1 The Art of Surgical Technique�

CHAPTER OUTLINE Introduction 1Preparation for the Operation 1Firm Plan with Contingencies 1Skin Marking and Local Anesthesia 2Preparing and Draping the Patient 4Instruments 4Cutting the Skin 5Hand Position 5Scalpel Blades 6Other Cutting Tools 6Placement of Skin Incisions 7Anxiety and Tremor 7Cutting Tissue with Scissors 8How Do Scissors Cut? 8Types of Scissors 8Cutting with Scissors (You Learned

This as a Child) 10Retraction and Exposure 11Fingers as Retractors 11Skin Hooks 12

Forceps 12Dissection Technique 13Retractors 13Hemostasis 15Preoperative Considerations 15Tamponade 15Cautery 15Bone Wax 17Drugs 17Drains 17Suction 17Suturing 18Types of Suture Material 18Types of Needles 19Needle Holders 20Suturing Technique 21The Surgical Assistant 24Major Points 27Suggested Reading 28

VIDEOS ’ 1.1 Surgical Instruments: Using the Tools of Your Trade Effectively’ 1.2 Sutures and Suturing Technique

Visit Expert Consult (expertconsult.inkling.com) for videos on topics discussed throughout the text.

IntroductionWelcome! I hope that this book will add to your success inthe clinic and operating room. It is my pleasure and honorto make any contribution I can to your learning! For me,three decades of practice have been more fun than work,and even after all these years I am still learning and improv-ing my technique. My wish is that you do the same.This chapter serves as your introduction to some of the

theoretical and practical technical aspects of actually per-forming surgery. A successful operation starts with plan-ning before you enter the operating room. To be effective,you must have a plan and let the operating room teamknow what it is. If you are prepared, you will inspire theteam to follow your leadership. You will coordinate thesetup of the operating room and equipment necessary foryour procedure.To be effective, you need to know the tools of the trade

and how to use them. In this chapter, we discuss differenttypes of instruments and their general and special uses. We

stress some fundamental techniques, including holding andcutting of the skin. We describe the important instrumentsused in retraction, hemostasis, suctioning, and suturing. Inthe last section, we talk about the role of the assistant, whohas an underestimated and important job.

As you read this chapter and the others, look at the big pic-ture first. I suggest that you read the chapter three times, goingintomore depth each time. Scan the chapter initially to get theflow of the material, and then go back and peruse the contentcasually. Don’t labor over the details of each section; rather,read the text several times as your abilities and interestsincrease, each time taking in more detail. If you are like me,you have read a text and carefully underlined passages in it,and then realized that you don’t remember a thing! There is alot of information here. Learning happens in layers over time.

Preparation for the Operation

FIRM PLAN WITH CONTINGENCIES

When you enter the operating room, you should have afirm plan in mind. Early in your career, it is helpful to have a

�Chapter title is in recognition of Dr. Milton Edgerton’s excellent book bythe same name, which I recommend all surgeons read.

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set of contingency plans if things don’t go as expected. Asyour surgical expertise increases, your need to make formalcontingency plans will disappear. At the early stage, or laterwhen you are planning a new procedure, it is helpful towrite down the steps of the operation and list the necessaryequipment and then bring the list to the operating room.The nursing staff will appreciate your preparation and beconfident in your abilities.

You are the team leader in the operating room. Yourbehavior sets the stage for how the operation goes. You setthe pace and the quality of the entire effort. If you are oper-ating in a new setting, be sure to introduce yourself to thenursing staff. Discuss your plans for surgery with the team.Your preparation and willingness to include them in yourplans will improve the overall effort and give the team confi-dence in your ability to get the job done. This approachapplies to every surgeon, from new residents to experiencedsurgeons in practice for many years.

Room Setup

Part of your plan should be to know where the operatingequipment is placed. Generally, the setup is as shown inFigure 1.1. In most cases, the position and orientation willbe the same for each procedure in a particular operatingroom. For example, usually the head is away from thedoor and away from the flow of traffic in the room. Insome cases, the operated eye will be placed away from theanesthesia equipment. You, as the surgeon, will sit atthe head of the bed. Your assistant will sit at the side of thebed corresponding to the operated eye. For some proce-dures, you may find it easier to sit at the patient’s side(e.g., for lateral tarsal strip and lateral orbitotomy proce-dures). Feel free to move throughout the operation and becomfortable. The nursing table is placed on the side of theoperating table, opposite any anesthesia equipment andstaff.

Equipment Setup

For most operations, you will be in the sitting position. Ifyou are planning to move around the patient during theoperation, as in an orbital floor exploration for a blowoutfracture, you may want to stand. If so, consider step stoolsto make the assistant and surgeon relatively the sameheight.

Once you have decided whether to sit or stand, youshould position the operating room table. Often it is helpfulto angle the head of the table away from the anesthesiaequipment. Remember to consider where the operatingroom overhead lights are when positioning the table. Adjustyour chair to an appropriate height with your feet flat onthe ground. Adjust the table height so that your elbows arebent slightly more than 90 degrees. Make sure that thepatient’s head is at the top edge of the operating table andthe plane of the face is parallel to the floor so you will nothave to lean over the patient. Take the patient’s pillow andplace it under the patient’s knees.

Do your best to position the patient for the comfort ofboth the patient and yourself. When operating on chil-dren, your view will improve if you place a towel rollunder the patient’s shoulders to hyperextend the neck,bringing the face into the same plane as the table. Older

patients with neck arthritis may require a roll under thehead for comfort. Markedly kyphotic patients may need apillow under the neck and shoulders for comfort. Youmay have to operate standing at this patient’s side withthe head of the bed elevated. In some cases, you can raisethe foot of the bed so that a kyphotic patient is flatteron the table. Do your best to maintain reasonable posture.Many older surgeons have to alter or stop their surgicalpractices because of the neck aches and back pains thatresult from years of poor body mechanics. Learn to pre-serve your spine and neck from the beginning of your sur-gical career!

If you expect significant venous bleeding, as in nasal sur-gery, put the patient in about a 10% reverse Trendelenburgposition (head up, feet down) before adjusting thetable height. Once the table is at the chosen position andheight, make sure that it is locked into position.

If you are using an operating microscope, this is the timeto make adjustments to the scope and your chair. There areseveral possible positions for the scope base, but the mostcommon is off the shoulder of the patient opposite to the eyeon which you are operating. Set the base of the scope toallow for the full range of the microscope’s arm. Make grossadjustments to the microscope height. Set the interpupillarydistance of the microscope heads for the surgeon and theassistant. Set the focus of the microscope. If you are doing aconjunctival or canalicular procedure, set the focus of themicroscope in the middle of the range. If you are doing deeporbital surgery, set the focus at the top of the focus travel sothat you are able to adjust the focus with the foot pedal tosee deeper tissue without repositioning the operating scopeas the dissection continues into the orbit. Most proceduresare performed without a wrist rest, but don’t hesitate to useone if it increases your steadiness. If you plan to drape thescope, swing the microscope arm away without alteringyour microscope base position and have the scrub nursedrape the scope away from the operating field. Considerusing sterile handles or sterile baggies over the handlesrather than draping the whole scope to save time andmoney. Position the microscope and cautery foot pedals inthe appropriate spot underneath the head of the table. Ifyou don’t do this, you may be surprised at how many timesyou start the operation and reach for the cautery pedal butfind that it is not yet ready to use. Do all this before you leaveto scrub.

SKIN MARKING AND LOCAL ANESTHESIA

Many oculoplastic procedures require skin marking as aguide to incision placement. Most incisions are placed in nat-ural skin creases, such as the upper lid skin crease for ptosisand blepharoplasty operations. Other skin incisions areplaced adjacent to anatomic structures so the scar will be hid-den. You should mark the skin before any local anesthetic isinjected. Two good choices for marking eyelid skin are avail-able: (1) gentian violet solution and (2) the surgical mark-ing pen. Gentian violet can be applied with the sharp end ofa broken applicator used as a quill. With experience,you can draw a fine line that does not easily wash off withprepping, but this takes some experience to keep frommaking a mess. Usually, we use a thin-tipped surgical

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marker (Blephmarker 1424 Gentian Violet Twin UltraFine Tip Ruler Sterile, Viscot.com, reference 1424SR-100).Be sure to degrease the skin with an alcohol wipe beforemarking.You should use a local anesthetic with epinephrine for

all procedures to provide some hemostasis (due to the vaso-constriction). The most common local anesthetic mixtureis 2% lidocaine with 1/100,000 epinephrine in combina-tion with 0.5% bupivacaine. Some surgeons choose to addhyaluronidase to the mix, but I have not found this neces-sary. For larger scalp and face procedures, you may wantto consider “tumescent” anesthesia. With this technique, alarge amount of very dilute local anesthetic with epineph-rine is injected into the subcutaneous tissues. This tech-nique firms up the tissues and makes it easier to developflaps and perform liposuction. This is not needed for perio-cular procedures.Local anesthetics sting badly (if you are not feeling sym-

pathetic, have a colleague inject 1 mL of local anesthetic

into your eyelid; you will not soon forget how it feels). Twofactors are thought to be responsible: (1) a difference in pHand (2) the distention of the tissues during rapid injection.To minimize the pain, try injecting a tiny amount—about0.1 mL—into two or three places and then massage thelocal anesthetic into the tissues. After a few seconds, injectmore anesthetic very slowly. This greatly minimizes thepain. Some surgeons buffer the local anesthetic using onepart 7.5% sodium bicarbonate in nine parts 2% lidocainewith epinephrine (2 mL of bicarbonate in 20 mL of lido-caine). I have not found this worth the trouble, but manysurgeons swear by it. If you operate with an anesthesiolo-gist, using appropriate sedating agents, the patient is totallyunaware of any local injections.

Remember to inject just beneath the eyelid skin. Avoidplacing the needle into the muscle to prevent a hematoma,which may make intraoperative adjustments of the eyeliddifficult; this is especially true with anterior ptosis correc-tion. Avoid putting the needle in the crease at the junction

Anesthesiologist

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"Back" instrumenttable

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Figure 1.1 Typical operating room setup for an operation on the right eye.

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of the lateral one third and medial two thirds of the eyelid.There is a vessel that, if torn, will guarantee a hematomabefore you start the procedure! For an upper eyelid proce-dure, such as a blepharoplasty or ptosis repair, you shouldinject 1 to 1.5 mL of local anesthetic mix.

The topical solutions that provide anesthesia are EMLAcream and Betacaine gel. EMLA cream should be appliedin a thick coating 1 to 2 hours ahead of the procedure andcovered with an occlusive dressing (topical lidocaine 2.5%and prilocaine 2.5%). BLT cream (20% benzocaine, 6%lidocaine, and 4% tetracaine) is an alternative. Betacainegel (topical lidocaine 5%, http://www.sanofi.com) can beapplied for 20 to 30 minutes ahead of the procedure with-out an occlusive dressing. These preparations providesome anesthesia but do not cause vasoconstriction, so anadditional local injection with epinephrine is required forsurgical procedures. Topical agents are also useful prior toBotox or filler injections and can be helpful in children.Overdosing with a systemic reaction is unlikely but possi-ble. Most of the time, I do not use these preparations, butyou might find them helpful in some situations. You maybe able to avoid taking a child to the operating room forsuturing if you apply topical cream before injection of anylocal anesthesia.

Most eyelid and lacrimal operations can be performedunder local anesthesia. If you choose to operate withoutthe benefit of an anesthesiologist, you should considerintravenous (IV) sedation to minimize the patient’s anxi-ety. Doses of midazolam in 0.5- to 1.0-mg increments arereasonable to achieve some relaxation. I find it helpful tohave a midazolam drip running (1 to 3 mg/hour) ratherthan give intermittent doses of the medication. Some sur-geons prefer preoperative oral sedation with 2 to 10 mgof oral diazepam. Additional pain relief can be givenintraoperatively using small doses of a narcotic, such asmorphine (1 to 2 mg IV). Intravenous fentanyl is usefulbecause of its short duration, but keep in mind that this isa very potent opiate narcotic and a highly abused drug.Surgical centers often do not permit the surgeon toadminister this without anesthesia staff oversight. Avoidoversedation to the point that the patient has lost inhibi-tions and gets restless or is too sleepy to follow yourinstructions. A supportive attitude from you and thenursing staff (sometimes called talk-esthesia or vocallocal) is helpful. I am always impressed by how manypostoperative patients comment on how helpful it was tohave the circulating nurse offer to hold hands during theprocedure. The nurse can also alert you when the patientis feeling discomfort.

If your operating situation allows for the efficient use ofmonitored anesthesia care, your anesthesiologist can medi-cate your patient to the point at which there is no memoryof any pain from the injection and often no memory of theentire operation. The downside of this is more staffing andan increased cost. The majority of my eyelid and lacrimalprocedures are done with monitored anesthesia care in ourpractice-owned ambulatory surgery center. If you plan toask for any intraoperative patient cooperation, such as eye-lid opening for a ptosis adjustment operation, make surethat no IV midazolam is administered until you have com-pleted the adjustment. As you would expect, working withthe same anesthesia and nursing team on a regular basis

increases your efficiency greatly and can make your life inthe operating roommuch better.

