So we have blocked the patient. He's got the corneal protector in place which is very important. So what we're going to try to do, you can see here how rolled inward the upper eyelid is and the lashes rolled inward toward the globe. Here we are trying to divide the anterior lamella from the posterior lamella.
So the anterior lamella is the lamella of skin and orbicularis muscle. It also contains the eyelash follicles. Normally, the upper lid border is horizontal. There's a flat part. But when you've got all the cicatricial change, the eyelid becomes rounded instead.
So it makes the... identification of the normal architecture a lot more difficult and tricky. So you can see here that I've started dividing the lid into anterior where the lashes are here, they're cut, and posterior because I'm going to want to move this entire layer back away from his eye. You can see the punctum.
I'm going to stay lateral to that. Now I might be able to get my traction suture in now that I've developed a little bit of a plane there. It was very difficult for me earlier.
I'm trying to leave the tarsus behind because that's our structure. I don't want to take the tarsus. I'm making it a little superficial. As long as the lashes are here, I want to be superficial here. Now we're starting to see the tarsal plate.
And now we can see our tarsal plate here. So I sharply divided the anterior lamella here that has our orbicularis muscle and our lashes from the posterior lamella, which is tagged by the traction suture here. And so the recession involves replacing this layer up higher and leaving it like that. This bare area will resurface on its own, but the lashes, the lash area will be superior to this. But.
Because the human body tends to want to undo the best things that we surgeons do, I'm going to try to improve the odds that he at least will not have lashes rubbing against his eye again by resecting the lash follicles. Now we can inspect and see if I've missed any follicles. A couple follicles right there, yes.
So I was a little shallow here. So we're just removing the rest, the final lash follicles that we see. And so now we have our anterior lamella, our posterior lamella, and we're going to now close by affixing this to our underlying tarsal plate in a recessed position.
This bare area of tarsus will re-epithelialize with skin. over the next two to three weeks or so. I'll take the 6-0 plain gut now. These are just partial thickness bites to the epithelium here. And I try to go as high up as I can get on the tarsus.
So now we're just re-affixing the anterior lamella. in a more superior position relative to the posterior lamella. This is a 6-0 plain gut, so it's absorbable. We don't need a large gauge. There's not a lot of tension here.
I usually just have all of my lid patients using some antibiotic ointment. on the wound, maybe on the eye for lubrication for the first seven days. After surgery. For long-term care after seven days, really not too much at all.
We just let this granulate in. So, again, this raw area will resurface. And it'll look very good when we're done. But now his lid edge has no lashes.
It's not being turned in as much.