The Art of Surgical Technique

Firm Plan with Contingencies

When you enter the operating room, you should have a firm plan in mind. Early in your career, it is helpful to have a set of contingency plans if things don’t go as expected. As your surgical expertise increases, your need to make formal contingency plans will disappear. At the early stage, or later when you are planning a new procedure, it is helpful to write down the steps of the operation and list the necessary equipment and then bring the list to the operating room. The nursing staff will appreciate your preparation and be confident in your abilities.

You are the team leader in the operating room. Your behavior sets the stage for how the operation goes. You set the pace and the quality of the entire effort. If you are operating in a new setting, be sure to introduce yourself to the nursing staff. Discuss your plans for surgery with the team. Your preparation and willingness to include them in your plans will improve the overall effort and give the team confidence in your ability to get the job done. This approach applies to every surgeon, from new residents to experienced surgeons in practice for many years.

Room Setup

Part of your plan should be to know where the operating equipment is placed. Generally, the setup is as shown in Figure 1.1 . In most cases, the position and orientation will be the same for each procedure in a particular operating room. For example, usually the head is away from the door and away from the flow of traffic in the room. In some cases, the operated eye will be placed away from the anesthesia equipment. You, as the surgeon, will sit at the head of the bed. Your assistant will sit at the side of the bed corresponding to the operated eye. For some procedures, you may find it easier to sit at the patient’s side (e.g., for lateral tarsal strip and lateral orbitotomy procedures). Feel free to move throughout the operation and be comfortable. The nursing table is placed on the side of the operating table, opposite any anesthesia equipment and staff.

Skin Marking and Local Anesthesia

Many oculoplastic procedures require skin marking as a guide to incision placement. Most incisions are placed in natural skin creases , such as the upper lid skin crease for ptosis and blepharoplasty operations. Other skin incisions are placed adjacent to anatomic structures so the scar will be hidden. You should mark the skin before any local anesthetic is injected. Two good choices for marking eyelid skin are available: (1) gentian violet solution and (2) the surgical marking pen. Gentian violet can be applied with the sharp end of a broken applicator used as a quill. With experience, you can draw a fine line that does not easily wash off with prepping, but this takes some experience to keep from making a mess. Usually, we use a thin-tipped surgical marker (Blephmarker 1424 Gentian Violet Twin Ultra Fine Tip Ruler Sterile, Viscot.com , reference 1424SR-100). Be sure to degrease the skin with an alcohol wipe before marking.

You should use a local anesthetic with epinephrine for all procedures to provide some hemostasis (due to the vasoconstriction). The most common local anesthetic mixture is 2% lidocaine with 1/100,000 epinephrine in combination with 0.5% bupivacaine. Some surgeons choose to add hyaluronidase to the mix, but I have not found this necessary. For larger scalp and face procedures, you may want to consider “tumescent” anesthesia. With this technique, a large amount of very dilute local anesthetic with epinephrine is injected into the subcutaneous tissues. This technique firms up the tissues and makes it easier to develop flaps and perform liposuction. This is not needed for periocular procedures.

Local anesthetics sting badly (if you are not feeling sympathetic, have a colleague inject 1 mL of local anesthetic into your eyelid; you will not soon forget how it feels). Two factors are thought to be responsible: (1) a difference in pH and (2) the distention of the tissues during rapid injection. To minimize the pain, try injecting a tiny amount—about 0.1 mL—into two or three places and then massage the local anesthetic into the tissues. After a few seconds, inject more anesthetic very slowly. This greatly minimizes the pain. Some surgeons buffer the local anesthetic using one part 7.5% sodium bicarbonate in nine parts 2% lidocaine with epinephrine (2 mL of bicarbonate in 20 mL of lidocaine). I have not found this worth the trouble, but many surgeons swear by it. If you operate with an anesthesiologist, using appropriate sedating agents, the patient is totally unaware of any local injections.