PREPARING AND DRAPING THE PATIENT

In most operating rooms, the patient can be prepped whileyou scrub. This gives time for the local anesthetic to takeeffect. A traditional povidone-iodine scrub applied in con-centric rings away from the planned surgical excisions,repeated three times, provides adequate cleaning of theskin. A surgical bonnet and a drape with a single stickyedge (bar drape) across the forehead keep the patient’shair out of the operating field. If the hairline is particularlylow or close to the operating field, tape can be used to pullthe hair away from the field. For most procedures forwhich the patient is awake, the entire face is preppedunder local anesthesia. If the patient is asleep, prep botheyes whenever there is a need to obtain symmetrybetween the two sides or if forced duction testing may berequired. A good general rule is to prep a larger area thanyou think you will need. Most of my patients are drapedwith a single split sheet (U-drape) spread over the face. Itis worth considering placing a towel over any endotra-cheal tube before placing the U-drape so that the adhesiveon the drape does not stick to the tube (and it is always agood idea not to pull the tube out when tearing the drapesoff the patient!).

InstrumentsIn the next sections of the chapter, we will discuss severaltypes of surgical instruments. These instruments include:

’ Scalpel blades and other cutting tools’ Scissors’ Forceps’ Retractors’ Cautery tools’ Suction implements’ Needle holders’ Sutures

You are undoubtedly familiar with several variations ofeach of these instruments. I am going to explain the instru-ments that I have found most useful in my practice. Youmay already have your own favorite tools for specific jobs,or you may choose to use the instruments that I havesuggested.

Particular instruments are available in different lengthsand calibers. In general, the length of the instrument isrelated to the depth of the surgical incision in which theinstrument is used. Most of the eye instruments are only4 inches long. These instruments are not used in deep inci-sions and are rarely used for incisions deeper than the eye-lid. The delicate instruments used for neurosurgery aremuch longer, often measuring 12 inches. An example is thecurved Yasargil scissors used in optic nerve sheath fenestra-tion. These instruments are 9 inches long and have a finertip than the familiar Westcott scissors used for eye and car-diac surgery. Ideally, for an optic nerve procedure, I use a6-inch instrument, but none is currently available in this

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scissor type so I make do with the longer instrument. Thecaliber or strength of the instrument varies, depending onthe type of tissue to be manipulated or cut. Conceptually,you want to pick the correct instrument based on lengthand caliber. We talk more about the individual variations ofeach of these instrument types later in this chapter.

Cutting the Skin

HAND POSITION

Once you are properly positioned at the head of the bed of apatient who has been prepped and draped, your next job isto make a skin incision. Remember you are positioned withyour feet flat on the ground and your elbows at your side in flex-ion slightly more than 90 degrees. Hold your hands in thefunctional position (like holding a pencil), with your hand inslight flexion at the wrist. This improves your dexterity andstrength.There are three tools used for cutting the skin:

’ No. 15 scalpel blade’ Microdissection needle (Colorado needle)’ CO2 laser

Most of my comments not only pertain to the traditionalscalpel but also to the cutting cautery needle and CO2 laser.It is worth learning the traditional surgical techniques withthe scalpel and scissors. As your skill increases, you willlikely find that using the microdissection needle or lasershortens the operating time. Although some surgeons use ablade and scissors throughout all operations, I use a micro-dissection 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 areawhere your index finger rests. The scalpel is supportedbetween 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 orthe assistant’s fingers. Let your ring finger rest on the

patient, stabilizing the skin or guiding your hand. Learn touse the ring finger on your dominant hand and the thumband forefinger on your nondominant hand to stabilize theskin (Figure 1.3). If the tissue is slippery, using a gauze padfor some traction will be helpful.

It is best to start the skin incision with the tip of the scalpelblade. As you move across the incision, lay the scalpel downso that you are cutting with the curved part of a no. 15blade. As the wound edges start to separate, observe thedepth of the wound. Ideally, you want to cut the eyelid skinonly and not extend the cut deep into the orbicularis. This isdifficult to do but, nevertheless, worthwhile. Controlling thedepth of any eyelid incision is critical. Remember that theeyelid is only slightly more than 1 mm thick at the skincrease, and you do not want to extend your incision into thecornea! You might find initially that using a corneal protec-tor is a useful safeguard. With experience, you will probablyfind it easier not to use a corneal protector for scalpel cuttingor cutting cautery incisions, but surgeons vary on this opin-ion. Adjust the pressure to maintain the proper depth of thewound. As if you were driving a car, look down the road asyou pull the scalpel across the skin. All of this is happeningas you or your assistant holds steady tension on the skin.Remember, tight skin is more easily and accurately cutthan more mobile skin. Like most instruments for eye andeyelid surgery, the scalpel is a finger tool. As you bring yourfingers toward your palm with the scalpel tip, you may needto reposition your hand and repeat the cutting process inlengths of the wound (Figure 1.4). As you get more experi-enced, you will be able to flex your fingers and move yourhand at the same time.

This is a good time to remind you about having a goodbody position. You should feel relaxed and at ease as you cut.

Figure 1.2 Holding the scalpel with the pencil grip. Note that thehand is in the functional position in slight flexion.

Figure 1.3 Skin stabilization. During upper eyelid blepharoplasty, theskinfold is stabilized and stretched with the surgeon’s fingers whilethe upper eyelid is drawn downward using a lid margin tractionsuture. Note that a Colorado microdissection needle� is being usedfor the incision. With experience, the traction suture can beeliminated and the surgeon can use fingers to stretch the skin tightly.(�The original micropoint electrocautery needle was called theColorado needle. Other brands of true microdissection needles arenow available. In this text, the terms Colorado needle andmicrodissection needle are used synonymously. However, this finetungsten microtipped needle should not be confused with the olderneedle point monopolar cautery tool available in many operatingrooms.)

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Make sure your elbows remain close to your side ratherthan up high; having them up high converts the scalpel toan arm tool rather than a finger tool. You will be makingmany incisions in your life, so learn to cut away from impor-tant structures such as your fingers and the eye. Familiarizeyourself with the several types of scalpel blades available.

SCALPEL BLADES

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

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

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

’ Beaver blades (www.bvimedical.com): The no. 66Beaver blade (376600) is a special-purpose right-angledblade. Its primary use is for making cuts in tight spaces.It is especially useful for nasal mucosal incisions indacryocystorhinostomy procedures. Angled keratomesdesigned for anterior segment surgery work in a similarfashion (Figure 1.5). Other useful blades are the no. 64blade (376400 rounded tip, sharp on one side) and theno. 76 blade (376700, a mini no. 15 blade), both ofwhich are useful for the delicate shaving of tissue offthe sclera or cornea. The needle blade 375910 is goodwhen you need to make a microincision. Beaverhandles come in a variety of lengths, the most commonbeing 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 sur-gery: the microdissection needle and the CO2 laser. Themicrodissection needle has been my choice for most perio-cular surgical procedures in recent years. This unipolar cau-tery device does an excellent job of cutting and cauterizingthe thin eyelid tissues. The needle is made of tungsten andhas an extremely fine tip. Tissue in contact with the tip isvaporized. Getting used to this instrument takes some prac-tice. Cutting the tissue should be done with superficial lightpassing over the tissue in a “painting” motion and the nee-dle 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 powerturned up too high. The trick of using this tool is cuttingonly at the very tip so that there is little thermal damage tothe surrounding tissues. You learn that “pulling” the layersof tissue apart is essential for this tool and gives a very cleandissection with little collateral damage to the adjacent tis-sues. Using a “blend” mode setting on the cautery machineprovides cutting and cautery. Try this for the dissection ofan upper eyelid blepharoplasty skin muscle flap. Once youget used to this “bloodless” field, you will have trouble goingback to scissors. You should use a smoke evacuator to elimi-nate the hazardous smoke produced by this tool. The patientrequires grounding, as with the use of any unipolar cauteryequipment. The use of this unipolar cutting tool is some-times limited to tissues anterior to the orbital septum,because the electric current is carried into the orbit andcauses pain for many patients under local anesthesia. Thetip works on the dry eyelid skin but works best on tissuesdeep to the skin. For this reason, some surgeons prefer usinga blade for the initial skin incision because the edges of thewound are cleaner. They switch to the needle for any deeperwork. You may find the Colorado needle with a foot pedaluseful, but I prefer the hand switch on the cautery handleitself. Several companies make a microdissection needle(e.g., Stryker makes the Colorado microdissection needle,www.stryker.com, and Medtronic makes the Valleylabtungsten microsurgical needle E1650, www.medtronic.com). The shortest-length needle is the easiest to work withon periocular tissues. The quality and price vary from man-ufacturer to manufacturer.

The CO2 laser is also a useful tool for cutting eyelid skin.Like the microdissection needle, tissues are vaporized, withexcellent cautery of capillaries and small veins. TheUltraPulse CO2 laser was introduced years ago and remainsa workhorse in my practice. The current model is theUltraPulse Encore made by Lumenis (www.lumenis.com).These lasers remain the gold standard for laser incisionaland resurfacing work. As when using a microdissectionneedle, large vessels are often cut with the laser rather thancauterized, so you need a bipolar cautery tool on the operat-ing room table, as well. Both of these cutting and cauteriz-ing tools can shorten operating times considerably. If youhave a CO2 laser available, you should try it as a cuttingtool. You must emphasize the pulling apart of the tissueswith your forceps, even to a greater degree than with amicrodissection needle. There is no touch or feel involved inthe cutting. It is all visual, so technique is very important.Once you learn it, you love it. Patients have less discomfortwith the CO2 laser than with the Colorado microdissection

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Figure 1.4 Flexion of the fingers with the scalpel blade followed by movement of the hand.

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needle. Some precautions are necessary. You need sand-blasted instruments to prevent reflection of the laser energy.Metal corneal shields are a must. Surgeons and staff mustwear protective goggles. Smoke evacuation is necessary.Care with oxygen and the use of wet drapes are importantto prevent fire. Most procedures in this text use the microdis-section needle, but I suggest you try the laser, especially forupper blepharoplasty. The skills that you learn using themicrodissection 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 wrinklelines (Figure 1.6). The upper lid skin crease is a natural placeto make incisions in the upper lid. The upper lid skin creaseis often carried laterally into a laugh line. If you are notfamiliar with the wrinkle lines of a certain area, ask the

patient to contract the facial muscles in that area. Seeingthe wrinkles and folds in the skin shows you where to placeyour incisions. You can anticipate these lines. The naturalskin creases occur perpendicular to the direction of the mus-cle fibers causing the creases. By contracting your frontalismuscle you are able to see the furrows of the forehead per-pendicular to the frontalis muscle fibers.

Other skin incisions can be camouflaged by placing themnear anatomic structures such as the eyelashes or eyebrow.Adults generally have no lower lid skin crease. Skin inci-sions in the lower lid are usually placed 2 to 3 mm inferior tothe lower lid lashes (subciliary incision). This incision canalso be carried laterally into a laugh line. Similarly, an eye-brow incision can be hidden by placing it adjacent to theupper or lower margin of the eyebrow hairs. Incisions can beplaced within the brow itself but can cause permanent visi-ble scarring as a result of the loss of cilia roots. Other exam-ples of camouflaging scars near facial structures includepretrichial hairline incisions, preauricular skin incisions,and incisions along the alae of the nose. Older-style incisionssuch as the Stallard-Wright lateral orbitotomy incision andthe Lynch incision have been largely replaced by incisionsthat leave a better scar.

ANXIETY AND TREMOR

Every surgeon has a tremor to some degree or another. Thistremor is worse when you are anxious, are tired, or havedrunk too much coffee. If you find that your tremor is both-ersome, try to eliminate these factors. I occasionally hear ofa resident who takes a beta-blocker before performing anoperation. This can serve as a confidence booster but islikely not necessary once you learn to relax during surgery,although I do know experienced surgeons that feel theirhands become “silkier” when they have taken a beta-blocker. A big part of being anxious when learning surgeryis the feeling that you will look bad to your teacher or othersobserving. Consequently, you get more nervous and yourtremor increases. Don’t forget, everyone in the operatingroom is on your side, doing everything they can to help youdo your best for your patient. If you are feeling a little shaky,you might want to explain to your mentor that you are ner-vous. Usually, this confession will bring some deservedempathy, and your tremor will settle down a bit. Take a fewdeep breaths. Make sure that your chair and thetable height are appropriate. Try to relax your forearms andloosen your grip on the instruments. If this does not work,consider a wrist rest. I have yet to see a student who had atremor that kept him or her from being a successful surgeon.

CHECKPOINT

• Remember to have a plan when you enter theoperating room. Let the staff know what the plan is.Know how the room is set up. Know the instruments.Your preparedness inspires confidence and sets the pacefor the operation.

• You must have a plan for the operation and somecontingencies if things don’t go as planned. You wouldbe surprised how many residents come to the operatingroom expecting to be “shown” what to do. As aresident, the more you prepare before entering the

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Figure 1.5 Surgical cutting instruments. (A) Colorado microdissectionneedles. Blue needle is shorter (preferred); red needle is longer. (B)Beaver blades 376400, 376600, 376700, 375910. (C) (Top down)scalpel blades no. 15, no. 11, and no. 10.

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operating room, the more you will get to do and thefaster you will learn.

• Get the patient, operating table, your stool, and yourbody in a comfortable position before starting. Have allthe equipment prepared before you make a skinincision.

• Why should you mark the skin and inject the localanesthetic before scrubbing?

• Do you need to write down the names of the specialinstruments, sutures, or equipment you will be using?

• Let the operating room nurses know what you areplanning, especially if you anticipate any change fromthe routine.

