Prof. M. Sjaifuddin Noer, dr., Sp.B, Sp.BP-RE (K) BLEPHAROPLASTY oleh : dr Frederik Pembimbing : Prof. M. Sjaifuddin Noer, dr., Sp.B, Sp.BP-RE (K)

Anatomy Periorbital muscles The orbital bones Tulang orbita: tulang frontal, sphenoid wing, ethmois, os nasal di medial, os lakrimal, di bagian anterior: os zygoma dan os maksila. Otot: orbikularis occuli(pars pretarsal, preseptal, outter part), di bag superomedial: corrugator supercilli, procerus, frontalis. Periorbital muscles The orbital bones Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Tarsoligamentous sling and retinacular structure Ini adalah gambar tendon yang menunjang bola mata terfiksasi di dalam soket mata: lateral canthal tendon, medial canthal tendon (anterior limb, superior limb, posterior limb). Muller muscle(simpatetik) : otot yang menempel pada tarsus sup, bersama dengan levator (N III) untuk membuka kelopak mata Anatomy of the deepest structures of the posterior lamella and orbital fat pad Codner MA, Ford DT. Blepharoplasty. Grab and Smith Plastic Surgery 6th edition. Philladelpia: Raven, 2007

The anatomic variations in the upper eyelid Baggy eye lift: mata tua, terlihat lelah, kelopak mata atas tebal menutup eye lid. Levator app jatuh menutupi sebagian permukaan depan eye lid. Asian; levatop app jatuh sampai depan tarsus di ujung inferior tarsus superior dan septum orbita mencapai depan permukaan tarsus Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Anatomy Topography periorbital region (eyelid crease) Superior tarsus is 10 mm in height at its center Inferior tarsus 3.8-4.5 mm in vertical height

Orbicularis Oculi Muscle Divided into three subdivisions Pretarsal muscle Preseptal muscle Orbital muscle Orbital septum Fascial membrane that separates eyelid structures to deeper orbital structures Neither thin nor elastic would make analogous to weakened fascia

Anatomical comparison between Oriental and Caucasian eyelid Deep set eye Average depth Oriental

Oriental eyelid Supratarsal fold is absent Eyelid thick and hangs down like pseudoptosis Palpebral fissure is narrow Eyelashes point downward Plica mongolia is present in 50% of cases Khoo Boo-Chai

In sagittal section

Preoperative Evaluation General Condition Clinical history and physical examination Patient personality, expectations for surgery Psychological assessment Eye Function Visus, Intraocular pressure, Muscle Function Frame of the eyelid Forehead (ptosis, wrinkles), shape &position eyebrow Cheeks and depth of nasolabial folds Upper orbital rim

Preoperative Evaluation Orbicularis oculi Tarsal plate Stasior lid distention test Flower eyelid retraction test Skin and subcutaneous Pinch test Squinch test

Surgical technique Anesthesia Blepharoplasty is most frequently done under local anesthesia Use lidocain 1% with 1:100 - 200.000 epinephrine with 27 gauge needle

Surgical technique Basic surgical technique Think in terms of three layer: Skin (excision of redundancy) Muscle (excision of an appropiate strip of orbicularis oculi) Fat (removal of an appropiate amount of orbital fat if indicated)

Blepharoplasty Blepharoplasty superior - simple skin excision - Anchor blepharoplasty - Levator aponeurosis plication Blepharoplasty inferior - transconjungtival blepharoplasty - transcutaneous blepharoplasty - lateral canthal anchoring - Kuntz-simanovsky

Surgery marking Upper blepharoplasty Lower blepharoplasty Wanita 6-8 mm(asia), kaukasia 8-9 mm, laki-laki 7-8 mm. medial tidak memotong cantus medial. Ekor insisi max 6 mm. Upper blepharoplasty Lower blepharoplasty Codner MA, Ford DT. Blepharoplasty. Grab and Smith Plastic Surgery 6th edition. Philladelpia: Raven, 2007

Upper Blepharoplasty Skin Marking Supratarsal fold located at different distances from individual, varying 7 – 12 mm. There is no uniform distance to locate the line Usually 8-12 mm above centrally, 5-6 mm above medially and laterally canthal crease

Simple skin excision blepharoplasty Muda: lentikular, tua:trapezoidal. Bila ingin supratarsal lid jelas: muscle strip dibuang sedikit agar tampak lipatan. Septum dibuka dengan perhatian insisi septum dibuat cranial menjauhi insersi levator app dengan sedikit menekan lid bagian medial Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Anchor blepharoplasty technique Penjahitan dermis, di anchor ke levator app sehingga ukuran pretarsal lid fixed. Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Lower Blepharoplasty Objectives Transconjunctival approach Correction of periorbital fat or skin, or both Correction of 3 components lower lids: Orbicularis muscle The tarsus The orbital septum Transconjunctival approach Skin Muscle Flap Technique

Lower Blepharoplasty (transconjungtival approach) Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Lower Blepharoplasty (transconjungtival approach) Kekkurangan tehnik ini: kelebihan kulit tidak dapat dibuang, tidak dapat mengencangkan septum orbita inferior, limited exposure Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Fat pad removal-repositioning Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Septoorbitoperiostoplasty for the treatment of palpebral bags Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013

Skin Muscle Flap Technique

Correction a ‘muscle roll’

Post-operative care Bandaging of the eyes following operation is not essential Ice compresses (first 24 hrs to reduces edema and echymosis) Topical antibiotic ointment and oral during fifth day Suture removed on 4-5 post op Squeezing eye lids after 1 week Makeup on about 10 post-op

Komplikasi Retrobulbar Hematoma Wound Dehicense Short Term Long Term Loss of Vision Retrobulbar Hematoma Wound Dehicense Long Term Dry eye Syndrome Hypertrophic scar and Keloid Epiphora Infection Asymmetry

Daftar pustaka Few. J, Ellis. M in Neligan, PC. Blepharoplasty. Plastic Surgery 3rd edition. Washington: Elsevier, 2013 Codner MA, Ford DT. Blepharoplasty. Grab and Smith Plastic Surgery 6th edition. Philladelpia: Raven, 2007