By I. Ugo. Simmons College. 2019.

At the beginning of the The glans represents the distal extremity of the penis 3 ml careprost sale, and fourth week generic careprost 3ml amex, mesenchyme proliferation produces in both is totally or partially covered by a skin fold when flaccid: the sexes the genital tubercle at the cranial extremity of the cloa- foreskin generic careprost 3ml visa. On the sides of the cloacal membrane the glans presents a conical shape with a large and oblique base labioscrotal swellings and the urethral fold develop. On the glans ventral aspect, along the middle line, we observe a skin fold (frenulum) G. The frenulum joins the glans to the cor- Dipartimento di Chirurgia, Università di Roma “Sapienza”, Rome, Italy responding area of the foreskin, limiting its retractability e-mail: giovanni. The foreskin is made of an external layer, © Springer Berlin Heidelberg 2016 493 N. Sagittal section Pubic symphysis Prostate Suspensory ligament of the penis Bulbo- urethral Corpus gland spongiosum (Cowper) of the urethra Corpus cavernosum Bulb- cavernous muscle Glans penis Prepuce Urethral meatus Fig. The cavernous bodies and the spongy The vascularization of the penis originates from the body (Fig. All artery) from which the deep artery of the penis, the dorsal three bodies are surrounded by the thick Buck’s fascia from artery, and the bulbourethral artery arise. The superficial which the intracavernous septum originates and, more super- dorsal veins, which run externally on Buck’s fascia, and the ficially, by loose connective tissue that forms Colles’ fascia, dorsal deep veins, which run directly below the same fascia, proximally continuous to Scarpa’s fascia on the abdominal ensure venous drainage. The radix of the penis deepens into the anterior perineum The cavernous or erectile tissue is made of blood-filled in the penile space; it is composed of the proximal portions spaces lined by endothelium and surrounded by fibromuscu- of the cavernous bodies (fixed to the ischial and pubis rami) lar contractile elements of smooth muscle, elastin, and Male Genital Aesthetic Surgery 495 collagen. Fistulas are the most common complications increases the volume of the cavernous body during erection, recurring in patients undergoing this procedure; these may and then is drained by the venules; these run out of the albu- occur between the recreated urethral lumen and the penile ginea through the corresponding foramina and are com- skin (because of minor resistance areas following the ure- pressed during erection to allow its maintenance thral reconstruction), or anywhere the stitches slacken. Another potential complication is stenosis of the neo-urethra, The penis is maintained in its site by the suspensory liga- possibly due to the inappropriateness of the cutaneous flap ment and the tendinous insertions of the pubocavernous created to reconstruct the urethra or to postoperative infec- muscles. The cutaneous retraction and the lack of elasticity anterior aspect of the pubic symphysis for its entire length, resulting from the postoperative scarring process frequently and distally/dorsally inserts on the infrapubic penis tract, reduce the length of the cutaneous flap and shrink it, compro- which corresponds to the symphysis length and which is a mising the final result of the surgery. In any event, a high vertical fibroelastic bundle that then splits into two layers of percentage of recurrences often follow this type of fibrous tissue surrounding the cavernous bodies. To be adopted, tion and determines, in addition to other physiological mech- this technique requires that the ectopic orifice be within 1 cm anisms, erection and ejaculation. From the medial aspect of from the apex of the glans and that the skin next to the meatus the ischial tuberosities and ischiopubic branches, two ischio- be sufficiently movable to allow the urethra to be advanced. A vertical incision is per- formed along the middle furrow from the distal edge of the 3 Surgical Techniques ectopic meatus proceeding for 1 cm to the glans apex, then transversally suturing with a 6-0 suture. Using a skin hook In this section we discuss the surgical techniques used to cor- the ventral edge of the meatus is lifted and then moved for- rect the main disorders affecting male genitals, with refer- ward, thus creating an inverted V with the wings of the glans; ence to plastic and aesthetic surgery. This type of surgery the edges of the glans are sutured, unifying them along the allows not only to correct urethral orifice, foreskin, penile middle line in the achieved position (Fig. Next the middle raphe is aligned, potential foreskin cutaneous overabundance is resected, and the subcoronal access is sutured. Several but moderate recurvatum (easily recognizable after a