• Practice stabilizing and cutting the skin on pieces ofchicken at home. It is not the perfect model, but it canbe helpful. Practice everything you can at home,including cutting, suturing, and tying. Operating roomtime is very valuable.

• Learn to be comfortable and relaxed in the operatingroom. As a surgeon, it is your home and workplace fora big part of your career.

Cutting Tissue with Scissors

HOW DO SCISSORS CUT?

Scissors cut by the shearing action of the blades crossing soclose together that tissue between the blades is separated ina controlled fashion. The majority of skin incisions, espe-cially on thicker skin, should not be made with scissors,because of this crushing action of the scissors blades. Somesurgeons do, however, use scissors to cut the thin skin of theeyelid. Most surgeons reserve scissors for the dissection ofdeeper tissue planes.

TYPES OF SCISSORS

In the Storz instrument catalog (storzeye.com, now a part ofBausch and Lomb), there are more than 50 pages showingover 200 types of scissors. For a view of ENT and plastic sur-gery instruments check out www.bauschinstruments.com.I hope that after reading the next several paragraphs youcan make a sensible choice in selecting the right scissors for

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Figure 1.6 Facial incisions are typically hidden in natural skin creases or placed next to anatomic structures for camouflage. A, Upper lid creaseincision extended into lateral canthal laugh line for lateral orbitotomy. B, Traditional Stallard�Wright lateral orbitotomy incision (rarely used). C,Modified Berke lateral canthotomy incision. D, Transcaruncular incision. E, Frontoethmoidal (Lynch) incision (rarely used). F, Upper lid crease incision.G, Vertical lid split incision. H, Subciliary incision. I, Transconjunctival incision for medial orbitotomy. J, Inferior transconjunctival incision. K, Gingivalupper buccal incision. L, Forehead furrow incision. M, Suprabrow incision. N, Pretrichial incision. O, Transcoronal forehead incision. P, Endoscopicbrowplasty incisions.

8 1 • The Art of Surgical Technique

the surgical step you are doing. Scissors vary in the follow-ing characteristics:

’ Length’ Caliber’ Tip sharpness’ Blade design’ Cutting motion

Let’s look at each of these characteristics briefly.

Scissors Length

Choose scissors of the proper length for the depth of thewound in which you are working. Most of the instrumentson the eye tray are 4 inches long. This size goes with thescale and depth of the usual ocular procedures. Longerinstruments would be less steady and bump into themicroscope. You will use many 4-inch instruments inoculoplastic surgery. Plastic surgery instruments are usu-ally 6 inches long and fit the normal hand size better, forinstance, a Metzenbaum scissors. In most cases, the longerneurosurgical instruments are not useful. For orbit sur-gery, on occasion, you may use a longer neurosurgicalscissors for the particular tip rather than the length(Yasargil scissors).

Scissors Caliber

In general, thicker scissors blades are used for tougher tis-sues. This is fairly intuitive. You would not use a delicateWestcott scissors to cut through the thick dermis of thecheek. Similarly, you would not use the tough Mayo scissorsto cut eyelid skin. Remember it is the blade tip size, notthe length of the instrument, that you should consider forthe delicacy of the tissue you want to cut. Many longer deli-cate instruments are also available.

Scissors Tips

The tip of a pair of scissors may be blunt or sharp. Blunt-tipped scissors are usually used for dissection in tissueplanes. Sharp scissors are used to cut through tough tis-sues such as scar tissue. A sharp-tipped Westcott scissorsworks better than a blunt-tipped Westcott scissors to openan eyelid cyst. Facelift scissors have slightly sharpenedrounded tips to facilitate flap dissection in the subcutane-ous plane.

Scissors Blade Design

Scissors blades are straight or curved (Figure 1.7). Moststraight scissors are used for cutting sutures and bandagesand are sometimes called suture scissors. It is easier to cuta straight line with straight scissors than with curved scis-sors, and vice versa. Remember to use the curve of thescissors blade to your advantage (the curve of the scissorsshould follow the curve of the eyelid crease, for example).Curved scissors are useful for tissue dissections. Thecurved angle of the blade lifts the tissue planes apart as thetip cuts the reflected tissue, which is placed on stretch.The curve of a scissors blade is easy to palpate through tis-sues. You will learn to protect tissues against the convexsurface of the curve. An example of this technique is sepa-rating the levator aponeurosis muscle from the underly-ing Müller’s muscle. As the two layers are pulled apart, fine

tissue bands are seen stretching between the tissue planes(learning to “pull” the layers apart is the most importantsurgical technical tip I can give you; more on this later).The convex surface of the scissors can slide up the fibrousbands and rest against the aponeurosis. Cutting can beperformed without buttonholing the aponeurosis(Figure 1.8). This technique is useful for separating anytissue planes. Another good example is separatingMüller’s muscle from the conjunctiva.

Scissors Cutting Motion

Scissors are composed of opposing blades held together by acentral pin. Most scissors close and open with opposite handmotions, stabilized by one or more fingers in the ring holes(often called ring scissors). You can control the force whenopening the blades, as well as the force when closing the

Figure 1.7 Blades of the straight Mayo scissors compared with thoseof the curved Stevens tenotomy scissors. Notice that the length andcaliber of the scissors are also different.

Figure 1.8 Dissection of levator aponeurosis from Müller’s muscleusing curved Westcott scissors. Note how pulling the tissues apartcreates bands of tissue that are easy to see and cut. The convex sideof the scissors blades should be against the tissue that is thestrongest, in this case, the aponeurosis.

1 • The Art of Surgical Technique 9

blades, with your hands. This allows you to use the scis-sors tips as a dissecting tool as you spread open the tissueplanes by opening the scissors. Spring scissors open withthe recoil of a spring mechanism in the handle of the scis-sors. Westcott scissors are an example of this type. Thesescissors are generally used for fine tissues where minimalhand motion is important (finger tools). The springaction determines the force of the opening of the blades.Stevens tenotomy scissors are ring scissors with slendercurved blades; they are common 4-inch scissors used fre-quently in ophthalmic procedures (see Figure 1.7). Irisscissors are a type of delicate, sharp-tipped ring scissorsdesigned with short blades that are either curved orstraight. Although the usage is technically incorrect, theterm iris scissors has almost become generic and has beenapplied to any pair of straight scissors used as suture cut-ting scissors.

Westcott scissors can be used as a spreading tool usefulfor separating delicate layers, for example, separating theconjunctiva from Tenon’s capsule, orbital septum from orbi-cularis muscle, Müller’s muscle from levator aponeurosis,conjunctiva from lower eyelid retractors, or any adjacentdelicate tissues from each other. Remember that dissectionis more about pulling layers apart and using the convex sideof the blades to tease the tissues away from each other thanit is about cutting the tissues.

Scissors cut by a shearing action. Most ring scissors aredesigned as right-handed cutting tools. Imagine holding apair of scissors in your hand. Push your thumb away fromthe palm and pull your fingers toward your palm. Thisaction squeezes the blades of the scissors more tightlytogether, increasing the cutting power. You may recalldoing this as a child playing with dull scissors. You quicklylearn that squeezing the blades together increases the cut-ting power. Try doing this with your left hand; thereis much less shearing action. This is why left-handedchildren (and techs and surgeons, as well) sometimeshave trouble cutting with right-handed scissors. Trysqueezing the blades together the next time you use a pairof scissors. Compare cutting sutures or tissues with yourleft hand instead of your right hand; you will appreciatethe difference.

CUTTING WITH SCISSORS (YOU LEARNED THIS AS ACHILD)

Spring scissors, or Westcott scissors, are held as finger tools,like a pencil. As with any scissors, you should gently squeezethe blades together in a continuous action. As the scissorscut, watch the tissue separate. Avoid clicking or snipping thescissors closed in one quick motion (close the scissors like youmay have been taught to slowly squeeze the trigger of a gunor a camera shutter release button). Quick motions do notallow you to evaluate the depth or length of the scissors’ cutas you proceed. Observing how the tissues spread apart asyou cut them is the very best way to stay in the correct sur-gical plane.

If you watch less-skilled surgeons or nurses cut yoursutures you see that they often snip away at them. This typeof cutting is too inaccurate for tissues.

As you proceed with cutting tissue, do not close theblades completely to the tips. You lose your place in the

wound if you close the scissors. Again, remember when youfirst learned to use scissors as a child. Initially, every timeyou cut a piece of paper, you would close the scissors bladescompletely. It was difficult to make a straight, continuoussmooth line. You had to start over each time you cut. Asyou learned to use the scissors better, you found that youcould more effectively cut a continuous line by closing thescissors halfway to two thirds of the way and then advanc-ing the blades forward. This is the same technique that youshould use in cutting tissue. As the blades cut approximatelyhalfway closed, push the blade forward in the same plane and cutagain. Do not cut with the full closure of the blade until theend of the incision.

Remember when cutting with curved scissors to positionthe curve of the scissors along the curve of the incision.Many of the incisions that youmake, such as the skin creaseincision, are curved.

When using a ring scissors, rest your middle finger in onering and your thumb in, or on, the other ring. Use this gripwith the index finger providing three-point fixation of thescissors (Figure 1.9). These larger scissors are useful as afinger-and-hand tool. You will find a comfortable thumband finger position, often not totally within the ring. Thesame cutting motion that is described above should beused with this type of scissors. You might want to practicethis technique on a piece of paper to make sure that youhave the idea. You may be using scissors in more than oneway already. Dr. Edgerton’s book nicely describes thefunction of scissors. Scissors can be used for cuttingsutures and tissue, functioning as shearing cutters.Scissors can be used to spread open planes as push cutters(Figure 1.10). Planes may be dissected using lateralsweeps or pull wedges. Small vessels may be squeezedclosed with the shearing action of scissors. Palpation ofthe curved blade of scissors can be used to help guide adeep tissue dissection.

CHECKPOINT

• Compare two types of scissors that you may be familiarwith: straight Mayo scissors and Stevens tenotomy scissors(see Figure 1.7). Mayo scissors come in many variations,

Figure 1.9 Holding scissors. Left, Ring scissors (a finger-and-handtool). Right, Westcott scissors, the most common spring scissors usedin eyelid surgery (a finger tool).

10 1 • The Art of Surgical Technique

so look at the scissors pictured. This variation is almost7 inches long and has thick straight blades with fairlypointed tips. The Stevens scissors are just over 4 incheslong and have thinner curved blades with blunt tips.Which scissors would be best for cutting sutures in adeep abdominal wound? The Mayo scissors, of course.The straight, thick, pointed blades are not well suited fortissue plane dissection. The shorter, curved, blunt-tippedblades of the Stevens scissors are ideally suited for thetissue plane dissection of the relatively superficial layersof the eyelid.

• Think of which layers of the eye or eyelid would beappropriate for Westcott scissors. Would you choosesharp or blunt Westcott scissors for a conjunctivalperitomy? The soft conjunctival and episcleral tissueswould tear if sharp-tipped scissors were used.

• Remind yourself how to cut tissue using a plain piece ofpaper. Draw a straight and a curved line. Try cutting theline in “snips.” Now try cutting the line with smooth

continuous strokes, not closing the blades completely.Which is easier, more accurate, and faster? Cut thestraight line with a curved scissors. Cut the curved linewith the curved scissors using the curve of the bladeswith the curve of the line. Now cut the curved line withthe scissors blades turned against the curve. You shouldbe getting the idea that learning how to use your toolscorrectly produces a better and faster result.

Retraction and Exposure

FINGERS AS RETRACTORS

One of the major differences between learning ocular sur-gery and oculoplastic surgery is learning how to manipu-late and retract tissues. Most of the retraction done in

A

C

B

Figure 1.10 Uses of scissors. (A) Shearing cutters. The normal cutting action of the scissors is shown with Westcott scissors trimming redundant skinand muscle off a lower blepharoplasty flap. (B) Push cutters. The blades are open halfway (top), and the tissue is cut by pushing the scissors againstthe tissue (bottom). A good example is the dissecting of Müller’s muscle off the levator muscle as shown in Figure 1.8. (C) Lateral sweeps or pullwedges. The blades are inserted closed and opened in the wound or as they are pulled out. The action is with the outside of the scissor blade (dullside). This can be used to create a dissection plane, for example, between the orbicularis muscle and the orbital septum. Scissors are typically usedin this fashion to open an abscess pocket.

1 • The Art of Surgical Technique 11

ocular surgery is done with a lid speculum. You will learnto use a variety of tools to hold the tissues. You are alreadyfamiliar with the best and gentlest retractor of all, your fin-gers. All of the fingers on your nondominant hand can beused to support or stretch the tissues. As you are working,you can hold a cutting tool in your dominant hand withyour thumb and first and second fingers and, at the sametime, use the ring and small fingers as retractors (visualizeholding a blade with the pencil grip and stretching the tis-sues with your other fingers, and then try to do this). Afinger covered with a gauze sponge helps to stabilize slip-pery tissues.

SKIN HOOKS

You may not be familiar with the use of a skin hook. This isone of the oldest surgical instruments and, when used cor-rectly, one of the gentlest retractors. Skin hooks are avail-able in different sizes and with varying numbers of prongs.The most useful skin hook for eyelid surgery is the Storzdouble fixation hook, a small double-pronged hook (StorzE0533; Figure 1.11). There are also small single-prongedhooks that can be used for very delicate tissues (Tyrell irishook, Storz E0548) and rake-type skin hooks with multipleprongs that are used for lacrimal surgery (Knapp lacrimalsac retractor, Storz E4538). A large double-pronged skinhook, known as the Joseph double hook (Storz N4730), isuseful for retraction of large tissue flaps. The Senn retrac-tor (Storz N3553) has large hooks on one end and a right-angled narrow blade retractor on the other end. This is agood all-purpose, soft tissue retractor for facial proce-dures. Obviously, you must be quite careful not to pull thehook toward the eye where inadvertent puncture of theglobe could occur.

