Blackened surgical instruments are offered for laser oculoplastics

Surgeon took a cue from GI and laparoscopy instruments.

Issue: February 1, 2000

Although my surgical routine for upper and lower lid blepharoplasty varies little, I have designed and use a new set of surgical tools with a blackened surface in order to minimize the amount of laser energy that could be deflected from the surface of other equipment. In my experience, even the equipment polished to a dull finish can deflect light needlessly and result in aberrant laser burns.

New maneuvers

---Jaffe Laser Blepharoplasty and Facial Resurfacing Surgery Set minimizes the amount of laser energy that could be deflected from the surface of other equipment during surgery.

Patients are brought into the operating room, draped and prepped in the standard fashion. I use a surgical pen to delineate the upper lid crease about 10 mm above the lash line in women and 8 mm below the lash line in men.

I use a forceps from a specially designed resurfacing set (Jaffe Laser Blepharoplasty and Facial Resurfacing Surgery Set; Rhein Medical, Tampa, Fla.) to perform a pinch technique to determine the amount of redundant skin in the upper lid. That crease is then marked out, as well.

After that has been done, I complete a supraorbital nerve block with a local anesthetic consisting of 2% lidocaine with epinephrine. I also apply direct pressure to ensure that a hematoma does not develop.

I use the Coherent (Santa Clara, Calif.) UltraPulse CO₂ laser at 6 W in continuous wave mode. I make the initial incision along the surgical marks. The upper brow is then retracted superiorly and an assistant retracts the lid inferiorly. The 0.5-mm forceps is used to elevate the lateral edge of the skin, and the laser is used to resect it and the orbicularis muscle in its entirety down to the orbital septum in women. In men, I resect the skin alone.

The orbital septum is subsequently breached using the CO₂ laser. Then, I resect the fat paths medially and centrally. A defocused beam also is used to shrink back any extra fat. A running 6-0 nylon suture is used to close the incision and is left in place for 8 days. In my experience these wounds are more susceptible to dehiscence and require an extra day or two before the sutures are removed.

The lower lids are then approached. I place direct pressure on the corneal shield and the lower lid is everted, causing a bulge of the medial, central and lateral fat paths. These bulges are injected with 2% lidocaine and I make another incision about 2 mm below the tarsal plate with the laser set at 6 W.

The inferior portion of the conjunctiva is grasped with 0.12-mm Rhein forceps. I use blunt dissection down to the orbital rim. At this point, the lateral fat pocket has been isolated initially and sculpted to the orbital rim.

I repeat the same process for the medial and central fat pockets with small incisions measuring about 3 mm to 4 mm, each being used to extricate the excess fat. After this has been performed, the laser beam is defocused and heat cautery shrinks the anterior septum.

I do not use a suture in the lower lid. A 5-0 Vicryl suture in the upper lid is used to grasp the lateral canthal tendon through the upper lid incision and plicate the tendon to the lateral orbital rim.

Variations

I resurface the lower eyelid, using a pattern density of 5 or 6, all the way up to the tarsal plate. Then I use a density of 3 up to the lash line. The traditional settings have involved densities of 4 or 5, but using higher densities and fewer passes decreases the risk of hypopigmentation in the late stages of healing.

At the time that I do the lower eyelid, I avoid the area medially just inferior to the punctum of both lower lids and will often use the laser to resurface a portion of conjunctiva just inferior to the punctum of the lower lids. This often results in a mild punctal eversion and decreases the chances of an ectropion.

I vary from the standard surgical maneuvers by routinely plicating all lateral canthal tendons. I use blunt dissection to offer a complete view of the inferior orbital fat paths, and I use the Rhein equipment to ensure the safety of the patient and accuracy of the procedure.

All other surgical sets I have used are polished to a dull finish. Still, during several of my surgeries, burns occurred as the laser energy scattered off of the reflective coating. Most of the laser instruments used in other surgeries are often made of coated black material to prevent this.

While designing the kit, we decided to offer corneal protective shields, forceps and a modified bone plate with square edges to use while resecting skin. The bone plate ensures that we can make the resection of fat in a safe, efficient manner and prevent burns on the eyelids. A mouthguard protects teeth enamel during full face resurfacing and a lid speculum can be used during ptosis surgery.

For Your Information:

Mark R. Jaffe, MD, practices at 7550 Walnut Hill, #1104, Dallas, TX 75230; (214) 754-0000; fax: (214) 754-0079. Dr. Jaffe did not disclose whether he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any companies mentioned.

Rhein Medical Inc. can be reached at 5460 Beaumont Center Blvd., Ste. 500, Tampa, FL 33634; (813) 885-5050; fax (813) 885-9346.

Coherent Medical Group can be reached at 2400 Condensa St., Santa Clara, CA 95051-0901; (408) 764-3000; fax: (408) 764-3660.