DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Lower eyelid dermatochalasis fat prolapse.
POSTOPERATIVE DIAGNOSIS: Lower eyelid dermatochalasis fat prolapse.
SURGEON: John Doe, MD
OPERATION PERFORMED: Lower lid blepharoplasty, conjunctival approach.
ANESTHESIA: Local sedation.
COMPLICATIONS: None.
DISPOSITION: To surgery center.
DESCRIPTION OF PROCEDURE: After adequate local anesthesia consisting of Xylocaine 2% with 1:100,000 concentration of epinephrine and Marcaine 0.5% ratio 2:1 was injected into the lower lids, a total of 3 mL solution was used in each lower lid, the patient was prepped and draped in the usual fashion for lower lid blepharoplasty. Corneal protective lenses were placed into each eye after instillation of topical tetracaine.
Attention was directed to the right lower lid. A Desmarres retractor was placed into the inferior cul-de-sac and the lid held out inferiorly. Cutting cautery was then used to incise the conjunctiva approximately 3 mm below the tarsal plate, and dissection was carried through the lid retractors and orbital fat was identified. Three fat pockets were then separated; medial, central, and lateral. At this point, the lateral fat pad was injected with local anesthetic Xylocaine 2% with 1:100,000 concentration of epinephrine and then excised with cutting cautery. Central and nasal pads were similarly dissected, injected, and removed. The inferior oblique muscle was identified. Care was taken to avoid damaging the muscle.
At this point, attention was directed to the left lower lid where a similar procedure was performed, incising the conjunctiva with lid retractors and then identifying the fat pads and removing the fat pads. An equal amount of fat was removed from the lower lids on both sides. The patient was asked to look up at this point and there was noted to be good lid contour. At this point, it was decided that the skin was relatively taut, and no skin removal was performed. At this point, a single 6-0 plain catgut suture was passed in the center of the cut conjunctival edge inferiorly and then superiorly and tied with a buried knot. Again, this was done on both lower lids. After noting good hemostasis, the surgical area was cleansed. Gentak ointment was placed in the each eye and the patient left the operating room to the surgery center in good condition.