FORCEPS

The most common type of instrument for holding tissue is aforceps. All forceps work the same, using a pinching actionof the fingers to grasp tissue. Forceps differ in length, caliber,and tip. Length and caliber differ for the same reasons as allinstruments in general. The tips of forceps can either besmooth or have teeth.

Smooth forceps generally cause more trauma than for-ceps with teeth. Because there is low friction on the tip ofsmooth forceps, more pressure is required to hold tissue.Consequently, the tissue tends to be crushed. Smooth forceps(Figure 1.12) are used mainly for tying sutures. On occasionforceps without teeth may be used on delicate tissues if con-cern exists about tearing the tissue using forceps with teeth.Variations of smooth forceps include diamond dusting andsmall serrations on the inner surface of the blades. Thesevariations increase the friction of the forceps and reduce thepressure required to grasp the tissue.

Jeweler-type forceps are the smooth pointed forcepsthat you are probably already using to remove delicatesutures (Storz E1947 1). Jeweler forceps do not grasptissue well.

Forceps with teeth offer a better grip with less crushing oftissue. You should use forceps with teeth whenever possible.Several types of forceps with teeth are available. The mostcommon form has two teeth on one blade opposing a single

tooth on the other blade. In general, forceps with multiplesmall teeth are more delicate than forceps with fewer andlarger teeth. As you grasp the tissue with forceps you shoulduse gentle pressure to close the tips. The teeth should notleave marks in the tissue.

As you get more adept at using surgical instruments,you may use the single tooth of a toothed forceps as a skinhook to lift and sometimes unroll a skin edge. This blade isknown as a lifting jaw. When grasping tissue, select thelayer of tissue that is the least susceptible to injury. It isbetter to grasp the dermis or subcutaneous fat than theskin edge directly.

Figure 1.11 Skin hooks (left to right): Large double-pronged (Joseph)skin hook, lacrimal rake, small double-pronged skin hook, smallsingle-pronged hook (Tyrell).

A

B

Figure 1.12 Forceps. (A) From top down: Adson forceps (large forcepswith teeth, for cheek and scalp), forceps without teeth (smooth), andPaufique forceps with teeth (the most common forceps that you willuse). (B) Forceps tips. Left to right: Adson forceps, smooth forceps,and Paufique forceps.

12 1 • The Art of Surgical Technique

The Paufique forceps are great for most periocular work.They have small teeth that grasp delicate tissues, but theblades and grip are stout enough to work with heavier tis-sues. Manhattan forceps are similar to Paufique forceps;they have the same blades but smooth grips on the handle.You should be familiar with lighter and heavier forceps withteeth. Useful more delicate forceps include the Castroviejosuturing forceps, more familiarly known as point 1�2, point3, or point 5 forceps, referring to the caliber of the teeth(Castroviejo suturing forceps E1796, E1797, and E1798,respectively). These forceps have a tying platform proximalto the teeth so the suture will not slip with tying. Heavierforceps useful in the cheek, scalp, and lower face includeAdson and Brown�Adson forceps (Storz N5405 andN5420).It is worthwhile to page through the Bausch and Lomb

Storz ophthalmic and ENT/plastic surgery catalogs (www.bauschinstruments.com). You will be amazed at the varietyof instruments available.

DISSECTION TECHNIQUE

Most surgery is not cutting but rather separating tissueplanes. This concept may be the most important in this text.The surgeon and assistant should pull the tissues apart asthe surgeon separates the tissues with the cutting tool. Forexample, to separate the orbicularis muscle from the orbitalseptum, the surgeon should hold the scissors in the domi-nant hand and grasp the muscle with the forceps in thenondominant hand. The assistant should grasp the septumwith another forceps. Working together, the two pairs offorceps pull the orbicularis muscle off the septum. You willsee small fibrous bands that are easy to separate with thescissors, Colorado needle, or laser (Figure 1.13). In a sense,your nondominant hand shows your dominant hand whatto do. It is easy to operate with an experienced surgeon asyour assistant because the layers are pulled apart for you.Use this technique whenever possible. There are a fewplanes in which using this technique is not possible. Forexample, in the subcutaneous plane of the cheek, you have

to sharply incise the tissues. Have an experienced surgeoncheck your dissection technique to confirm that you are cor-rectly pulling the tissues apart and separating the planeswith the cutting tool. This concept of dissection is so impor-tant. Read this paragraph again and make sure that youunderstand the principle. Consciously try it next time youare in the operating room.

Remember to avoid “snips,”; close the scissors slowly.Watch how the tissues open. This can be one of the mostelegant and rewarding of surgical techniques (Box 1.1).

RETRACTORS

There are three types of retractors:

’ Self-retaining retractors’ Handheld retractors’ Suture retractors

The Jaffe eyelid speculum is an excellent self-retainingretractor for eyelid surgery (Figure 1.14). This speculum

Figure 1.13 The surgeon and assistant work together to pull thetissues apart. Notice that the bands of tissue stretched between theorbicularis muscle and the orbital septum are easy to cut.

Box 1.1 Dissection Technique That You Must Know

’ Most surgery is not cutting; rather, it is separating tissueplanes.

’ Grasp the tissue layers that you want to separate (don’t holdthe skin when you are separating the muscle from theseptum).

’ Grasp the tissues close to where you want to work on them.’ Learn to pull the tissues apart as you cut with the scissors or

Colorado needle.’ Look for the fibrous bands that show up as you pull the

tissues apart.’ Separate the layers with controlled closure of the scissors

rather than short “snips.” Watch the tissues open as you closethe blades.

Figure 1.14 Jaffe eyelid speculum in place. The speculum can beused to open the surgical wound (as shown here for a lacrimal glandbiopsy), or it can be used to elevate an eyelid away from theoperating site. It is a useful tool in almost every eyelid procedure.

1 • The Art of Surgical Technique 13

was originally designed for cataract surgery to retract theeyelids independently without any pressure on the globe. Iuse this retractor in almost every lid procedure (www.katena.com, K1�8000, sold as a pair). Self-retaining retractors arerarely used in orbital surgery because it is difficult to positionthe retractors adequately in the orbit. The constant pressureon the tissue with a self-retaining retractor can limit circula-tion to the eye. There are self-retaining retractors made forlacrimal surgery, but I have not found these instruments tobe satisfactory.

Handheld retractors are useful but require a good assis-tant. The well-trained assistant will move the retractorsas the surgery proceeds from one area to another (goodassistants “dance” with the surgeon as they move acrossthe surgical field). When maximum retraction is not nec-essary, the assistant eases the pressure on the retractor toimprove the circulation. The most commonly used hand-held retractor for eyelid surgery is the Desmarres lid retrac-tor (size 1: 13 mm; Storz E0981) (Figure 1.15). The shapeof the Desmarres lid retractor is helpful for atraumaticallyretracting the tissues. Useful orbital handheld retractorsare the malleable retractors and the Sewall orbital retrac-tors. The flat-bladed malleable retractors are availablethrough a number of companies and come in straight andtapered varieties (symmetrysurgical.com and surgicalinstru-ments.com are good sources). Tapered malleable retractorsare helpful in deep wounds but require special ordering.Sewall retractors are commonly used to retract orbital tissues.A disadvantage of both malleable retractors and Sewallretractors is that towing-in of the retractor may damage tis-sues, especially those deep in the orbit (experienced orbitalsurgeons fear the towed-in retractor as a cause of blindnessmore than any cutting instrument). You will find thatorbital exposure is improved by lining the wound withneurosurgical cottonoids (similar to the lap sponges you usedto pack off the bowel as a general surgery student)(Figure 1.16). I prefer cottonoids of 1/2-inch width and 3-inch

length for deep orbit cases. The familiar nasal speculum is atype of handheld retractor.

Sutures can be used as retractors. No manipulation by asurgical assistant is necessary. As many sutures as neces-sary can be placed to provide good tissue exposure (4-0silk). Handheld retractors can be placed on top of the sutureretractors to give extra retraction when necessary. As withany other static or self-retaining retractor, if problems withcirculation are anticipated, suture retractors should beavoided or frequently released (Figure 1.17). Small hookson elastic bands can be used as retractors, as well. Thehooks can be easily repositioned as the need for a differentexposure comes up (http://www.medline.com/product/Lone-Star-Retractor-Hooks-by-Cooper-Surgical/Z05-PF65677).These hooks are best for larger facial or neurosurgicaldissections. You need to be extra careful with hooked instru-ments around the eye.

Figure 1.15 The Desmarres lid retractor is used similarly to the Jaffelid speculum but must be handheld. This retractor can be placed overa Jaffe lid speculum for extra retraction, a useful combination. Here,the Desmarres lid retractor is opening a skin crease incision to drain asuperior orbital abscess.

Figure 1.16 Orbital retractors (top, left to right): malleable retractorsand Sewall retractors. (Below) Neurosurgical cottonoids.

Figure 1.17 Use of 4-0 silk suture retractors for exposure of anexternal dacryocystorhinostomy wound.

14 1 • The Art of Surgical Technique

Hemostasis

PREOPERATIVE CONSIDERATIONS

Achieving hemostasis is another new technique for mostophthalmic surgeons. You need to master some simple tech-niques for controlling bleeding if you are going to do eyelidsurgery safely. Effective hemostasis technique begins withusing an injection of local anesthetic with epinephrine(1/100,000) in every operation on the face. You shouldalways inject the local anesthetic before prepping thepatient and scrubbing, allowing about 10 minutes to passto achieve maximum hemostasis.Your time in the operating roomwill be shorter, and your

patients will suffer less postoperative bruising, if you remindthem to stop taking anticoagulant medications before surgery.General recommendations are as follows. Warfarin shouldbe stopped 5 days preoperatively with the consent of thepatient’s internist. Aspirin-containing products and otherplatelet aggregation inhibitors (e.g., clopidogrel, ticagrelor,or Aggrenox [ASA and dipyridamole]) should ideally bestopped 10 days before surgery. Nonsteroidal antiinflamma-tory medications should be stopped 3 to 5 days before sur-gery. There are many newer anticoagulant medicationsused as alternatives to warfarin. It is best to have yourpatient consult with the primary care doctor before disconti-nuing these medications. In some cases, bridging therapywith enoxaparin may be required. Under some circum-stances, operating on a patient who is anticoagulated maybe necessary, but to minimize the chances of hemorrhage,you should stop anticoagulants whenever reasonable. Thatbeing said, at times I do perform procedures for a patientwho is still taking anticoagulants. Obviously, traumapatients don’t have time to stop anticoagulants.There are no evidence-based studies that define the appro-

priate way to deal with anticoagulants prior to eyelid andorbital surgery. Damaging hemorrhage after these operationsis rare and consequently difficult to study in a randomizedfashion. Studies in the neurosurgical and dermatologic litera-ture suggest a less strict approach to discontinuing anticoagu-lants. You should consider any negative systemic effects ofdiscontinuing anticoagulants, prior to making any recom-mendations to your patients. In most cases, it is best to havethe patient consult with his or her primary care doctor aboutthe safety and duration of discontinuing anticoagulants. Asmany as one third of your adult patients are taking one ormore of these medications. This is an evolving discussion andlikely will continue to change over the next several years. Thebottom line is that a decision regarding anticoagulants shouldbe made on an individual basis in consultation with thepatient’s primary care physician.Most patients do not consider aspirin and other over-the-

counter medications as being important when you askwhat medications they are taking. You must ask specificallyabout these medicines. A long list of herbal remedies canaffect coagulation, especially when used in combinationwith other anticoagulants. Among others, the three G’s(garlic, ginseng, and ginkgo) should be stopped before anoperation. More than 3 g per day of fish oil can affect hemo-stasis. High doses of vitamin E can negatively affect coagula-tion, as well.

TAMPONADE

An easy way to temporarily control bleeding is tamponade.Your finger, a gauze pad, or a cotton swab compressing thebleeding tissue against bone will stop most bleeding epi-sodes. Similarly, you can obtain hemostasis by pinching thetissue between your fingers or in a forceps. This is usually atemporary measure, but it will minimize blood loss and facil-itate your attempts to use cautery. An example of this is thebleeding that occurs after a wedge resection of the lid. Themarginal artery usually bleeds. By holding the lid marginbetween the blades of the forceps, you can control the bleed-ing while you apply bipolar cautery.

If the point of bleeding cannot be identified, the woundmay be packed with a gauze sponge to control bleeding. As thepacking is removed, you may be able to isolate individualbleeding spots.

Most arteries encountered in oculoplastic surgery do notrequire clamping and tying to gain control of bleeding.However, placing a small hemostat on a bleeding arterymay facilitate your attempts to use cautery. For larger arter-ies, suture ligatures or vascular clips can be used, but this isusually necessary only in large orbital procedures. You canavoid bleeding in enucleation surgery by clamping the opticnerve before cutting it. This requires some practice butleaves a dry orbit after the removal of the eye. The stump ofthe optic nerve can be cauterized and the clamp removed.