Remember to inject just beneath the eyelid skin. Avoid placing the needle into the muscle to prevent a hematoma, which may make intraoperative adjustments of the eyelid difficult; this is especially true with anterior ptosis correction. Avoid putting the needle in the crease at the junction of the lateral one third and medial two thirds of the eyelid. There is a vessel that, if torn, will guarantee a hematoma before you start the procedure! For an upper eyelid procedure, such as a blepharoplasty or ptosis repair, you should inject 1 to 1.5 mL of local anesthetic mix.

The topical solutions that provide anesthesia are EMLA cream and Betacaine gel. EMLA cream should be applied in a thick coating 1 to 2 hours ahead of the procedure and covered with an occlusive dressing (topical lidocaine 2.5% and prilocaine 2.5%). BLT cream (20% benzocaine, 6% lidocaine, and 4% tetracaine) is an alternative. Betacaine gel (topical lidocaine 5%, http://www.sanofi.com ) can be applied for 20 to 30 minutes ahead of the procedure without an occlusive dressing. These preparations provide some anesthesia but do not cause vasoconstriction, so an additional local injection with epinephrine is required for surgical procedures. Topical agents are also useful prior to Botox or filler injections and can be helpful in children. Overdosing with a systemic reaction is unlikely but possible. Most of the time, I do not use these preparations, but you might find them helpful in some situations. You may be able to avoid taking a child to the operating room for suturing if you apply topical cream before injection of any local anesthesia.

Most eyelid and lacrimal operations can be performed under local anesthesia. If you choose to operate without the benefit of an anesthesiologist, you should consider intravenous (IV) sedation to minimize the patient’s anxiety. Doses of midazolam in 0.5- to 1.0-mg increments are reasonable to achieve some relaxation. I find it helpful to have a midazolam drip running (1 to 3 mg/hour) rather than give intermittent doses of the medication. Some surgeons prefer preoperative oral sedation with 2 to 10 mg of oral diazepam. Additional pain relief can be given intraoperatively using small doses of a narcotic, such as morphine (1 to 2 mg IV). Intravenous fentanyl is useful because of its short duration, but keep in mind that this is a very potent opiate narcotic and a highly abused drug. Surgical centers often do not permit the surgeon to administer this without anesthesia staff oversight. Avoid oversedation to the point that the patient has lost inhibitions and gets restless or is too sleepy to follow your instructions. A supportive attitude from you and the nursing staff (sometimes called talk-esthesia or vocal local) is helpful. I am always impressed by how many postoperative patients comment on how helpful it was to have the circulating nurse offer to hold hands during the procedure. The nurse can also alert you when the patient is feeling discomfort.

If your operating situation allows for the efficient use of monitored anesthesia care, your anesthesiologist can medicate your patient to the point at which there is no memory of any pain from the injection and often no memory of the entire operation. The downside of this is more staffing and an increased cost. The majority of my eyelid and lacrimal procedures are done with monitored anesthesia care in our practice-owned ambulatory surgery center. If you plan to ask for any intraoperative patient cooperation, such as eyelid opening for a ptosis adjustment operation, make sure that no IV midazolam is administered until you have completed the adjustment. As you would expect, working with the same anesthesia and nursing team on a regular basis increases your efficiency greatly and can make your life in the operating room much better.

Preparing and Draping the Patient

In most operating rooms, the patient can be prepped while you scrub. This gives time for the local anesthetic to take effect. A traditional povidone-iodine scrub applied in concentric rings away from the planned surgical excisions, repeated three times, provides adequate cleaning of the skin. A surgical bonnet and a drape with a single sticky edge (bar drape) across the forehead keep the patient’s hair out of the operating field. If the hairline is particularly low or close to the operating field, tape can be used to pull the hair away from the field. For most procedures for which the patient is awake, the entire face is prepped under local anesthesia. If the patient is asleep, prep both eyes whenever there is a need to obtain symmetry between the two sides or if forced duction testing may be required. A good general rule is to prep a larger area than you think you will need. Most of my patients are draped with a single split sheet (U-drape) spread over the face. It is worth considering placing a towel over any endotracheal tube before placing the U-drape so that the adhesive on the drape does not stick to the tube (and it is always a good idea not to pull the tube out when tearing the drapes off the patient!).