phar- meatoplasty techniques have been illustrated to treat balanic macologically induced erection or, during surgery, through hypospadia [1], of which the most frequently adopted is dis- hydraulic erection). After having per- formed a urinary catheterization, the margins of the glans wings are juxtaposed and double-layer sutured to each other with a 5-0 absorbable filament. Finally, the wings of the glans are sutured to the ventral margin of the cleared neo-meatus. The V incision is performed glans apex, an incision is performed along the entire balano- on the glans with a knife along the previously marked lines, preputial furrow, vertically going down to the ectopic meatus and the margins of the flap are then freed with scissors, and here making an elliptical incision around it. The skin of obtaining three flaps (one centrally and two laterally) from the penis and the foreskin are lifted, cleaving Colles’ fascia the glans, all separated from the underlying structures. A 5-0 (tunica dartos) from Buck’s fascia; the urethra and the meatus absorbable suture is produced on the central flap along the are separated from the cavernous bodies. The possible pres- middle line anchoring the glans to the tunica albuginea, ence of a fibrous cord is evaluated through a hydraulic erec- along with three internally knotted stitches with an absorb- tion, and removed if necessary. After having positioned two able 6-0 filament on the apex of the flap to fix it to the dorsal traction points laterally on the foreskin, a rectangular flap is margin of the meatus; a small V incision may be performed obtained from the dorsal skin of the penis, V-shaping its proxi- on the meatus to make the flap margins fit with it. The flap is mobilized and a buttonhole incision is mal paraurethral portion of the elliptical flap is dissected, made along the middle line of the peduncle (Fig. The suture of the flap margins closes the neo-urethra and a middle incision is executed on the ventral aspect of the glans to obtain two triangular flaps. The distal margin of the neo- urethra is sutured to the distal edges of the glans flaps so that the urethral meatus is recreated at the apex of the glans; the distal portion of the neo-urethra is covered with the glans flaps, suturing the flap margins to each other to recreate the glans. Finally, the skin of the penis is sutured to the crown, thus obtaining an aesthetic result similar to circumcision. The phi- mosis may be primary or secondary to inflammatory or trau- matic processes. The surgical treatment of the phimosis mainly consists in circumcision, which means the full removal of the phimotic foreskin, exposing the glans both during erection and also when the penis is flaccid. The out- comes of this kind of surgery frequently include aesthetic flaws and the reduction of glans sensitivity. From a func- tional and aesthetic point of view, the ideal surgical treat- ment is postectomy. This allows the glans to be partially covered at rest and grants a higher sensitivity preservation, sparing as much penile skin as possible. This expedient allows enlargement of the cir- cumference of the following suture and prevention of a poten- tial postoperative stenosis. Scuderi’s technique: suturing the urethral margin underlying Colles’ fascia, which is dorsally incised and par- to the proximal portion of the flap tially removed. After having remodeled the internal and the external layer, some interrupted (single) 3-0 absorbable attention to preserve vascularization. Then the flap is ventrally stitches are placed to suture the margins, starting from the four transposed, pushing the glans and the cavernous bodies cardinal points (to juxtapose the margins correctly). The technique includes the circumcision and the skin, which was previously prepared by performing a flute- entire scalping of the penis to its base. The outcome Curved penis, or “recurvatum,” consists of an altered shape is verified with another induced erection, to proceed to of the erect penis, which appears curved on one or more potential further corrections. The curvature can be ventral, dorsal, 25–30 % risk of recurrences, including the loosening of the lateral, or mixed, and associated or not with urethral defor- traction points or of the sutures. Congenital penis curvatures are due to an abnormal cause a relevant shortening of the penis in cases of dorsal or development of the cavernous bodies, the tunica albuginea, ventral curvatures. Over the years numerous surgical techniques have aesthetic flaws of the suture, consequences of the circumci- been devised to correct curvatures. It consists in simply folding the tunica extremely simple and an easy-to-perform technique, which albuginea with a non-absorbable continuous suture, per- is why, to date, it is still frequently adopted.