CAUTERY

You must learn how to use cautery to do eyelid surgery.Three types of cautery are available:

’ Heat’ Bipolar cautery’ Unipolar cautery

Battery-operated handheld cautery units can be used for smallareas of bleeding. In general, these are too inefficient for any lidsurgery other than the smallest procedures, such as lid biopsiesor chalazion incision and drainage. There are several brandsavailable. The high-temperature model is best for perioculartissues. You can control the temperature of the heated wiresomewhat by turning the cautery unit off and on. If youdepress the finger switch on continuouslywhile you apply cau-tery, the tip gets very hot (more than 2000� F) and will burnthrough the tissue, often causingmore bleeding. On occasion, Iuse the hot tip as a cutting and cautery tool for dissection ofdelicate vascular tissues, as in the separation ofMüller’smuscleand the levator aponeurosis muscle, and it works nicely.Remember to turn off any supplemental oxygen when usingthis tool. Under certain conditions, a fire can result.

Bipolar Cautery

Bipolar cautery is commonly used in oculoplastic surgery.Because the current passes between the tips, there is littlespreading of tissue damage. Normally, the tissue is wet enoughto conduct the current between the cautery tips (this type ofcautery is also referred to as a wet field cautery). Many sur-geons accustomed to doing ocular surgery have a difficult timeusing bipolar cautery for eyelid surgery. The main problem is

1 • The Art of Surgical Technique 15

holding the cautery tips too closely together, preventing ade-quate amounts of tissue from being cauterized. The currenthas to flow through the tissue held between the cautery tips toaffect coagulation. Using a bipolar cautery with nonstick tips(Weck Biceps coagulator with nonstick tips) works well. Likeother instruments, bipolar cautery forceps aremade in differentlengths with different tips (the jeweler forceps tip is a good sizefor eyelid operations).

You must become adept at bipolar cautery to do eyelidsurgery. Consider these three steps:

’ Exposure’ Tamponade’ Cautery

Your assistant should provide exposure of the bleeding areawith fingers, handheld retractors, or forceps. If there is consider-able bleeding, the assistant can provide a temporary tampo-nade with a gauze pad while you ready a cotton-tippedapplicator and the bipolar cautery tool.Bipolar cautery techniqueis easiest if the surgeon, rather than the assistant, applies the tampo-nade (the roles can be reversed, but the same person using thecautery tool should provide the tamponade). The surgeonplaces the bipolar tips in proximity to the cotton-tipped applica-tor. The applicator is rolled away from the bleeding site, andcautery is applied immediately. If bleeding is brisk, you may beable to provide tamponade on the tissues proximal to the bleed-ing site to decrease the flow of blood. If this does not work, suc-tion can be used to provide exposure of the bleeding vessel.

Unipolar Cautery

Unipolar cautery (also called monopolar cautery) can pro-vide periocular hemostasis. The most useful form of unipolar

cautery is the microdissection or microsurgical needle dis-cussed above. When placed on the blend mode this needleprovides simultaneous cutting and cautery and reduces thebleeding of soft tissues dramatically. Keep in mind that thereis some collateral tissue damage when using a unipolar sys-tem, so the power settings should be as low as possible forcoagulation (on our machine, 12 cut/12 cautery/12 bipolarblend mode). Your hands usually move more slowly whenyou are a beginner. You might consider using a slightlylower setting on cut and cautery to minimize the spread ofthe current. As you may have figured out by now, this nee-dle is often referred to as the Colorado needle, the proprie-tary name of the original product. The microdissection (ormicrosurgical) needle should not be confused with thebroader needle of other unipolar systems. The tungsten tipof the microdissection needle is much finer and causes lessthermal damage to the surrounding tissue. Unipolar cau-tery with a wider flat blade is used only when all otherattempts to stop bleeding fail. Remember that teamwork isnecessary for efficient hemostasis techniques. A helpfulassistant can make a big difference.

In my opinion, a smoke evacuation system is necessarywhen using this instrument (Figure 1.18). The smoke plumecan contain toxic gases and vapors (such as benzene, hydrogencyanide, and formaldehyde), bioaerosols, dead and live cellularmaterial (including blood fragments), and viruses. Breathingthe smoke can cause respiratory symptoms. No reported infec-tions due to smoke inhalation have been confirmed so far. Invitro studies have shown amutagenic potential.

Surprisingly, many operating rooms do not routinely usethese units. Most commonly I use a suction hose (smoke evac-uation wand) attached to an air filter machine (buffalofilter.com). This requires that the scrub person use a free hand tovacuum the smoke. As an alternative, vacuum attachments

A B

Figure 1.18 Smoke evacuating system. (A) A handheld flexible hose may be attached to a smoke evacuator (e.g., see www.buffalofilter.com).(B) Alternately, a smoke evacuation “pencil” may be used, which combines the handle of the microdissection needle and the suction tubing (e.g.,Buffalo Filter PlumePen Pro or PlumePen Elite). (A courtesy CONMED, Utica, NY.)

(A courtesy of Buffalo Filter, Lancaster, New York.)

16 1 • The Art of Surgical Technique

that fit directly on the cautery handle can be used. Although Ifind that these can be a bit bulky, they do make the smokeevacuation process easy (see Figure 1.18).

BONE WAX

You will encounter bleeding from small perforating vesselsin bone. Bipolar cautery will not stop this bleeding. Unipolarcautery can be used to provide hemostasis in bone becausethe current spreads directly into the bone. As a better alter-native, you can use small pieces of paraffin or bone wax toplug the bleeding sites. The surrounding bone must be dryto get the wax to stick.Placing a small amount of bone wax on a Freer elevator

and spreading it over the bleeding bone works well. A goodalternative in deeper surgical wounds is to put a tiny ball ofwax on the end of a cotton applicator and push/twist theapplicator onto the bleeding bone. For larger, easily accessi-ble areas, bone wax on your finger works well.

DRUGS

We have already talked about the preoperative use of epineph-rine in the local anesthetic (1/100,000 or 1/200,000) todecrease bleeding. You will notice the effect of the epineph-rine on the surgical site by the blanching of the injectedarea. Similarly, injections can be used intraoperatively foradditional vasoconstriction. Initially, the hydrostatic pres-sure effect of the injected fluid into the tissue helps controlcapillary bleeding, as well. You can apply 0.05% oxymeta-zoline or 5% cocaine solution topically to the nasal mucosato cause vasoconstriction. Agents such as Gelfoam, Avitene,and Surgicel can be used to promote clotting, increasingplatelet activation. Surgicel is now available in a powderedspray, which is useful when you encounter nasal mucosalbleeding. Thrombin (topical Thrombogen) works a step laterin the clotting cascade, stimulating the conversion of fibrin-ogen to fibrin. A small piece of Gelfoam soaked in thrombinsolution as a packing material is an excellent way to stoprecalcitrant bleeding from the nasal mucosa (because itenhances platelet aggregation and fibrin formation).If you start constructing bigger flaps or doing reconstruc-

tive craniofacial work, you will become familiar with pro-ducts that can be “lifesaving.” To stop troubling bleedingor cerebrospinal fluid leaks, FLOSEAL and TISSEEL (www.baxter.com) are especially helpful. FLOSEAL containsbovine thrombin suspended in gelatin granules, so themechanism is similar to the Gelfoam/thrombin combina-tion. The mix sticks to wet tissue and does not swell to thedegree that Gelfoam does. TISSEEL (a fibrin glue) containshuman fibrinogen, bovine thrombin, and an antifibrinolyticagent (to stabilize the clot). FLOSEAL tends to be more usefulfor cranioorbital applications, but you should know aboutboth. Stammberger Sinu-Foam (carboxymethylcellulosefibers mixed with saline in a syringe) and similar productsare designed for endoscopic sinus surgery to control bleed-ing, prevent adhesions, and improve mucosal healing. Yourneurosurgical and ENT colleagues can give you tips on howto use these materials.Occasionally, special situations occur in which hypoten-

sive anesthesia can be used to reduce bleeding. This tech-nique is not commonly used in the United States. You willfind that when removing vascular tumors, preoperative

intraarterial embolization of large vessels to minimize bleed-ing encountered during surgery is very helpful.

DRAINS

Suction drains can be used postoperatively to increasehemostasis and decrease swelling and the risk of infection. Ifyou are performing surgery involving large flaps, active suc-tion devices (grenade type) attached to a Jackson�Prattdrain are helpful. Some surgeons use passive drains, such asPenrose or rubber band drains, routinely for orbital surgicalprocedures. I rarely use drains with periocular procedures.For large reconstructive facial flaps and facelift procedures,drains can be helpful. Remember that a drain is not a substi-tute for intraoperative hemostasis.

SuctionSuction is a useful technique to clear unwanted blood, irri-gation fluid, or other fluid from the surgical site to increaseexposure of the operative wound. Three types of suction tipsare used in oculoplastic surgery (Figure 1.19):

’ Flexible suction catheter’ Yankauer tonsil suction tube’ Frazier and Baron suction tubes

The flexible suction catheter can be used to suction bloodand irrigation fluid out of the nostril when you are perform-ing tear duct surgery. It is also useful to pass this catheterdown the nasopharynx to remove fluid before extubation.The Yankauer tonsil suction tube is an all-purpose suctiontip used primarily in wide surgical wounds when a large-bore general suction device is needed, but it can be used inthe throat, also. The Frazier suction catheter is the mostuseful suction device for oculoplastic surgery. This metalangled catheter (9 French) provides directed and accuratesuction to individual bleeding sites. A small version of theFrazier suction catheter is called the Baron catheter (avail-able as a 3, 5, or 7 French). Most suction catheters have aport that can be occluded to increase the pressure. For mild

Figure 1.19 Suction types (top to bottom): Yankauer tonsil suction,Frazier suction tubes, Baron suction tube, and flexible suction catheter.

1 • The Art of Surgical Technique 17

bleeding, this port does not need to be occluded. Whenmorebleeding is present, the port may be occluded to give moresuction. When dealing with tissues that are easily suckedinto the catheter tip, such as orbital fat or brain, you shouldsuction over a gauze pad or neurosurgical cottonoid to clear thefluid without damage to the underlying tissue.

Smaller suction tips get occluded easily and require irriga-tion of the suction tube with clear fluid as necessary. Youmight find that clamping the suction tubing when it is notin use makes the operating room quieter.

The rigid suction tubes can also be used to provide gentleretraction of tissue. For the most effective control of bleed-ing, the surgeon should use the suction tube and the cau-tery tool simultaneously, rather than the assistant andsurgeon each holding one.

CHECKPOINT

• What is the best retractor?• How are forceps with teeth like retractors? Which isgentler: forceps with teeth or smooth forceps?

• Try the Jaffe lid speculum on the next ptosis procedureyou perform (your operating room may have to orderone for you).

• Review the different types of self-retaining and handheldretractors. When you place suture retractors, try placingthem at the intersection of the thirds on each side of thewound.

For cautery with an assistant, there are four hands avail-able. The assistant’s hands provide retraction, usually withtwo pairs of Paufique forceps or skin hooks. The surgeon’shands hold a cotton-tipped applicator (or gauze or suction)and the cautery tool. The surgeon’s steps for bipolar cau-tery are:

• Apply tamponade with the cotton-tipped applicator.• Ready the cautery tool.• Release the bleeding vessel: Slowly roll the cotton-tippedapplicator away to expose the exact point of bleeding.

• Coagulate the vessel (making sure you have enoughtissue between the blades).

Ask the operating room nurses what types of suctiontips and drains are available in your operating room.This is a good time to remind you to get the big picture.

Don’t worry about the name of each instrument or thepart number of each suture needle. They are there foryour reference later. Skip over the details. Learn the mainpoints as you go through the text the first or second time.You will pick up the details as you need them.

Suturing

TYPES OF SUTURE MATERIAL

Suture material varies in three basic characteristics:

’ Absorbable or permanent’ Monofilament or multifilament’ Natural fiber, synthetic, or metal wire

Absorbable sutures degrade naturally over time, so noremoval is required. Common absorbable sutures are madeof gut (fast-absorbing, plain, and chromic), polyglactin 910(Vicryl), polyglycolic acid (Dexon), poliglecaprone 25(Monocryl), or polydioxanone (PDS). These sutures vary indegradation time from 5 days to a few months. Permanentsutures do not degrade in human tissue. Examples includenylon, polyester, polypropylene (Prolene), and stainless steelsutures. These sutures can remain indefinitely in a deep clo-sure but must be removed if used on the skin.

Monofilament sutures are made of a single strand of mate-rial.Multifilament sutures are made of braided strands of sin-gle filaments. Monofilament sutures cause less tissuereaction and are easier to pull out than multifilamentsutures. Braided sutures are easier to handle than monofila-ment sutures (said to have a better “hand”). Multifilamentsutures have a higher coefficient of friction and thereforemaintain tension on a wound and hold a knot better thanmonofilament sutures. You need to use the 3-1-1 tie withmonofilament sutures, but you can usually use a 1-1-1 tiewith braided sutures. Silk sutures (permanent multifilamentbraided sutures) are considered the gold standard in termsof handling and tying. Manufacturers sometimes combinecharacteristics to make a more versatile suture. An exampleof this is braided nylon sutures, which are permanentsutures with little tissue reactivity; they have a better handthan monofilament nylon.

