Robert Alan Goldberg . . . . . . . . . . . . . . . . . . . . . . . . vgPreface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viiContributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii

Part I Preoperative Evaluation

1 Preoperative Evaluation of the Cosmetic Patient . . . . . . . 3Jemshed A. Khan

2 Evaluation of the Cosmetic Patient . . . . . . . . . . . . . . . . . . . 6Rona Z. Silkiss

3 Preoperative Patient Counseling for CosmeticBlepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11William P.D. Chen

Part II Anesthesia

4 Guide to Local Anesthetic Medications . . . . . . . . . . . . . . . 15Vivian Schiedler and Bryan S. Sires

5 Motor Nerve Blocks in Oculofacial Surgery . . . . . . . . . . . . 18Vivian Schiedler and Bryan S. Sires

6 Regional Nerve Blocks in Oculofacial Surgery . . . . . . . . . 22Vivian Schiedler and Bryan S. Sires

7 Procedural Sedation in Oculofacial Surgery . . . . . . . . . . . . 27Vivian Schiedler and Bryan S. Sires

8 Preoperative Preparation and Anesthesia . . . . . . . . . . . . . . 30William P.D. Chen

9 Digital Diffusion Technique for the Administrationof Local Anesthetic in Eyelid Surgery . . . . . . . . . . . . . . . . . 32Rona Z. Silkiss

10 Anesthesia for In-Offi ce Oculoplastic Surgery:fiHow We Do It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Brent R. Moody and John B. Holds

x Contents

Part III Upper Lid Blepharoplasty

Section One Preoperative Evaluation

11 Upper Eyelid Blepharoplasty: The Evaluation . . . . . . . . . . 41 Evan H. Black, John D. Siddens, Frank A. Nesi,

Shoib Myint, and Geoffrey J. Gladstone

12 Preoperative Examination Checklist for Upper Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Philip L. Custer

13 Preoperative Evaluation and Documentation in Upper Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Cat Nguyen Burkat

Section Two Incision Planning

14 Marking Strategies for Upper Blepharoplasty . . . . . . . . . . 51 Guy G. Massry

15 Orbit Size and Lid Marking in Upper Blepharoplasty . . . 53 Philip L. Custer

16 Incisional Guidelines When Marking the Ski