Incision and dissection in .NET framework

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Incision and dissection
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A standard subciliary incision placed 15 mm below the cilia can be initiated laterally with a no 15 Bard-Parker blade The incision is extended medially to within 2 mm of the lacrimal punctum using sharp Westcott scissors or with a no 15 Bard-Parker blade Lateral to the lateral canthal angle, the incision is directed inferotemporally along a natural laugh line This lateral portion of the lower lid incision is extended if more skin needs to be removed, but initially, the length need only facilitate skin and muscle dissection inferiorly A 6-0 polypropylene or silk suture placed at partial thickness through the tarsus centrally and just at the subciliary incision (avoiding skin puncture) is useful for providing countertraction Generally, a combined skin and muscle ap method is used However, it may be advantageous to elevate skin only in the pretarsal orbicularis area, since keeping the muscle layer undisturbed may decrease the chance of developing a depressed subciliary scar Once the orbicularis muscle has been exposed, a pair of blunt-tipped scissors is used to buttonhole the preseptal muscle The muscle is then opened across the full extent of the wound and dissection is performed inferiorly in the suborbicularis oculi plane until the inferior orbital rim is exposed Meticulous hemostasis is maintained during this dissection
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Fat repositioning
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Traditional blepharoplasty techniques emphasizing fat removal alone are now recognized to be too limited a strategy in rejuvenative surgery In the presence of significant cheek fat descent, rejuvenation may additionally require a midface lift, discussion of which is beyond the scope of this chapter Tear trough deformities without signi cant malar descent can be corrected by fat preservation and repositioning In this setting, nasal fat removal would worsen a sunken lid appearance The inferomedial orbital rim is palpated and the septum is incised at the arcus marginalis, near the origin of the levator labii superioris alaeque nasi muscle A periosteal elevator is used to create a subperiosteal pocket 10 mm distal to the incision spanning the length of the trough to be lled Damage to the infraorbital foramen located 7 to 10 mm inferior to the rim at the junction of the medial third and lateral third of the eyelid is avoided The medial fat capsule is incised to liberate the fat lobules and allow fat to be advanced anteriorly without creating traction The fat is fashioned into a mallet-shaped fat ap with a pedicle of 5 to 7 mm diameter and positioned into the subperiosteal pocket If properly performed, there should be no tendency for the fat to recoil posteriorly, and extraocular motility should not be restricted The fat can be secured using a 6-0 polygalactin or nylon horizontal mattress stitch that loosely engages the anterior edge of periosteum and part of the fat pedicle
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Removal of hypertrophic orbicularis muscle
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When orbicularis muscle hypertrophy is present, a skin ap can be dissected to expose the muscular bulge The superior edge of prominent orbicularis mounding often begins 3 to 5 mm below the lash line and is accentuated with smiling The muscle is reduced by partially and super cially excising muscle tissue layers along the orientation of the bers, decreasing the anterior to posterior prominence Bleeding is anticipated but is easily controlled in this region An alternative method uses electosurgical modi cation and ablation of the orbicularis muscle to reduce the muscle prominence
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| Regional Approach to Aesthetic Rejuvenation
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The skin-muscle ap is draped without traction over the subciliary incision The amount of skin to be removed is determined with the patient gazing upward and opening his or her mouth Excess skin extending above the subciliary incision is excised with sharp Westcott scissors The primary lid skin tightening effect is achieved by horizontal shortening at the laugh line, rather than by shortening vertically Therefore, conservative amounts of skin are removed from the subciliary region Aggressive vertical shortening is almost guaranteed to cause lower lid malposition The excised subciliary skin is a horizontally oriented triangle with apex pointing medially with maximal widths usually ranging from 1 to 4 mm As mentioned, skin tightening should be accomplished in the horizontal vector The edge of the skin-muscle ap is draped laterally along the curvature of the lower lid with a gentle amount of traction and the overlap is excised to reduce skin redundancy The extra dog ear of tissue is eliminated by a combination of extending the original laugh line incision (usually not more than 15 mm) and excising a triangle of the skin-muscle ap with apex at the inferior extent of the lateral incision
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