Hand Position

Once you are properly positioned at the head of the bed of a patient who has been prepped and draped, your next job is to make a skin incision. Remember you are positioned with your feet flat on the ground and your elbows at your side in flexion slightly more than 90 degrees . Hold your hands in the functional position (like holding a pencil), with your hand in slight flexion at the wrist. This improves your dexterity and strength.

There are three tools used for cutting the skin:

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  No. 15 scalpel blade

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  Microdissection needle (Colorado needle)

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  CO ₂ laser

Most of my comments not only pertain to the traditional scalpel but also to the cutting cautery needle and CO ₂ laser. It is worth learning the traditional surgical techniques with the scalpel and scissors. As your skill increases, you will likely find that using the microdissection needle or laser shortens the operating time. Although some surgeons use a blade and scissors throughout all operations, I use a microdissection needle for most surgeries.

As you hold the scalpel with the pencil grip , you notice that, on the scalpel handle, there is a groove or flat area where your index finger rests. The scalpel is supported between your thumb, index finger, and middle finger ( Figure 1.2 ).

The eyelid skin is mobile. Precision cutting requires immobilization of the skin with the help of your fingers or the assistant’s fingers. Let your ring finger rest on the patient, stabilizing the skin or guiding your hand. Learn to use the ring finger on your dominant hand and the thumb and forefinger on your nondominant hand to stabilize the skin ( Figure 1.3 ). If the tissue is slippery, using a gauze pad for some traction will be helpful.

It is best to start the skin incision with the tip of the scalpel blade. As you move across the incision, lay the scalpel down so that you are cutting with the curved part of a no. 15 blade. As the wound edges start to separate, observe the depth of the wound. Ideally, you want to cut the eyelid skin only and not extend the cut deep into the orbicularis. This is difficult to do but, nevertheless, worthwhile. Controlling the depth of any eyelid incision is critical. Remember that the eyelid is only slightly more than 1 mm thick at the skin crease, and you do not want to extend your incision into the cornea! You might find initially that using a corneal protector is a useful safeguard. With experience, you will probably find it easier not to use a corneal protector for scalpel cutting or cutting cautery incisions, but surgeons vary on this opinion. Adjust the pressure to maintain the proper depth of the wound. As if you were driving a car, look down the road as you pull the scalpel across the skin. All of this is happening as you or your assistant holds steady tension on the skin. Remember, tight skin is more easily and accurately cut than more mobile skin. Like most instruments for eye and eyelid surgery, the scalpel is a finger tool. As you bring your fingers toward your palm with the scalpel tip, you may need to reposition your hand and repeat the cutting process in lengths of the wound ( Figure 1.4 ). As you get more experienced, you will be able to flex your fingers and move your hand at the same time.

This is a good time to remind you about having a good body position . You should feel relaxed and at ease as you cut. Make sure your elbows remain close to your side rather than up high; having them up high converts the scalpel to an arm tool rather than a finger tool. You will be making many incisions in your life, so learn to cut away from important structures such as your fingers and the eye. Familiarize yourself with the several types of scalpel blades available.

Scalpel Blades

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  No. 11 blade: This blade has a sharp point that is good for tight angles and curves. It is a good “stabbing” knife for draining an abscess or a chalazion. It is not useful for longer incisions.

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  No. 15 blade: This is the best all-purpose scalpel blade for eyelid and facial skin; 99% of your eyelid surgery with a scalpel will be done using a no. 15 blade.

