DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Blepharochalasis.
2. Brow ptosis.
POSTOPERATIVE DIAGNOSES:
1. Blepharochalasis.
2. Brow ptosis.
OPERATION PERFORMED:
1. Bilateral upper blepharoplasties.
2. Bilateral lower blepharoplasties.
3. Contour Thread brow lift, bilateral.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This (XX)-year-old Hispanic female is here for elective blepharoplasty surgery along with Contour Thread lift of each brow.
OPERATIVE FINDINGS AND DESCRIPTION OF OPERATION: The patient’s upper lids were marked and turned in sitting position in the holding area. She was brought to the OR and placed on the OR table in the supine position. General anesthesia was induced. The entire face and scalp were prepped and draped in an aseptic fashion. Lidocaine 1% with epinephrine was infiltrated into the upper and lower eyelids. A small amount of same local was infiltrated into the frontal scalp as marked.
A 15 blade was used to excise excess skin from each upper eyelid as marked. A strip of orbicularis oculi muscle was resected from each upper eyelid, thereby opening each orbital septum. Excess fat from the medial and central compartments was bipolar cauterized and resected. Hemostasis was achieved in each upper lid using bipolar cautery, and 6-0 Prolene was used to close each upper eyelid incision.
A subciliary incision was then made in each lower eyelid using a 15 blade. Skin muscle flap was elevated from each lower lid, thereby opening each orbital septum. Excess fat from the medial, central, and lateral compartments was bipolar cauterized and resected. The leading edge of each lower lid was then resected, removing excess skin and muscle appropriately. Bipolar cautery was used again for hemostasis, and 6-0 Prolene suture was used to close each lower eyelid wound.
Attention was turned to each brow. Four Contour Threads were used to elevate each brows, two per brow. The threads were inserted appropriately from small incisions made in the bitemporal scalp. On each side, the threads were sutured to each other at the level of the scalp incision, and the threads were brought out below each brow appropriately, cutting off each trocar after the threads were passed. With the threads in proper position, a thumb was used to gently massage each forehead in a cephalad direction, until each brow was appropriately elevated. The right threads had to be repeated twice to obtain symmetry, but ultimately, symmetry was achieved. At this point, the patient had a nice improvement with elevation of the lateral brows. Ice, saline, gauze, sponges were applied to the eyes after application of ophthalmic antibiotic ointment. At this point, the patient was awoken from anesthesia and transferred to the PACU in stable condition. No complications.