Natural fibers, including silk and gut, are available.Chromic sutures are gut (collagen) sutures that have beentreated for greater resistance to absorption. Fast-absorbinggut sutures are used on the skin and are reabsorbed in 5 to7 days. Synthetic sutures include nylon, polyester, Prolene,and expanded polytetrafluoroethylene (PTFE or Gore-Tex).Wire sutures, usually stainless steel, are used in some typesof fracture and telecanthus repairs. Skin staples can be usedin the scalp where a less precise closure is necessary.

You might notice that we have not mentioned glue sofar. Surgical skin adhesives can be useful but really havenot caught on much at this point. Dermabond Advanced(Ethicon) is an alternative for sutures. You can use it on smalllacerations in children and avoid the local anesthetic. I haveused it on external dacryocystorhinostomy incisions andfunctional skin crease incisions with good success, and it isused in many other areas of surgery. It is helpful to put oint-ment on the skin around the wound where you do not wantthe glue to adhere. I expect we will see more use of surgicalglues in the coming years. Youmaywant to give them a try.

The choice of suture material depends largely on the sur-geon’s experience and individual preference. As you can see,there is no perfect suture, but rather there are many goodmaterials fromwhich to choose. If you are interested in detailedclosure choices, read on. If not, skip to the section on needles.

These are the common suture choices for me. In the last5 years I have moved away from absorbable sutures formost cases. Absorbable sutures tend to scar more, oftenuntie or break, and frequently are not entirely gone at 1week, causing the patient some consternation. Sometimessuture tracks form. The benefit of absorbable sutures is thatthey do not have to be removed (and patients don’t like tohave sutures removed), and no need for removal means sav-ing some time postoperatively in the office, but usingProlene sutures makes removal easy. The suture material is

18 1 • The Art of Surgical Technique

slick, and it is easy to pull out an entire running suture. Ioften put two extra interrupted sutures in the skin creaseprior to placing a running closure. The blue color of thesesutures makes them easy to see, especially around the eye-brow hairs. In cases where you are trying to end up withthe least possible amount of scarring, a subcuticularProlene suture removed at 5 to 8 days is a nice option (seebelow). For subcutaneous closure, I use PDS sutures (orsometimes Vicryl). There is a tendency for Vicryl sutures to“spit” (that is, sterile abscesses may rise to the surface as thesutures become absorbed). The monofilament absorbablesutures, PDS and Monocryl, do not do this, but they requiremore careful knot tying because they are slipperier. Clearsutures do not show through thin skin but are more difficultto place. Silk sutures (4-0) placed with a cutting needle aremymain choice as a tissue retraction suture.

TYPES OF NEEDLES

Several types of needles are available. Needles have the sameparts but vary by shape, size, and point (Figure 1.20) as follows:

Shape’ 3/8 circle’ 1/2 circle’ 1/4 circle

SizePoint

’ Tapered’ Cutting’ Reverse cutting’ Conventional cutting’ Spatula

The most common shape is the 3/8-circle needle (seeFigure 1.20B). These needles are used for all general-purposesuturing. Other shaped needles are used for special purposes.

The half-circle needle is used to suture in tight spaces.These needles are often used. The most common use for ahalf-circle needle in oculoplastic surgery is to attach the lat-eral tarsal strip to the periosteum (4-0Mersilene, braided poly-ester, Ethicon 1779G, double-armed S-2 spatula needle). 4-0Polydek with a half circle is another good choice (TeleflexDeknatel, Inc., “silky” II Polydek double-armed ME-2 half-circle needle; www.teleflex.com). The sharp curve of the nee-dle is ideal for reaching between the periosteum of the lateralorbital rim and the orbital tissues. The 4-0 Mersilene andPolydek sutures are permanent and do not cause as manysuture granulomas as 4-0 Vicryl sutures. I use a double-armed suture that nicely “tucks in” the strip against theperiosteum. The mucosal flaps of an external dacryocystorhi-nostomy can be closed with a short half-circle needle (only

Point

Body

Swaged end

3/8

1/2

1/4

Taper Conventional cutting Reverse cutting Spatula

A

C

B

Figure 1.20 (A) Needle shapes. (B) Needle parts. (C) Needle points.

1 • The Art of Surgical Technique 19

8 mm) and a chromic gut suture (Ethicon 798; 4-0 chromicgut G-2 half-circle cutting needle). The 6-0 chromic needlewould be a better choice, but the available 11-mm needle istoo long. Because the mucosa heals fast and is not under ten-sion, a chromic suture is used. G-2, S-2, and ME-2 are all des-ignations for short half-circle needles. In oculoplastic surgery,5/8-circle needles are rarely used.

The needle point will determine how easily sutures passthrough tissue. Two types of needle points are available:taper and cutting (see Figure 1.20C). Taper-point needlescome to a sharp point and push through tissue. There is nocutting edge of the needle. Taper needles are used in delicatetissues such as bowel (and conjunctival blebs). In oculoplas-tic surgery, taper needles are used for bridle sutures underextraocular muscles to minimize injury to the muscle ifpenetrated.

Most needles you use are cutting needles. Cutting needleshave sharpened edges along the curvature of the needle.Rather than push through the tissue, these needles cut thetissue, facilitating penetration of the needle throughthe tissue. The two common types of cutting needles avail-able are:

’ Reverse cutting needle’ Conventional cutting needle

The most commonly used needle is the reverse cutting needle.This needle, when viewed on end, appears as an up-ended tri-angle (see Figure 1.20C). The sharp edges of the needle areon the outer curvature.

The conventional cutting needle, when viewed on end, is atriangle pointed upward. The sharp edge of the cutting needleis on the inner curvature. Typically, a conventional cuttingneedle creates a bigger hole in the tissue than a reverse cut-ting needle. The natural motion of passing a needle tends topull the needle superiorly out of the wound. If the cuttingblade is facing upward, the needle tends to cut superiorly aswell as along the needle pass. The reverse cutting needleeasily pushes through the tissue without enlarging the nee-dle tract.

Several variations of cutting needles are available. Themost common variation is the spatula needle (seeFigure 1.20C). The spatula needle is designed to passthrough tissue in a lamellar fashion. Spatula needles areuseful when you want to pass a suture in a lamellar fash-ion through thin tissues, such as the sclera or tarsus. Youhave likely used a 5-0 Vicryl spatula needle to reattach aneye muscle to the sclera. Many surgeons use a spatulaneedle to reattach the levator aponeurosis to the tarsuswhen performing a ptosis operation (more on that in acouple of sentences).

Many other variations of taper and cutting needle pointsare available. For example, I like a cardiac taper-point nee-dle (C-1 needle, Prolene, Ethicon 8235H (5-0) and 8306H(6-0)) as a tarsal suture and as a general skin closure needle.To help you appreciate the differences in needle points, com-pare passing a taper needle with a cutting needle of thesame size and shape. Try to pass a tapered 4-0 silk suturethrough the lid margin as a traction suture. Repeat thesame needle pass with a 4-0 silk suture on a reverse cuttingneedle. There is an amazing difference in the way the needleis passed.

The size of the needle corresponds to the size of the suture.This choice largely depends on how much strength isrequired to keep the tissues sewn together. Thicker tissuesunder greater tension require larger sutures. Often, thechoice of needles and suture size is a process of elimination.A smaller suture would break and a larger suture seemstoo big.

The next time you are in the operating room, ask thenursing staff to show you the suture packs. There is a dia-gram of the needle shape and point on each package. Youare guaranteed to be overwhelmed if you browse theEthicon suture catalog online. It has some good illustrationsshowing comparisons of needle sizes and shapes that areuseful when you are looking for a new suture and needle.You might find it interesting to look at some of the needleand suture brochures available from the major suture man-ufacturers (often they are available in the operating room).The thought that go into the development of these super-sharp stainless steel needles, as well as their fine detail, isimpressive but often taken for granted.

NEEDLE HOLDERS

Two types of needle holders are used in oculoplasticsurgery:

’ Spring handle (Castroviejo needle holder)’ Ring handle (Webster-type needle holder)

The most common needle holder is the Castroviejo needleholder. This spring-action needle holder is excellent for thedelicate work of oculoplastic surgery. The Castroviejo needleholder is held with the traditional pencil grip because it is afinger tool (Figure 1.21). The index finger and thumb con-trol precise movements for delicate suturing. I prefer thelocking variation of the Castroviejo needle holder. It shouldnot be used for needles larger than 4-0, however.

The traditional plastic surgery ring handle needle holderis used for 4-0 or greater sized needles. The most commonlyavailable ring handle needle holder is the Webster needle

Figure 1.21 Holding the needle holder. Left, The pencil grip of thespring (Castroviejo) needle holder. This is the most common needleholder that you will use. Right, The thumb/ring finger grip of a ringhandle (Webster) needle holder.

20 1 • The Art of Surgical Technique

holder. This type of needle holder is held with the thumb/ring finger grip. The index finger serves to direct the tip of theneedle holder. This grip allows the needle holder to be usedwith finger, hand, and wrist motions (Box 1.2).The needle should be loaded on the needle holder approx-

imately three fourths of the way back on the needle. If youlook at a larger needle, you will notice that there is a flatplatform that ends where the suture is swaged onto the nee-dle (see Figure 1.20A). If you hold the needle on the roundpart of the needle holder, you will lose control and the nee-dle will rotate.

SUTURING TECHNIQUE

Passing the Needle

Let’s talk about the passage of a single stitch. You haveselected the appropriate size, curve, and point of the needleand have positioned it properly in the needle holder. Youare holding the needle holder with either the pencil grip fordelicate surgery or the thumb/ring finger grip for a conven-tional needle holder. Now position your body comfortably,facing the wound directly. If you are right-handed, it is easi-est to suture from left to right so that the tail of the suture isaway from the site of the next needle pass. Always suturewith your dominant hand. Most of the thin skin in the perio-cular area requires fixation with forceps to facilitate the nee-dle pass. Efficient suturing techniques require that youcontrol the tissues, that is, get the tissues to act the way thatyouwant them to act. Grasp the tissue lightly with the toothof the forceps very close to where you want to place the nee-dle point. Place the point of the needle directly adjacent to theforceps and drive the needle through the tissue followingthe curve of the needle, pushing the needle toward yourchest. Take note of the depth at which the needle emergesfrom the wound. Grasp the near side of the wound and placethe tip of the needle at the same depth. Continue passing theneedle until the needle holder touches the skin and the passis complete. Regrasp both wound edges directly adjacent tothe needle and begin to pull the needle out of the wound. Donot grasp the tip of the needle. Advance the needle until youcan regrasp it three fourths of the way back, so you can loadthe needle for the next suture pass (Figure 1.22).An alternative technique is to pass the needle through

the wound and then grasp the curve of the needle with theforceps and pull it out. As the needle is being pulled out, youuse your needle driver to reload the needle. My preference isthe former method. You might try both. The important partis not to spend a lot of time reloading the needle. Practicereloading the needle as you pull it out. This is a good exer-cise to do at home. Borrow a needle holder and suture.Practice with suturing fabric or even passing a suturethrough the skin of an orange or apple. You will save lots oftime in the operating room by learning more and gettingmore experience ahead of time. Then, in the operatingroom, you can learn the things that only operating roomexperience can teach you!Recently, I have begun using a helpful long-time suturing

technique. Hang a single-prong iris skin hook from the endof the wound. This puts the wound under some tension, sta-bilizes the edges for suturing, and helps with spacing. Thetechnique works well for upper eyelid skin crease incisions.

Superficial and Deep Sutures

Suture placement can be considered either deep or superfi-cial.Deep, or buried, sutures are used to close the subcutane-ous or deeper layers of tissues. These sutures close deadspace, provide wound stability, and remove tension fromthe final skin closure. Deep sutures are not required on theeyelid skin but are used in the periocular area. Deep suturepasses may be placed through periosteum, muscle, subcuta-neous fat, or the dermis of thicker skin. Any dead spaceshould be closed with deep sutures to prevent hematomaformation. Deep sutures may be used to anchor skin andmuscle flaps and provide fixation and usually some degreeof anatomic overcorrection. Long-lasting absorbable suturematerial (such as PDS, Vicryl, Dexon, or Monocryl) is usu-ally used for buried sutures. My personal preference is PDSsuture for most subcutaneous closures.

Superficial sutures are placed on the skin. Superficialsutures may be either interrupted or running (continuous).Interrupted sutures provide accurate wound alignment andappropriate eversion of the wound edges. When repairing acomplex laceration, you can use interrupted sutures ini-tially to tack together the wound in an anatomically correctalignment. When you are suturing a long wound, a goodplace to start is to divide the wound into halves with inter-rupted sutures. This prevents misalignment of the woundedges and the creation of a dog-ear at one end of the wound.

You can use running or continuous sutures to close inci-sions placed in natural skin creases or wrinkle lines becauseslightly more inversion of the wound may occur. Runningsutures are faster to place and easier to remove than inter-rupted sutures. Generally, I use a continuous runningsuture with 6-0 Prolene to close eyelid incisions. Often, Iplace two interrupted sutures at the junction of the thirds ofthe wound to fix the skin crease at the top of the tarsus. Ialso place an interrupted suture at the most lateral end ofthe wound to prevent the bunching that can occur when arunning suture is tied. This was a common complaint of mypatients until I started adding this single interrupted sutureto the running closure.