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  No. 10 blade: The no. 10 blade is shaped like a no. 15 blade except it is bigger. This blade is used primarily for thicker skin incisions. It is not used for periorbital incisions but can be helpful in facial flaps.

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  Beaver blades ( www.bvimedical.com ): The no. 66 Beaver blade (376600) is a special-purpose right-angled blade. Its primary use is for making cuts in tight spaces. It is especially useful for nasal mucosal incisions in dacryocystorhinostomy procedures. Angled keratomes designed for anterior segment surgery work in a similar fashion ( Figure 1.5 ). Other useful blades are the no. 64 blade (376400 rounded tip, sharp on one side) and the no. 76 blade (376700, a mini no. 15 blade), both of which are useful for the delicate shaving of tissue off the sclera or cornea. The needle blade 375910 is good when you need to make a microincision. Beaver handles come in a variety of lengths, the most common being 10 cm. Longer-length handles (13 and 15.5 cm) are useful for deep orbitotomies or craniotomies.

  

Other Cutting Tools

Two other useful cutting tools are available for eyelid surgery: the microdissection needle and the CO ₂ laser. The microdissection needle has been my choice for most periocular surgical procedures in recent years. This unipolar cautery device does an excellent job of cutting and cauterizing the thin eyelid tissues. The needle is made of tungsten and has an extremely fine tip. Tissue in contact with the tip is vaporized. Getting used to this instrument takes some practice. Cutting the tissue should be done with superficial light passing over the tissue in a “painting” motion and the needle slightly angled as if you are using a paintbrush. If you find that carbon is building up on the tip of the instrument, you are moving too fast, cutting too deep, or have the power turned up too high. The trick of using this tool is cutting only at the very tip so that there is little thermal damage to the surrounding tissues. You learn that “pulling” the layers of tissue apart is essential for this tool and gives a very clean dissection with little collateral damage to the adjacent tissues. Using a “blend” mode setting on the cautery machine provides cutting and cautery. Try this for the dissection of an upper eyelid blepharoplasty skin muscle flap. Once you get used to this “bloodless” field, you will have trouble going back to scissors. You should use a smoke evacuator to eliminate the hazardous smoke produced by this tool. The patient requires grounding, as with the use of any unipolar cautery equipment. The use of this unipolar cutting tool is sometimes limited to tissues anterior to the orbital septum, because the electric current is carried into the orbit and causes pain for many patients under local anesthesia. The tip works on the dry eyelid skin but works best on tissues deep to the skin. For this reason, some surgeons prefer using a blade for the initial skin incision because the edges of the wound are cleaner. They switch to the needle for any deeper work. You may find the Colorado needle with a foot pedal useful, but I prefer the hand switch on the cautery handle itself. Several companies make a microdissection needle (e.g., Stryker makes the Colorado microdissection needle, www.stryker.com , and Medtronic makes the Valleylab tungsten microsurgical needle E1650, www.medtronic.com ). The shortest-length needle is the easiest to work with on periocular tissues. The quality and price vary from manufacturer to manufacturer.

The CO ₂ laser is also a useful tool for cutting eyelid skin. Like the microdissection needle, tissues are vaporized, with excellent cautery of capillaries and small veins. The UltraPulse CO ₂ laser was introduced years ago and remains a workhorse in my practice. The current model is the UltraPulse Encore made by Lumenis ( www.lumenis.com ). These lasers remain the gold standard for laser incisional and resurfacing work. As when using a microdissection needle, large vessels are often cut with the laser rather than cauterized, so you need a bipolar cautery tool on the operating room table, as well. Both of these cutting and cauterizing tools can shorten operating times considerably. If you have a CO ₂ laser available, you should try it as a cutting tool. You must emphasize the pulling apart of the tissues with your forceps, even to a greater degree than with a microdissection needle. There is no touch or feel involved in the cutting. It is all visual, so technique is very important. Once you learn it, you love it. Patients have less discomfort with the CO ₂ laser than with the Colorado microdissection needle. Some precautions are necessary. You need sandblasted instruments to prevent reflection of the laser energy. Metal corneal shields are a must. Surgeons and staff must wear protective goggles. Smoke evacuation is necessary. Care with oxygen and the use of wet drapes are important to prevent fire. Most procedures in this text use the microdissection needle, but I suggest you try the laser, especially for upper blepharoplasty. The skills that you learn using the microdissection needle and the laser are complementary; learning to use one helps you with the other.