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The presence of flutter/fibrillation is associated with failure of pacing to terminate the arrhythmia cheap careprost 3 ml online. Relationship Between Atrial Flutter and Fibrillation Atrial flutter and fibrillation frequently coexist in the same patient buy careprost 3 ml without a prescription. They may exist as separate individual arrhythmias at different times or can exist as one arrhythmia discount careprost 3 ml visa, which then undergoes a transition to the other arrhythmia. As stated previously in this chapter, during atrial fibrillation organized wavefronts of activation can be 122 noted. Organization of electrical signals in the right atrial free wall produces large wavefronts that usually move in a craniocaudal direction during 102 104 atrial fibrillation. When this occurs, fibrillatory waves demonstrate greater amplitude than when intracardiac recordings demonstrate less organized activity. This organized activity, which resembles that seen in counterclockwise flutter, may be produced by activation of the right atrium from the septum, which produces transverse block in the crista and forces the wavefront of excitation to move along a trabeculated right atrium in the manner in which it does in flutter. Such a hypothesis favors the septum and/or the left atrium as perpetuators of atrial fibrillation. The critical role of the septum in the conversion of atrial flutter to 67 fibrillation is shown in Figure 9-59. Disorganization of electrograms in the septum and left atrium, while the right atrium remains organized, is also not uncommon during fibrillation (Fig. The conversion from fibrillation to flutter is associated with reorganization of septal activation so that it once again moves in a counterclockwise direction (caudocranial) (Fig. In experimental models with detailed mapping, fibrillation turns to flutter when large 98 arcs of block are formed to create a single broad wavefront. While this block always appears to involve the crista terminalis in man, whether or P. The transition from atrial fibrillation to flutter in response to a type I antiarrhythmic agent in man is not uncommon and is associated with the formation of a fixed line of block 20 along the crista terminalis. No catheter or intraoperative mapping involving the septum and left atrium during this phenomenon has been performed, thus the exact sites and extent of lines of block produced by these drugs 98 is not clearly understood. In the canine pericarditis model, the length of the line of block required to change atrial fibrillation to atrial flutter was 24 ± 4 mm and occurred over several beats. This phenomenon, however, is of great clinical importance because atrial flutter can be simply and successfully ablated, thus forming the basis for a hybrid therapy P. Of note, termination of atrial fibrillation is frequently preceded by organization of atrial activity (Fig. Atrial electrograms and activation sequences in the transition between atrial fibrillation and atrial flutter. Atrial electrograms and activation sequences in the transition between atrial fibrillation and atrial flutter. Atrial electrograms and activation sequences in the transition between atrial fibrillation and atrial flutter. Recording His bundle electrograms during these complexes is the single most accurate way of determining their origin. In this particular instance, there was no long-short coupling to initiate the wide complex tachycardia, yet intracardiac recordings confirm supraventricular origin on this wide complex rhythm associated with infra-His conduction delay and the appearance of a left bundle branch block. This is not uncommon during digitalization for control of the ventricular response during atrial fibrillation, in which case fascicular (ventricular) rhythms, which are relatively narrow, could be mistaken for aberration and further digitalis may be given. Another situation in which wide complexes are common is when Class I agents are given P. Analysis of the His bundle electrogram reveals those complexes to be supraventricular aberrations because they are associated with an increase in the H-V interval from 55 (the normal complex is on the left) to 80 msec. The third complex shown in the panel demonstrates a right bundle branch block pattern with left-axis deviation. Analysis of the His bundle electrogram reveals