Skin marking

A line is drawn with a methylene blue marking pen, beginning at the lateral canthus and extending in a horizontal direction of approximately 1 cm. This line marks the site of the lower lateral canthal incision. The site of the predetermined eyelid crease is then marked. When the surgeon is drawing the eyelid crease marks, the eyebrow must be elevated to reduce the excess upper eyelid skin fold and to make the upper eyelid skin taut and the lashes slightly everted. If this is not done, the crease may result in being much higher than desired because the skin is usually loose before it is marked.

The temporal, central, and nasal crease sites are marked by placing a millimeter ruler so that the zero line is at the eyelid margin. The distances above the eyelid margin can then be viewed and marked with a specially designed marking instrument. In women, the temporal mark usually is placed 10 mm above the upper eyelid margin; the central mark, 11 mm above the margin; and the nasal mark, 9 mm above the margin. In men, the marks are usually 9 mm temporally, 10 mm centrally, and 8 mm nasally.

The temporal, central, and nasal marks are then connected and are extended with a line, which begins at the punctum and ends at the lateral canthus (Fig. 7-1A). The line sweeps laterally approximately 1 cm temporal to the lateral canthus in a slightly upward direction. There should be at least 5 mm of skin between this line and the line placed for the lower lateral incision.

Figure 7-1 A, A line is drawn on the eyelid at the level of the eyelid crease.

B, A smooth forceps is used to eliminate redundant upper eyelid skin and to slightly evert the eyelashes.

C, Connection of superiorly marked dots to the nasal and temporal ends of the eyelid crease incision line.

D, A blunt Westcott scissors is used to make a buttonhole incision in the orbicularis oculi muscle.

E, The orbicularis oculi muscle along the lid crease incision is severed with a disposable cautery.

F, A disposable cautery is used to cut the orbicularis oculi muscle at the superior border of the skin incision.

G, The orbital septum and suborbicularis tissue are penetrated with Westcott scissors just beneath the orbital septal rim until herniated orbital fat is visible.

H, The nasal fat pocket is removed.

I, A 6-0 polyester fiber (Mersilene) suture enters the superior surface of the levator aponeurosis and exits through the inferior surface. Then the suture passes through the orbicularis oculi muscle.

J, The 6-0 polyester fiber suture passes through the levator aponeurosis inferiorly to superiorly.

K, Three 6-0 polyglactin (Vicryl) sutures are passed through skin, levator aponeurosis, and skin centrally, temporally, and nasally to further establish the eyelid crease.

L, The eyelid skin is united with a continuous 6-0 black silk running suture, which is passed nasally to temporally.

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