SUTTER COAST HOSPITAL
DAVID E. CINK, M.D.
STANDARD OPERATIVE REPORT - BLEPHAROPLASTY
[Date of operation and surgeon's name are put in
automatically]
ASSISTANT:
PREOPERATIVE DIAGNOSIS:
dermatochalasis.
POSTOPERATIVE DIAGNOSIS:
dermatochalasis.
Bilateral upper lid
OPERATIVE PROCEDURE:
Bilateral upper lid
Bilateral upper lid blepharoplasty.
PREOPERATIVE INDICATIONS:
DESCRIPTION OF PROCEDURE: After informed consent was
obtained, the patient was taken to the main operating room
where monitors were applied and confirmed to be functioning
well. A marking pen was used to place a mark following a
natural skin crease along the upper lids, from a point just
superior to the upper punctum, to a point 10 mm lateral to
the lateral canthus. This mark was approximately 6 mm
above the lashes centrally. The appropriate amount of
redundant upper lid skin was determined by grasping the
upper lids with Graefe forceps and the superior aspect of
the wound was outlined.
The patient was given an IV dose of propofol and while
asleep the skin was infiltrated with 0.5% Marcaine with
epinephrine. Intermittent digital pressure was applied to
ensure adequate anesthesia. The patient was then prepped
and draped in the normal sterile ophthalmic fashion.
Attention was focused on the right upper lid. The skin was
incised with a #15 blade, and a skin-muscle flap initiated
with Westcott scissors and completed with bipolar cautery.
The orbital septum was then incised with Westcott scissors,
exposing a moderate amount of preaponeurotic fat. The fat
was dissected from its underlying fascial attachments,
clamped at its base with a curved hemostat, and then
removed with a #15 blade. The residual fat was cauterized
while grasped with the hemostat prior to release. The
wound was carefully inspected to ensure complete hemostasis
and the skin was then closed using interrupted and running
6-0 nylon sutures.
Attention was focused on the left upper lid where the
procedure was performed in exactly the same fashion. At
the conclusion of suturing, Bacitracin ointment was applied
to the incision lines. A Telfa pad was applied. Ice bags
were applied and the patient was transported to the SameDay Stay area in stable condition.