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428429) Addressing the Upper Lid completedbeforeaddressingthelowerlid markestimatedskintobeexcisedbybringingtogetherredundant skin with forceps while patient is in an upright position (pinch technique), correct amount should begin to move the eyelashes upward but not move the lid margin, ideally lid should leave a slight (12 mm) lagophthalmos intraoperatively, lower incision begins at the superior lid crease (hooding may be addressed by extending the incision lateral to the orbital rim) astripoforbicularismusclemaybeexcisedintheheavylidwith thick skin, allows for better definition of lid crease opentheorbitalseptumandexcisethepseudoherniatedfat(amount typically determined by excising the fat that extrudes out of the septum when placing gentle digital pressure on the globe) ptoticlacrimalglandmaybeaddressedbyplicatingtothe periosteum accentuationofthesuperioreyelidcreasemaybeconsideredby plicating the skin margin of the inferior skin incision to the levator aponeurosis Addressing the Lower Lid Approaches: skin-muscle flap (most common, more avascular dissection), skin flap (allows for independent modification of skin and muscle, more skin trauma, increased risk of vertical eyelid retraction), and Top Forex Binary Options EUR/SEK (indicated for excessive fat herniation with minimal skin redundancy, no external scar, avoids eyelid retraction, may be combined with a chemical peel or laser resurfacing to Top Forex Binary Options EUR/SEK rhytids) exciseredundantskin(markedsimilarlytotheupperlid) exciseorbicularisoculiifneeded excisepseudoherniatedfat(medialcompartmenttypicallyrequires more aggressive excision) PHYSICAL METHODS OF PENETRATION ENHANCEMENT III © 2006 by Taylor Francis Group, LLC 370 CHAPTER 27 FIGURE 27.

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