ORLANDO The difference between acceptable and unacceptable results for a blepharoplasty can be as little as a millimeter, so small improvements in anesthestic control and precision can have a large effect, Dr. Marc Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.
"A tolerance of 1 mm or less is a very high standard to live up to," said Dr. Cohen, a cosmetic surgeon at Wills Eye Hospital in Philadelphia. "The simple truth is that you cannot make the type of intraoperative decisions that give you that type of precision unless the surgery at each step is performed under tremendous control."
Dr. Cohen offered tips that can make a big difference in results when it comes to maintaining patient comfort and giving the anesthetic block. "Every surgery has a weakest link in terms of surgical control. … Interestingly, the weakest links that I've foundin terms of bleeding and bruisingtend to be the least technically difficult parts of the surgery," he said.
Keeping the patient comfortable during surgery can have the biggest impact on the quality of the end results. Patient pain and anxiety cause bleeding. The anesthesiologists that he works with understand that he wants patients as sedate as is medically safe throughout the entire procedure.
There are several tricks that can be used to perform a block without bruising. "All of us have had a case where we've given a block and developed a big bruise. The rest of the operation is more difficult," Dr. Cohen said.
He uses Xylocaine (lidocaine) with epinephrine and hyaluronidase injected in the smallest possible needle (32 gauge). The needle is injected at one site laterally. The injection should be superficial to avoid the highly vascular orbicularis.
"Once the needle is in place, it's not moved and a 2- to 3-cc bolus injection is given," Dr. Cohen explained. Remove the needle and massage the bolus immediately.
A transconjunctival block poses more of a bruising problem because the conjunctiva is highly vascular. Dr. Cohen's trick is to constrict the blood vessels before giving the block by using a drop of 2.5% phenylephrine.
There are, however, patients for whom it just is not prudent to have heavy sedation. "You're at a significant disadvantage with these people because they are much more likely to bleed and bruise during surgery," said Dr. Cohen. This is especially true for performing a block. "We go to great lengths to ensure that the block is painless so there is no bruising."
For these patients, Dr. Cohen uses a syringe device called the Wand (Milestone Scientific), which has a microprocessor. The microprocessor controls the rate of flow so there is a constant pressure that is below the pain threshold. When using this device, Dr. Cohen uses the same technique as for a standard block. He reported no conflict of interest with the device.
The needle is not moved during the injection of a 2- to 3-cc bolus. After the needle is removed, the bolus is massaged immediately. Courtesy Dr. Marc Cohen