this to be a fascicular premature depolarization as documented by the shortened H-V interval of 20 msec. In this instance, the His bundle deflection represents retrograde activation from the site of origin in the posterior fascicle of the left bundle branch. Another situation for which intracardiac recordings are useful is to document a site of block during atrial fibrillation or atrial flutter with variable ventricular response. This finding does not indicate impaired His–Purkinje function since the input to the His–Purkinje system may be quite rapid in the presence of enhanced A-V nodal conduction. Summary It is apparent that atrial flutter and fibrillation are certainly related arrhythmias. These observations attest to the functional nature of lines of block in the atrial myocardium that determine whether or not atrial fibrillation or atrial flutter is present and whether or not they are perpetuated or terminated. Drugs can alter these electrophysiologic properties and convert atrial fibrillation to atrial flutter. In addition, the autonomic nervous system may play a role since enhanced vagal tone or sympathetic tone can shorten atrial refractoriness and increase the rate of fibrillatory intervals by shortening the arcs of block around which the wavefronts must pass. As noted earlier, vagal discharge, sympathetic discharge, or adenosine can all induce atrial fibrillation by a similar mechanism of shortening refractoriness enough to initiate reentrant rhythms. The important observation that focal atrial tachycardias or rotors can result in fibrillatory conduction and atrial fibrillation has important therapeutic implications (see Chapter 14). In my opinion, the underlying substrate of atrial conduction and refractoriness as well as the three-dimensional anatomy dictate the response to these premature complexes. A greater understanding of this substrate using newer mapping techniques may lead to different therapeutic options that target the substrate and not the triggers of these arrhythmias. Histological substrate of atrial biopsies in patients with lone atrial fibrillation. Electrophysiologic characteristics of human atrial muscle in paroxysmal atrial fibrillation. The functional role of structural complexities in the propagation of depolarization in the atrium of the dog. Cardiac conduction disturbances due to discontinuities of effective axial resistivity.

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The aim of the present consent paper is to offer the patient order careprost 3 ml with visa, in addition to the preoperative conversation with the sur- geon cheap 3 ml careprost otc, the information regarding the characteristics and the 14 purchase careprost 3 ml with amex. Please read care- fully the following, discuss with the surgeon the explana- It can occur on the skin, nipple-areola complex, or glandulo- tion of every term that is not clear, and then sign this adipose tissue (liponecrosis). The presence of necrotic tissue document as a confirmation of having understood the can inhibit the healing of the surgical wounds and require a information given. It can be due to an infection, a vascular sufferance The reduction mammoplasty is the operation that of the tissue, or a wound dehiscence. Cigarette smoking can reduces and remodels a big-size breast (breast hypertro- interfere with the healing processes increasing its incidence. The operation causes the presence of cutaneous scars, at least one around the areola and another vertical one that goes from the areola to the infra- 14. During the operation Usually the quality of the scars is good, but sometimes, drainage tubes will be placed coming out from the armpit. The function of breastfeeding can be altered (depending on the surgical technique). The aesthetic outcome could be compromised • At the time of discharge, have somebody drive you home. In order to maintain the result, when standing it is a • Do not smoke for at least a couple of days in order to good practice to always wear a bra. It is normal that in the first postoperative period, the • A cautious return to sexual activity not before 15 days is breasts appear excessively high, swollen, and unnatural and allowed. In • Do not perform wide movements with the arms and do order to obtain a satisfying aesthetic result, it is usually nec- not lift weights for at least 2 weeks. In order that the scars whiten, it