1. 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)

2. 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

3. 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

4. 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

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

6. 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

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

8. 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

9. In sagittal section

11. 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

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

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

14. 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)

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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

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

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

25. Skin Muscle Flap Technique

27. Correction a ‘muscle roll’

28. 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

29. 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

30. 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