1. How to Avoid and or Treat Periocular and Eyelid Surgical Complications 36th Annual Hugh Greenway Superficial Anatomy & Cutaneous Surgery Steven Pratt MD, FACS, ABIHM La Jolla, California

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3. Pre-Op Evaluation Fat Pockets Medial Webbing Patient Expectations
Doctor’s Expectation
Lid Crease Position
Slit Lamp Exam?

4. Pre-Op Evaluation Lagophthalmos Previous Surgery
Pre-Existing Lash Loss
Pre-Existing Scars
Brow Position
Medications
Platlet Inhibitors – herbals. *****
Fair Complexion and Red Hair

5. Pre-Op Evaluation Asymmetry = Take Photo Psychological Profile
h/o Dry Eye/Keratitus
h/o Claustrophobia
Schirmer Test?
Bell’s Phenomenon
Corneal Sensation
Thyroid Evaluation – Lid Retraction
h/o Laser Vision Therapy
Lid Margin Disease
h/o laser skin resurfacing

8. RED FLAG

10. Treatment options

22. Sleeping Mask Post Suture Removal ?

25. SOMETIMES A FULL THICKNESS LID BIOPSY IS NECESSARY

28. Periocular Surgery

30. Excise and Granulate

35. Excise and Suture

39. Avoid Skin Graft Here

42. Pedicle Advancement Flap

43. Cautery Ablation of Hypertrophic Skin Grafts

56. Botox and Trigger Points
It never corresponds to the deep furrow

59. Beware of Loose Lids

66. Skin Incisions Puncta as Medial Guideline
Lid Crease as Inferior Incision
Line on Upper Lids
2mm Below Cilia on Lower Lids
Lateral Orbital Rim
Langer’s Lines
Sweep Up Laterally on Upper Lid Incisions
Symmetry
Take your time marking the “dot-to-dot”

67. Beware of High Lid Crease

68. Beware of “Lateral Brow Fat Pad”
Lateral Brow Fat Pad vs. Prolapsed Palpebral Lobe of the Lacrimal Gland
Warn patient of prolonged post-operative lid edema
Record this in your pre-operative note to show patient later

72. “Cosmetic Lid/Eye Patch”
Is the only thing the patient sees in the immediate post-op period
Sloppy patch = ?? Sloppy surgery

74. NO POST-OP SHIELD VS POOR WOUND HEALING

75. Eye Shield to “Protect” Your Work

79. Post-Op Instructions Typed instructions are important
Patients love to have a drawing showing them exactly where to apply ointments

81. Meticulous Pre-Operative Marks
“Take your time”
The adult version of “Dot-to-Dot”
Don’t drop local anesthetic on your marks
“One wipey no rubby” during prep

90. Beware of Post-Operative Hypertrophic Scars
Switch from a pure antibiotic ointment to a steroid-antibiotic combination when sutures are removed
Tobradex ophthalmic ointment
Maxitrol ophthalmic ointment
Lotemax ophthalmic ointment

94. Always Granulate the Junction of the Eyelids in the Medial/Lateral Canthus

96. Cicatricial Ectroptions often are Accompanied by Skin Cancer
Multiple biopsies pre-op to rule out skin cancer are often needed

98. Identify the Need for Skin Grafts/Lid Tightening at the Time of the Post-Mohs Defect

99. Always Use A Pull-up Suture

100. Always Use a Pull-up Suture

101. Cautery Ablate Xanthelasma

108. Beware of Poor Healing

109. Call For Help !!

111. Medial Canthal Touch-Up

113. When in Doubt, Put a “Reference Mark”

115. Final Thoughts
All surgery is cosmetic Call your patients the first post-op night Decrease MRSA with dried fruit, spice When possible primary closure best Painless suture removal = more referrals Pre-op platelet inhibitor history Point out “asymmetry” pre-op-photos (old & new)

116. Final Thoughts Steady hand while removing sutures
Granulate medial and lateral canthal tendon areas
AD patients+ family + boxing gloves
Post-op instruction sheet
Shield over sutures
Wound care 101

117. Final Thoughts D/C cigs pre-op and for at least 2 weeks post op
Thin your grafts/flaps
No make-up/lotion on day of surgery
Red flag when your biopsy leaves a web
“Perfect dressings”
Soak off scabs pre-suture removal+ointment

118. Final Thoughts Verify patient/family reads pre-op instructions
Post-op instruction sheet
Beware of medial lower lid defects
Finger flatten sutured areas
Beware of sunlight + “red” incisions
Flap survival protocol