Placement of Skin Incisions

Most skin incisions are hidden in natural creases or wrinkle lines ( Figure 1.6 ). The upper lid skin crease is a natural place to make incisions in the upper lid. The upper lid skin crease is often carried laterally into a laugh line. If you are not familiar with the wrinkle lines of a certain area, ask the patient to contract the facial muscles in that area. Seeing the wrinkles and folds in the skin shows you where to place your incisions. You can anticipate these lines. The natural skin creases occur perpendicular to the direction of the muscle fibers causing the creases. By contracting your frontalis muscle you are able to see the furrows of the forehead perpendicular to the frontalis muscle fibers.

Other skin incisions can be camouflaged by placing them near anatomic structures such as the eyelashes or eyebrow. Adults generally have no lower lid skin crease. Skin incisions in the lower lid are usually placed 2 to 3 mm inferior to the lower lid lashes (subciliary incision). This incision can also be carried laterally into a laugh line. Similarly, an eyebrow incision can be hidden by placing it adjacent to the upper or lower margin of the eyebrow hairs . Incisions can be placed within the brow itself but can cause permanent visible scarring as a result of the loss of cilia roots. Other examples of camouflaging scars near facial structures include pretrichial hairline incisions, preauricular skin incisions, and incisions along the alae of the nose. Older-style incisions such as the Stallard-Wright lateral orbitotomy incision and the Lynch incision have been largely replaced by incisions that leave a better scar.

Anxiety and Tremor

Every surgeon has a tremor to some degree or another. This tremor is worse when you are anxious, are tired, or have drunk too much coffee. If you find that your tremor is bothersome, try to eliminate these factors. I occasionally hear of a resident who takes a beta-blocker before performing an operation. This can serve as a confidence booster but is likely not necessary once you learn to relax during surgery, although I do know experienced surgeons that feel their hands become “silkier” when they have taken a beta-blocker. A big part of being anxious when learning surgery is the feeling that you will look bad to your teacher or others observing. Consequently, you get more nervous and your tremor increases. Don’t forget, everyone in the operating room is on your side, doing everything they can to help you do your best for your patient. If you are feeling a little shaky, you might want to explain to your mentor that you are nervous. Usually, this confession will bring some deserved empathy, and your tremor will settle down a bit. Take a few deep breaths. Make sure that your chair and the table height are appropriate. Try to relax your forearms and loosen your grip on the instruments. If this does not work, consider a wrist rest. I have yet to see a student who had a tremor that kept him or her from being a successful surgeon.

How do scissors cut?

Scissors cut by the shearing action of the blades crossing so close together that tissue between the blades is separated in a controlled fashion. The majority of skin incisions, especially on thicker skin, should not be made with scissors, because of this crushing action of the scissors blades. Some surgeons do, however, use scissors to cut the thin skin of the eyelid. Most surgeons reserve scissors for the dissection of deeper tissue planes.

Types of Scissors

In the Storz instrument catalog ( storzeye.com , now a part of Bausch and Lomb), there are more than 50 pages showing over 200 types of scissors. For a view of ENT and plastic surgery instruments check out www.bauschinstruments.com . I hope that after reading the next several paragraphs you can make a sensible choice in selecting the right scissors for the surgical step you are doing. Scissors vary in the following characteristics:

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  Length

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  Caliber

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  Tip sharpness

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  Blade design

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  Cutting motion

Let’s look at each of these characteristics briefly.