is • Sports activities can be restarted after 1 month. It rarely causes long-term problems; however, occa- sionally, it should be drained. It can occur in the immediate postoperative face and the nail polish from the fingers and the toes, period or at a later time after surgery. Inverted-T Scar Reduction Mammoplasty 225 • Necrosis: It can occur on the skin, nipple-areola complex, 14. Ann Plast Surg 3:211–218 of necrotic tissue can inhibit the healing of the surgical 15. It can be due to an infec- J Plast Surg 20:78 tion, a vascular sufferance of the tissue, or a wound dehis- 16. Plast Reconstr • Pathological scars: Usually the quality of the scars is Surg 85:728–738 good, but sometimes, because of a specific individual 18. Aesthetic Plast Surg reactivity, such scars increase in consistency and thick- 8:231–236 19. Rev Iber Latino ness (hypertrophic scars or cheloids) and/or widen Am Cir Plast 3:28 (atrophic). Plast Reconstr Surg 94:100–114 suggest to discuss these aspects with the surgeon before 22. Perspect Plast Surg 4:67 Poor quality scars as well as small residual asymmetries 23. Wettstein R, Christofides E, Pittet B, Psaras G, Harder Y (2011) Leipzig, p 370 Superior pedicle breast reduction for hypertrophy with massive pto- 2. J Plast Reconstr Aesthet Surg 64(4):500–507 mamma without mutilation of the organ. Guinard M (1903) Comment on: Rapport de l’ablation esthetique using different techniques. Thorek M (1922) Possibilities in the reconstruction of the human Reconstr Surg 112(2):693–694 form. Aubert V (1923) Hyperthophie mammaire de la puberte: resection Surg 110(2):705–706; author reply 706 partielle restauratrice. Br J Plast Surg 13:79–80 (2009) Draining after breast reduction: a randomised controlled 9. Al-Shaham A (2010) Pedicle viability as the determinant factor for inferior pedicle technique. Can J Plast Surg 18(1):e1–e4 Vertical Breast Reduction Diego Ribuffo , Matteo Atzeni , and Francesco Serratore 1 Introduction In an effort to reduce scars during the 1990s, both in Europe and in South America, surgeons obtained good results with Before the 1900s, attempts to reduce breast size were limited various types of short T scars/circumareolar techniques asso- to volume reduction without regard to nipple position and ciated with the superior pedicle, although with time these pro- viability, not to breast shape. In the first part of the twentieth cedures were restricted to small reductions or mastopexies. To maintain via- patient and the surgeon alike as a result of unsightly scars bility, two-stage procedures were often recommended, even and long-term “bottoming out” of the breast, has promoted if this is nowadays hard to believe. As time progressed, surgeons focused on better preserva- At the end of the twentieth century, finally, an old and aban- tion of nipple sensation, skin flap circulation, and shape. Differently from Lassus, Odontostomatologiche, Università di Cagliari , Cagliari , Italy Lejour’s technique [8] included liposuction and a wide skin e-mail: diegoribuffo@libero. This maneuver will determine the central ity of the vertical reduction with both patients and surgeons. The vertical lines are joined to each In 1999, Hall-Findlay [9] described a vertical reduction other 3–6 cm above the inframammary fold. Because of with a moderate hypertrophy/ptosis, a “pure” superior pedi- its relative simplicity, this technique was adopted by many cle might be chosen (Figs. Otherwise, a lateral or surgeons seeking improvement on the limitations of the Wise medial pedicle (Fig. The nipple-areola complex is However, a number of complications were still identifi- marked with a 45-mm-diameter areola ring. These include kinking of the Schwartzman maneuver, the inferior pole breast skin is pedicle in the very fibrous breast, an ill-defined inframam- undermined, starting below line g-g’ to 1–2 cm above the mary fold, and poor nipple-areola sensitivity. The ideal thickness of the skin flap is sensation following use of the superior pedicle technique similar to a mastectomy skin flap. A crescentic resection was significantly compromised up to 6 months after surgery, (Fig. The distance The recent discovery of the importance of the horizontal between points c and g is usually 6–8 cm. The gland will septum in reduction mammaplasty has been emphasized by easily peel off the inferior surface of the horizontal septum Hamdi et al.