Some surgeons close the skin crease using a “subcuticu-lar” suture. This suture enters the end of the wound, andthe trailing end is tied on itself. The needle is passed in andout of the wound edges in a plane parallel to the skin sur-face. The suture travels through the most superficial portionof the orbicularis muscle (“subcuticular” here is really amisnomer; there is no subcutaneous layer of the eyelidskin). At the end of the wound, the needle is broughtthrough the skin and the suture is tied on itself. After about1 week, the knot at one end of the wound is cut and thesuture is pulled out. Prolene suture, 6-0, is ideal for this clo-sure as it is slippery and easy to pull out. Remember thatProlene requires a 3-1-1-1 tie to ensure a secure knot.

For wounds outside of skin crease lines, it is best to useinterrupted sutures to give better wound eversion, prevent-ing a depressed scar. Two types of interrupted sutures areused to close the surgical wound:

’ Simple suture’ Vertical mattress suture

Simple suturing is the most commonly used interruptedsuturing technique (Figure 1.23A). When correctly placed,

1 • The Art of Surgical Technique 21

Box 1.2 Sutures for Oculoplastic, Orbital, and Lacrimal Surgery

2-0 Sutures’ 2-0 Vicryl: strong stitch to use as deep anchoring suture on cheek flaps (Ethicon J328H CT-3 taper point)’ 2-0 Vicryl: strong smaller reverse cutting needle also good for anchoring flaps (Ethicon J459H X-1 needle)’ 2-0 PDS: good anchoring suture for SMAS lift procedures, longer lasting than Vicryl (Ethicon Z317H 26-mm SH taper point, violet)’ 2-0 Prolene: used for suturing scalp to skull bone tunnels during endobrow operation (RB-1 17-mm 1/2-circle 8559H)

3-0 Sutures’ 3-0 Vicryl: strong small reverse cutting needle good for anchoring flaps and deep closure in scalp and cheek (Ethicon J458H X-1 needle)’ 3-0 Vicryl: strong smaller taper needle and stitch good for anchoring sutures in tight areas for cheek or scalp flaps (Ethicon J305H RB-1

needle)’ 3-0 PDS: similar to Vicryl, above, but longer lasting. Clear suture is good for anchoring facial flaps (Ethicon Z423H 19-mm FS-2 reverse

cutting, clear)’ 3-0 PDS: similar to Vicryl, above, but longer lasting. Violet suture is helpful in hair-bearing areas (Ethicon Z398H 19-mm FS-2 reverse

cutting, violet)’ 3-0 PDS: deep cheek lifting suture (Z497G PDS2 PS-2 19-mm 3/8-circle reverse cutting)’ 3-0 Mayo trocar: for threading fascia during frontalis sling (Richard�Allan 216703, www.aspensurgical.com)

4-0 Sutures’ 4-0 chromic: long reverse cutting needle for Quickert suture and suturing oral mucosa (Ethicon 793G G-3 needle, double-armed)’ 4-0 chromic: short half-circle needle useful for suturing the flaps for external dacryocystorhinostomy (Ethicon 798G G-2 needle, double-

armed)’ 4-0 Vicryl: short 1/2-circle reverse cutting needle, useful for tight spaces that require subcutaneous closure or anchoring (cheek tissue at

lateral canthus) (Ethicon J504G P-2 needle)’ 4-0 Vicryl: short reverse cutting needle for subcutaneous closure (Ethicon J464G P-3 needle)’ 4-0 Vicryl: longer reverse cutting needle for brow closure (Ethicon J682H PS-1 needle)’ 4-0 Vicryl: shorter and sturdier than the PS-1 needle, good for tight spaces (Ethicon J496G PS-2 reverse cutting needle)’ 4-0 PDS: for subcutaneous flap suture (Ethicon Z494G 13-mm P-3 needle reverse cutting, clear)’ 4-0 PDS: anchoring suture for subcutaneous closure in hair-bearing areas (Ethicon Z513G 19-mm PS-2 needle reverse cutting 3/8 curve,

violet)’ 4-0 PDS needle: anchoring suture for subcutaneous cheek or pretrichial scalp closure suture, clear does not show through the skin

(Ethicon Z496G 19-mm PS-2 reverse cutting 3/8 curve, clear)’ 4-0 PDSII also good for cheek flap suspension (Ethicon Z507G PS-4 16-mm 1/2-circle reverse cutting, clear)’ 4-0 PDSII P-2 needle: shorter and sturdier than the PS-2 needle, good for tight spaces (Ethicon Z504G 8-mm P-2 needle reverse cutting,

clear)’ 4-0 silk: reverse cutting needle for traction sutures (Ethicon 789G G-3 needle, single-armed)’ 4-0 silk: traction suture (Ethicon 735G C-3 13-mm 3/8-circle reverse cutting, double- armed)’ 4-0 silk: taper needle for bridle sutures under extraocular muscles (Ethicon K871H RB-1 needle, single-armed)’ 4-0 Mersilene S-2: short 1/2-circle needle (S-2), braided polyester, for lateral tarsal strip operation (Ethicon 1779G, double-armed)’ 4-0 silky II Polydek: alternate choice for lateral tarsal strip operation (Deknatel 6�692 ME-2 8.8-mm 1/2-circle reverse cutting

5-0 Sutures’ 5-0 fast absorbing gut: used as skin suture (Ethicon 1915G PC-1 needle)’ 5-0 chromic: for medial spindle operation (Ethicon 792G G-3 needle, double-armed)’ 5-0 chromic: alternate choice for medial spindle (Coviden G-1792K HE-3 3/8c 13-mm cutting, double-armed)’ 5-0 Vicryl: anchoring deep flaps, retractor reinsertion (Ethicon J493 P-3 13-mm 3/8-circle reverse cutting, single-armed, undyed)’ 5-0 Vicryl: for enucleation: EOM and lamellar passes through sclera to reattach EOM (Ethicon J591 S-14 8-mm 1/4-circle spatula, double-

armed, violet)’ 5-0 PDS: anchoring suture for periocular tissues; less “spitting” than Vicryl; clear best for non�hair-bearing tissues (Ethicon Z493G 13-

mm P-3 needle reverse cutting, clear)’ 5-0 PDS: anchoring suture for periocular tissues; less “spitting” than Vicryl; violet best for hair-bearing tissues (Ethicon Z463G 13-mm P-3

needle reverse cutting, violet)’ 5-0 Prolene: anterior ptosis, forehead skin/ear skin closure (Ethicon 8717 C-1 13-mm 3/8-circle taper, double-armed), C-1 needle is great

for anterior ptosis and eyelid skin (my favorite needle, a super-sharp taper needle)’ 5-0 Prolene: periocular skin closure; blue color especially useful for repair of lacerations or incisions in hair-bearing areas; extra knots

required; running sutures are easily removed; P-3 needle is a little less kind to periocular tissues (Ethicon 8698G P-3 needle)’ 5-0 nylon: an alternative to the 5-0 Prolene for suturing levator aponeurosis to tarsus in ptosis surgery; periocular and brow skin closure

(Ethicon 7731G S-24 spatula needle, double-armed)’ 5-0 nylon: an alternative to the 5-0 Prolene for skin periocular and nasal skin closure (Ethicon 698G P-3 needle)

6-0 Sutures’ 6-0 fast-absorbing gut: for conjunctival closure or eyelid skin (Ethicon 1916G 13-mm 3/8-circle reverse cutting needle)’ 6-0 Vicryl: double-armed for tarsal fracture operation and Jones’ tube suture (Ethicon J-570G with S-14 spatula needle, longer needle

would be helpful)’ 6-0 nylon: used with pigtail probe for repair of canalicular lacerations (Ethicon 1698G P-3 needle)

22 1 • The Art of Surgical Technique

simple sutures provide good wound alignment and eversionof the wound edges. When a greater amount of wound ever-sion is necessary, vertical mattress sutures can be used (seeFigure 1.23B). The far�far, near�near suture pass is espe-cially useful to provide wound eversion of the lid marginwhen you are repairing a lid laceration. In skin creases, asimple running suture is used (see Figure 1.23C).

My new favorite suturing technique for forehead andother periocular incisions is the running vertical mattresssuture (I first saw it in the newest version of the textbookEyelid Surgery: Principles and Techniques by C. McCord, Jr.,and M. A. Codman). After tying the first interruptedsuture, take a wide deep bite and move backward andplace a narrow, more superficial suture, and then repeatalternating the wide deep and (moving backward) narrowsuperficial sutures. This is a great way to get the eversionbenefits of a vertical mattress suture with the speed of arunning suture.

To maintain spacing of the wound closure, use the “halv-ing” method. Successively divide the wound into halves(Figure 1.24A). If, despite careful wound closure, redundant tis-sue or a dog-ear exists at the end of thewound, it can be excisedat the expense of a slightly longer scar (see Figure 1.24B).

Tying the Suture

Most sutures passed in oculoplastic surgery are tied with aninstrument tie. There are some simple tricks that you shouldlearn to make your knot tying secure and efficient(Figure 1.25A). Imagine passing a suture through the woundedges. As you withdraw the needle, the two arms of the suturemake a V. Place your instrument in the V and wrap the needleend of the suture around the needle holder twice (seeFigure 1.25B). Grasp the end of the suture with the needleholder (see Figure 1.25C) and pull your instrument towardyou (see Figure 1.25D). Pull the suture down to the tissue,approximating the wound edges closed with gentle pressure.Do not apply more force than necessary to approximate thewound edges. You have created a new V in the suture arms.Repeat the wrapping of the needle holder and now reverse thepull of your hands with the needle holder being pulled awayfrom you (see Figure 1.25E). Make sure that the knot lies downsquarely on the first pass. Repeat this for a third time, complet-ing the 2-1-1 surgeon’s square knot (see Figure 1.25F).

Let’s add two refining steps. When you start a tie, graspone end of the suture with your forceps (held in your non-dominant hand) close to the end of the suture. Orient thesuture to be parallel to the needle holder (sometimes using agentle twist or pulling the suture). Now wind the suturearound the needle holder (not the needle holder around the

’ 6-0 Prolene: eyelid skin closure (used as single arm), posterior ptosis (Ethicon 8726 C-1 13-mm 3/8-circle taper, double-armed), anotherfavorite needle and suture!

7-0 Sutures’ 7-0 chromic gut: for conjunctival closure (Ethicon TG100-8 needle), great for suturing mucous membrane grafts in conjunction with

TISSEEL, easiest to do using the microscope’ 7-0 Vicryl: suture for closure of conjunctiva (Ethicon J-546 TG140-8 needle), used when you need a more secure closure than chromic

Notes

These are personal preferences. There are many good alternatives to these.

’ I rarely use Vicryl owing to the “spitting” of sutures; my preference is for PDS.’ I rarely use nylon, preferring Prolene. The blue suture is much easier to see around eyelashes and brow hairs. The Prolene is slippery,

making it easy to take several suture passes before pulling through the tissue. Extra knots are required, five throws.’ I like the C-1 needle on the Prolene, super-sharp tip; there is a good feel in the tarsus, and the taper causes less bruising in the

orbicularis and Müller’s muscle’ 7-0 Vicryl sutures work well to hold periocular wounds closed, but they need to be removed. They stay too long and leave suture tracks,

so I rarely use them. An exception is to provide a long-lasting skin crease in a pediatric ptosis case.’ Fast-absorbing gut is okay for eyelid skin closure but often breaks early. I usually use 6-0 mild chromic for eyelid skin in children and

adults where I don’t want to remove sutures postoperatively.

A

C

B

D

Figure 1.22 Passing the needle through the wound. (A) Pass theneedle to enter perpendicular to the skin. (B) The needle should leaveand enter the wound edges at the same depth. (C) Use the Paufiqueforceps to grasp both edges of the wound. Advance the needle withthe needle holder, first pushing the needle in and then pulling theneedle out. Take care not to grasp the tip of the needle to avoiddulling. (D) When the needle is advanced enough, reload it before youremove it from the tissue. You are then ready for the next needle pass.

1 • The Art of Surgical Technique 23

suture). Because the needle holder and the suture are paral-lel, there will be very little “spring” in the suture and littletendency for the suture to unwind from the needle holder.Be sure that you understand this. The second point toremember is that before you wind the suture around theneedle holder, place the needle holder close to the end of thesuture you are about to grasp to complete the tie. Avoid thetendency to bring the needle holder to the end of the freesuture once the suture is wrapped around the needle holder(the videos accompanying this text should be helpful foryou). Practice with large sutures until you have this tech-nique mastered, and then practice with smaller sutures. Asyou get better, concentrate on how to minimize your handmovements, making each tie look “easy.” If you play violinor guitar, you know that minimizing your finger movementsis the only way that you can play a rapid rhythm. Learn tooperate quickly, not by hurrying but by moving your hands effi-ciently. If each step takes twice as long as necessary, thewhole operation will be twice as long as necessary.

The Surgical AssistantThe job of the surgical assistant is to anticipate and facilitate.It is said that good surgeons make surgery look easy, but thefact that good assistants make surgeons look good is seldomappreciated. If you are just learning surgery, you may notbe aware of how important a good assistant is. Every dayyou may be operating with experienced surgeons assistingyou. For you to appreciate the value of the assistant, tryoperating with a surgeon even less experienced than you.You will quickly realize the value of an interested and expe-rienced assistant.

You also may not be aware of how your success as anassistant relates directly to your abilities as the primarysurgeon. An experienced teacher can easily identify stu-dents with excellent surgical potential by the way theyassist in surgery. Don’t underestimate your value as anassistant or your ability to learn while assisting.

B

C

AD

E

Figure 1.23 Placement of skin sutures. (A) Simple interrupted suture. (B) Vertical mattress suture used for maximum wound eversion. (C)Interrupted suture closure. (D) Running suture closure. (E) Running vertical mattress suture closure.

