This is Richard Allen at the University of Iowa.
This video demonstrates replacement of a weight in a patient with a history of a facial nerve palsy. The patient's previously placed gold weight had extruded. A 4-0 silk suture is placed through the upper lid at the level of the tarsus. A 15 blade is then used to make an incision along the eyelid crease marking. The patient has some cicatricial retraction of the upper eyelid. Dissection is then carried out through the orbicularis muscle to the underlying orbital septum. The orbital septum is then opened and the preaponeurotic fat is dissected from the underlying levator aponeurosis. The levator aponeurosis is then disinserted from the anterior surface of the tarsus with the thermal cautery. Dissection is then carried out between the levator aponeurosis and the underlying Mueller's muscle. The anterior surface of the tarsus is then exposed by dissecting the pretarsal orbicularis muscle from the anterior surface of the tarsus inferiorly. A platinum weight will then be placed since the patient extruded the previous gold weight. This is placed with the inferior holes of the weight fixated to the superior border of the tarsus. This weight will be placed somewhat higher compared to the typical position of weights due to the previous exposure. These are sutured into position with 6–0 Prolene suture. Inspection of the palpebral conjunctiva shows that patient had a previous pillar tarsorrhaphy placed. The sutures had not been placed full-thickness through the lid. The levator aponeurosis is then draped over the weight. The eyelid crease is then created by engaging the orbicularis of the inferior portion of the incision followed by the cut end of the levator aponeurosis. The suture used is a 7-0 Vicryl suture and approximately 3-5 sutures are placed. This will result in re-creation of the patient's lid crease. Superiorly, there was a small defect in the upper border of the incision. This is closed with the same 7–0 Vicryl sutures. The skin is then closed with interrupted 6-0 Prolene sutures. At the conclusion of case, the patient will use erythromycin ophthalmic ointment 3 times a day. The patient will follow-up in approximately 1 week for reevaluation.
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