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    1 : BLEPHROPLASTY By Dr Zahid Iqbal Bahtti T.R.
    2 : BLEPHROPLASTY Aesthetic surgery of Periorbital Area. Eye focal point to analyzing aging. Brow & midface rejuvenation has direct interplay with orbital region. Knowledge of Anatomy Integrated with correction of brow position & midface descent.
    3 : Goales. Upper Lid. Preservation of upper orbital fullness & well defined upper lid crease. Lower Lid Smooth transition b/w lid & cheek while restoration youthful eye shape.
    4 : Anatomy Of Eyelid. Anterior Lamella. Posterior Lamella. Orbital septum. Upper Lid Retractor(Lavator Palp.apon. Muller) Lower Lid Retaractor(Capslopalpbral Fs)
    5 : Lev.Palp.ap fuses distally orbital septum(ant.)& tarsal plate(post) Tarsal Plate. Lateral Canthal Tendon. Medial Canthal tendon.
    6 :
    7 : Orbital septum Seprates ant./post. Lamella & maintains periorbital fats in anatomic boundry. Interpad & intrapad septal structure. Upper lid 2 Lower lid 3 pad
    8 : Lacrimal Gland. Ptosis by dehiscence by somering Lig. Eisler Fat Pad in eisler pocket , useful during canthoplasty suture.
    9 : Vascular & Nerve Supply
    10 : Forehead Anatomy. In superolateral orbit, forehead firmly attached to the underlying periostium, orbicularis fascia & temporal fascia. Frontalis is brow elevator & inserts dermis of suprolateral rim.( Tranverse furrows) Medial brow depressor & glabellar fuurows (Orbicularis,currogator supercili,procerus & depressor supercili).
    11 : Midface Anatomy Smooth transition b/w cheek & lid. Prezygomatic Space is triangular & apex nasl side. Upper border Orbitomalar Lig. Lower Border Zygomatic Lig..
    12 : Tear Trough Malar Mound. Preperiosteal fat
    13 : Age Related Changes. Palpebral Fissure 30 X 8-10 mm Lateral Commisure 2mm Normally Smooth arch & highest b/w medial limbus & pupil With aging, shift lateral.
    14 : Upper Crease levator insertion dermis Upper lid fold by excess skin & muscle overhanging crease. Lower Lid Crease is low insertion of orbital septum & Levator aponeurosis.
    15 : With Aging, Herniation of postseptal fat accentuation of tear trough & malar bags. Increased length, Resitricted by orbitomalar Lig.& arcus marginalis Midface ptosis restricted by zygomatic Lig.
    16 : Brow Ptosis Upper lid hooding & narrowed brow lash distance.
    17 : Preoperative Evaluation General Visual Acuity. Occular movement. Visual Field test. Photograph
    18 : Upperlid & Brow. (Evaluation) Sequential Accessment. BROW. done under brow relaxation symmatery, ptosis relationship b/w med/lat. brow.
    19 : Evalaution(Upperlid & Brow) Upper Lid. Fold for asymmatry Ptosis (Cong. & Acquired) Excess skin. Lacrimal Gland Prolapse.
    20 : Lower Lid & Face (Evaluation) Lower Eyelid Canthal tilt Laxity Redundant skin & muscle Herniated postseptal fat. Relation of globe to bony orbital rim. Scleral Show.
    21 : Midface. Elongation of lower lid Ptosis Tear Trough Malar Bags.
    22 : Dry Eyes evaluated BY Bells Phenomenon. Shirmer’s Test.
    23 : Systemic Conditions Risk Of complication are increased Eyelid inflammatory diseases Grave’s Disease Dry Eye syndrome. Rosacea Sarcoidosis
    24 : Operative Technique G/A or Intravenous conscious sedation. L/A with 1:100,000 epinehrine infilterated To avoid injury to marginal Arterial arcade & deep orbital structure.
    25 : Upper Lid Marking magnifying loop & calipers. Upperlid crease 4-6 mm above lid margin in midpupilary region Marking tapered. Nasal side crowse feet
    26 : Superior margin of excision by forceps. Lateraly,10 mm b/w lat.brow & lid margin. Nasally, excision conservative.
    27 : Lower Lid Marking Nasal extension of marking parallel to lid margin & close to lash line. Laterally, from lat. Canthas, a line extended inferolaterally 6-10 mm in crows feet.
    28 : Upper lid Blephroplasty. Upper incision Preservation of interpad septum. Excess fat Cautry Excess skin muscle & orbital septum excised in conservative manner.
    29 : Supratarsal fixation of pretatsal skin&ms ROOF fat. Lacrimal Gland suspension. Internal Browpexy. Irrigated with Normal saline Incision closed
    30 : Lower Lid Blephroplasty Initial incision Lateral to Canthus.( OO) Skin Ms flap anterior to septum up to infra orbital rim, superficial to preiostium Orbitomalar ligament is divided Release of Orbitomalar lig.allows elevation of SOOf with skin & ms
    31 : Tear Trough deformity Fat removed from three compartments conservatively Removal of septum with excess fat. N/Saline irrigation
    32 : Avoid injury to Inferior Oblique ms. Arcuate expansion of lockwood lig. Preserved. Closure.
    33 : Lateral Canthal Anchoring Evaluation Lower lid Laxity intraoper. Minimal Lid Laxity. 1-2 mm ( OO susp) Moderate 3-6 mm (pexy) Significant >6 mm. (Plasty)
    34 : Canthopexy Suturing of tarsal plate & lateral retinaculum to inner lateral orbital rim. Position of Lateral Canthal suture at horizental midpupillary line
    35 : Canthoplasty Lateral canthotomy with canthoplasty. Resection of 2-3 mm F.T. lid margin Lateral commisure reconstructed. Skin muscle flap redrapped. Orbicularis ms suspended
    36 : Postopertive Care. Frost Suture.( Ecchymosis,chemosis) Tarsorraphy Suture. (temporary) Head Elevation & ice application. Antibiotics eye ointment. Suture removed (5-7 d) Avoid Eyelid makeup & contact lens 2W
    37 : Complications Visual Loss. Diplopia temporary due to oedema/ Thermal injury to oblique ms. Ptosis Corneal Irritation Impaired Visual acuity Lid Malposition/ Ectropion
    38 : Thanks

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