24 1 • The Art of Surgical Technique

CHECKPOINT

• Do you remember the main differences between mono-filament and multifilament sutures for handling andtying?

• Which has the better “hand?” What type of suture isthe gold standard for handling?

• What are the main needle types and shapes? What isthe most common needle point for sewing skin?

• Practice suturing using the pencil grip for theCastroviejo needle holder and the thumb/ring fingergrip for the Webster needle holder.

• Explain the in-the-V technique for suturing to acolleague also learning to suture. Try the refinementssuggested to make your ties smoother (Box 1.3)

• Can you make smaller movements to increase yourefficiency?

A

B

Figure 1.24 (A) The “halving” method for closure of surgical wounds. (B) Dog-ear excision of redundant tissue.

1 • The Art of Surgical Technique 25

“V”

A CB D

E F G

Figure 1.25 The instrument tie. (A) Place the needle holder in the V. (B) Wrap the suture around the needle holder three times. Try to make thesuture and the needle holder parallel so there is not much “curl” in winding the suture. (C) Grasp the end of the suture (it should be near theneedle holder to minimize your movements). (D) Pull the needle holder toward you and the suture end away from you. Notice that the knot shouldlie flat as you pull it down with each throw. (E) Put the needle holder in the V and wrap the suture around the needle holder once. Grasp the sutureend and pull your hands in the opposite direction. (F) Repeat a third time, pulling your hands in the opposite direction again. (G) Each time, watchthe knot so it is tied flat.

Box 1.3 Instruments of Special Interest for Eyelid Operations

Retractors

’ 4-0 silk traction suture (Ethicon 783 P-3 cutting needle)’ Jaffe lid retractor: recommended for all lid procedures as a self-retaining retractor (Storz E0997)’ Senn�Kanavel retractor (Storz N4780)’ Desmarres lid retractor: useful handheld retractor for eyelids and eyelid incisions

’ Size 0: 11 mm (Storz E0980)’ Size 1: 13 mm (Storz E0981)’ Size 2: 15 mm (Storz E0982)’ Size 3: 17 mm (Storz E0983)

Skin hooks’ Storz double fixation hook: fine double hook (Storz E0533)’ Tyrell iris hook: fine single hook (Storz E0548)’ Joseph double hook: larger double hook (Storz N4730)’ Knapp lacrimal sac retractor: four-pronged blunt tip (Storz E4538)

Forceps’ Paufique forceps: good all-purpose tissue forceps (Storz E1831)’ Adson forceps: cheek tissues (delicate, Storz N5405)’ Brown�Adson forceps: cheek tissues (Storz N5420)’ Sanders�Castroviejo suturing forceps: delicate forceps

’ 0.12 mm teeth (Storz E1796)’ 0.3 mm teeth (Storz E1797)’ 0.5 mm teeth (Storz E1798)

’ Bishop�Harmon straight tissue forceps: useful to thread fascia through Mayo trocar needle eye (Storz E1500)’ Lambert chalazion forceps (clamp)

’ Large, 15 mm (Storz E2632)’ Small, 10 mm (Storz E2630)

’ Halstead mosquito hemostatic forceps (Storz E3922)’ Kelly hemostatic forceps: larger than Halstead type (Storz N5511)’ Jeweler-type forceps for fine suture removal (Storz E1947 1)

26 1 • The Art of Surgical Technique

Major Points

’ Being prepared demonstrates your competence and instills confi-dence in the operating room team.

’ Have the room setup in mind before you enter the operating room.Set your operating stool height first, then the operating table, andfinally the microscope. Adjust the interpupillary distance on theeyepieces and set the focus of the scope. Position the necessary footpedals before you scrub.

’ Use a local anesthetic with epinephrine on all patients. Mark andinject the skin before preparing the patient.

’ Learn as much as you can about the tools of your trade’ Scalpel blades and other cutting instruments’ Scissors’ Forceps’ Retractors’ Cautery’ Suction’ Needle holders’ Sutures

’ Spread and stabilize the skin before any incision. Be aware ofyour body position. Always inject or cut away from the eye oryour fingers. The no. 15 scalpel blade and the microdissectionneedle are the most useful cutting tools.

’ Hide incisions in wrinkle lines or natural skin creases, whenpossible.

’ Scissors vary in the following characteristics’ Length’ Caliber’ Tip sharpness’ Blade design’ Cutting motion

’ The scissors you will use most often are Westcott spring scissorsand Stevens iris-type scissors. Use the curve of the scissors bladeto your advantage. Make cutting a continuous motion. Avoid“snipping.”

’ Oculoplastic surgery requires skill in retracting tissues. Types ofinstruments used to retract tissues are the following’ Your fingers’ Forceps’ Skin hooks’ Retractors

’ Use forceps with teeth whenever possible. Learn to pull the tissuesapart as you dissect with any cutting tool. To separate theorbicularis muscle off the orbital septum, grasp the muscle withone forceps and the septum with another forceps (using anassistant). Gently pull the layers apart as you separate them withthe scissors. Most surgery is not cutting, but it is, rather,separating tissue planes.

’ There are three types of retractors’ Self-retaining retractors’ Handheld retractors’ Suture retractors

’ The most useful self-retaining retractor is the Jaffe lid speculum.Handheld retractors, including the Desmarres vein retractor (foreyelids) and the Sewall and malleable ribbon retractors (fororbital retraction), are very important tools; 4-0 silk sutures areexcellent suture retractors.

’ Intraoperative hemostasis begins with stopping aspirin andnonsteroidal antiinflammatory medications well in advance ofsurgery. Inject local anesthetic with epinephrine 10 minutesbefore making any incision. Learn to tamponade tissues.

’ Learning an effective bipolar cautery technique is a must.Consider these three steps

Needle holders’ Castroviejo needle holder: the most useful needle holder’ Straight-locking, heavy, for 4-0 needles (Storz E3850)’ Straight-locking, medium, for 5-0 and smaller needles (Storz E3861)’ Webster needle holder: used for 3-0 or larger needles’ 19 mm jaw (Storz N5712)

Scissors’ Stevens tenotomy scissors

’ Curved (Storz E3562)’ Straight (Storz E3560)

’ Westcott tenotomy scissors: curved right, blunt tips, used for most delicate dissections (Storz E3320 R)’ Westcott stitch scissors: sharp-tipped, good for punctoplasty procedures (Storz E3321 WH)’ Mayo scissors

’ Straight (Storz N5235)’ Curved (Storz N5236)

’ Metzenbaum scissors: curved regular, useful for cheek dissections (Storz N5111)’ Facelift scissors

Elevators’ Freer septum elevator (also called a periosteal elevator)’ 4.5 mm (Storz N2348)’ 6.5 mm (Storz N2349)

Suction and hemostasis’ Frazier suction tube (9 French): general-purpose suction catheter (Storz N2421)’ Baron suction tube: small Frazier-type suction tube (Storz N0610)’ Yankauer tonsil suction tube: blunt-tipped suction catheter used for mouth and throat (Storz N7550)’ Colorado microdissection needle’ Bipolar cautery’ Unipolar cautery’ Disposable high-temperature cautery

1 • The Art of Surgical Technique 27

’ Exposure (assistant)’ Tamponade (surgeon)’ Cautery (surgeon)

’ The roles can be reversed.’ Three types of suction tips are used in oculoplastic surgery

’ Flexible suction catheter’ Yankauer tonsil suction tube’ Frazier and Baron suction tubes

’ Suture material varies in three basic characteristics’ Absorbable or permanent’ Monofilament or multifilament’ Natural fiber, synthetic, or metal wire

’ Monofilament sutures are less reactive than multifilamentsutures, but working with them is more difficult. Multifilamentsutures hold tension and maintain a knot better thanmonofilament sutures.

’ Needles vary by shape, size, and point. Half-circle needles are bestfor tight spaces (lateral canthoplasty). Reverse cutting needles areused on the skin. Spatula needles are used for most lamellarpasses through tissue.

’ Two types of needle holders are used in oculoplastic surgery’ Spring handle: Castroviejo needle holder’ Ring handle: Webster-type needle holder

’ Use the pencil grip for the Castroviejo needle holder and thethumb/ring finger grip for the Webster needle holder.

’ Sutures may be continuous or interrupted. Continuous suturesare used in natural skin creases or wrinkle lines (upper lid skincrease). Two types of interrupted sutures are used to close thesurgical wound:’ Simple suture’ Vertical mattress suture

’ The vertical mattress suture provides the most wound eversion.’ The job of the surgical assistant is to anticipate and facilitate.

Your success as an assistant relates directly to your abilities asthe primary surgeon. To be a good assistant, you need to be apart of the operation. Don’t wait to be told what to do. Learn to“dance” with the surgeon. Don’t underestimate your value as anassistant or your ability to learn while assisting.

’ The surgeon and the assistant work as a team. As with any team,all the players must know what the surgical plan is. As anassistant, you should be entirely familiar with the steps of theoperation and any changes that the surgeon may have in mindfor a particular patient. You can’t anticipate if you don’t knowthe steps of the operation.

’ Your job as an assistant starts with the room and equipmentsetup. You may be the person to administer the local anestheticor prep and drape the patient while the surgeon scrubs. Once inthe operating room, you need to position yourself where you cansee what is happening and be a part of the operation. You wouldbe surprised at the number of surgical students who don’t do wellas assistants, claiming that they can’t see the operating field. Ifyou can’t see, move so you can see. If you can’t get in areasonable position to see, let the surgeon know so the situationcan be changed. To be a good assistant, you need to be a part ofthe operation. If the lighting is poor, adjust the operating roomlights. If there is bleeding, provide exposure and tamponade.Perhaps you can offer suction. As the dissection proceeds, movewith the surgeon, constantly adjusting your retractors to providethe best exposure possible. If you can’t see the area of interestwell, it is likely the surgeon can’t either. As the dissection

continues, provide gentle countertraction to facilitate the cuttingof tissue or spreading of the tissue planes. If you don’t know howto help, ask what you can do to help.

’ If you see the surgeon passing a suture, have a suture scissorsready to cut the ends of the suture. Use scissors with a straightblade and sharp tips. Hold the scissors with the tripod or thumb/ring finger grip. This allows you to stabilize the scissors with yourindex finger. Sometimes, it is helpful to rest the scissors on yournondominant index finger as if you were using a pool cue. Thesurgeon should pull the suture to the side (not straight towardyou) so that you can see the full length of the suture. It is difficultto cut a suture if you are looking down the length of the suture.You may find it helpful to slide the scissors down the suture for afew inches to the knot. Exerting a slight bit of pressure against thesuture helps control your movement. This gives you both visualand proprioceptive input as to where to close the scissors. Try tocut with the scissors tips to improve your accuracy. Remember toclose the scissors slowly rather than snip the suture.

’ Your efforts practicing as an assistant will help you to become agood surgeon. Take advantage of the opportunity to learn. Beinterested. Ask questions. Develop a passion for the operatingroom. Operating will not only be how you support your family,but it will become a part of who you are. It all starts with you asan assistant.

Suggested ReadingAlbert D, Lucarelli M, eds. Ophthalmic plastic techniques: basic consid-

erations. In: Clinical atlas of procedures in ophthalmic surgery. Chicago:AMA Press, 2004, pp. 241�247.

Allen RC. Oculoplastic surgery techniques (videos). EyeRounds.org.University of Iowa Department of Ophthalmology and Visual Sciences;University of Iowa Carver College of Medicine, Iowa City, IA. Availableat: http://www.eyerounds.org/video/plastics/index.htm

Christie DB, Woog JJ. Basic surgical techniques, technology, and woundrepair. In: Bosniak S, ed. Principles and practice of ophthalmic plastic andreconstructive surgery. Philadelphia: WB Saunders; 1996:281�293.

Dutton JJ. Atlas of oculoplastic and orbital surgery. 2nd ed. Philadelphia:Wolters Kluwer,; 2018.

Edgerton MT. The art of surgical technique. Baltimore: Williams andWilkins; 1988.

Korn BS, Kikkawa DO. Video atlas of oculofacial plastic and reconstructivesurgery. 2nd ed. Philadelphia: Elsevier; 2016.

Linberg JV, Mangano LM, Odom JV. Comparison of nonabsorbable andabsorbable sutures for use in oculoplastic surgery. Ophthalmic PlastReconstr Surg. 1991;7(1):1�7.

McCord Jr C, Codner MA. Basic principles of wound closure. In: McCordC, ed. Eyelid surgery: principles and techniques. 2nd ed. Philadelphia:Lippincott-Raven; 2006:23�28.

Nerad J. The art of the surgical technique. Oculoplastic surgery: The requi-sites. St Louis. Mosby; 2001:1�24.

Sierra CA, Nesi FA, Levine MR. Basic wound repair: surgical techniques,flaps, and grafts. In: Levine MR, Allen RC, eds. Manual of oculoplasticsurgery. Boston: Butterworth-Heinemann; 2003:23�29.

Tanenbaum M. Skin and tissue techniques. In: McCord CD, TanenbaumM, Nunery WR, eds. Oculoplastic surgery. 3rd ed. New York: RavenPress; 1995:1�49.

Younis I, Bhutiani RP. Taking the “ouch” out—effect of buffering com-mercial xylocaine on infiltration and procedure pain—a prospective,randomised, double-blind, controlled trial. Ann R Coll Surg Engl.2004;86(3):213�217.

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