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Patients may complain of foreign body sen- • Insert the shell under the superior fornix from below sation careprost 3ml on line, dryness careprost 3ml generic, irritation cheap careprost 3ml on-line, blurry vision, photosensitivity, and • Evert the lower eyelid to allow the lower edge of the shell redness. These symptoms often arise from dried accumula- to move into the inferior fornix tion of clot or ointment on the eye and will respond to ocular lubrication with preservative-free teardrops and cool com- How to remove a corneal protective lens: presses. Alternatively, poor eyelid closure can cause expo- sure keratopathy, particularly along the inferior cornea. This • Instill a tetracaine or proparacaine ophthalmic eye drop diagnosis is made with a slit-lamp examination after the into the eye instillation of fluorescein drops. The examiner will see punc- • Gently place an ocular muscle hook posterior to the lower tate corneal staining under blue light illumination in the edge of the shell affected region of the cornea. Lubricating drops and oint- • Guide the shell inferiorly over the lower lid ment are often effective treatment measures. Patients with a hematoma should ing facial and periocular injection has been reported and is be evaluated for symptoms consistent with orbital hemor- secondary to retrograde arterial displacement of the foreign rhage. Unlike orbital hemorrhages, eyelid hematomas do not substance from a peripheral arteriole into the ophthalmic result in a posterior bleed, and as a result, patients do not arterial system [5, 6 ]. Once an orbital hemorrhage is ruled out, mild superficial hematomas can usually be treated conservatively with ice 2. Larger, stable hematomas should be followed for 7–10 days until adequate resolution of the hematoma has The diagnosis of a corneal abrasion is made by patient symp- occurred. Rarely do they need to be drained by needle aspira- toms (sharp, stabbing pain, foreign body sensation, light sen- tion or reopening of the wound. In severe cases, they may sitivity) and is usually apparent immediately after surgery. Expanding hemato- The diagnosis is confirmed by evaluating the cornea under a mas require immediate surgical exploration, evacuation and cobalt blue light after instillation of fluorescein drops. Abrasions are often caused by drying of the corneal sur- The development of cellulitis or abscess formation is exceed- face during surgery or inadvertent damage to the surface cor- ingly rare in the well-vascularized eyelid. Sometimes, taping of the eyes during presents with erythema and induration around the eyelids anesthetic induction causes an abrasion if the eyes are acci- and is usually confined anterior to the orbital septum. Careful insertion and removal of well-lubricated corneal Preseptal cellulitis tends to be a less severe disease than shields prevents this complication; as does the use of oph- orbital cellulitis (postseptal cellulitis), which can present in a thalmic ointment into each eye at the completion of the pro- similar manner. Abrasions can be treated with ophthalmic antibiotic Orbital cellulitis has a higher morbidity, requires aggres- ointment four times daily, and should be resolved within sive treatment, and may require surgical intervention. Patching should be avoided, as it may mask a more Patients present with proptosis, excessive pain, eyelid swell- serious complication, such as an orbital hemorrhage. Contrast-enhanced computed tomography is effective in Complications of Aesthetic Blepharoplasty and Revisional Surgeries 803 a Fig. Patients are managed by cul- turing any purulent discharge that is present and then begin- ning broad-spectrum intravenous antibiotics for 7–10 days. Figure 4 shows a patient who developed a pseudomonas preseptal cellulitis in three of four lids after blepharoplasty. She was treated with a combination of surgical drainage and intravenous antibiotics, but ultimately developed late cicatri- zation and skin dimpling. Complete eyelid sloughing can develop, necessitating mul- tiple eyelid reconstructive procedures which can ultimately place the patient at risk for cicatricial changes, persistent lag- ophthalmos and chronic ocular irritation from dry eye symp- toms (Fig. It can develop in the early or intermediate postoperative period due to various etiologies such as incomplete eyelid closure, ocular c allergy, sinusitis, or postsurgical edema. The surgeon was inadvertently handed formalin instead of local anesthesia and the patient immediately complained of pain. Four stages of eyelid reconstruction were needed to provide sufficient corneal coverage (c) 804 R. Note residual blepharoptosis in the postoperative photo (b) that mild persistent chemotic conjunctiva is present and can be a man- agement problem in patients with underlying thyroid or renal disease (b) Pearls to evaluate for preoperative ptosis include the edematous conjunctiva balloons around the cornea preventing following: adequate tear film dispersion. Additionally, the exposed con- junctival surface may keratinize, leading to worsening foreign • Assure that the frontalis muscle is blocked when examin- body sensation and ocular irritation. Often patients with ptosis involves preservative-free artificial tears and ointment. A mild and/or excessive dermatochalasis compensate with invol- topical steroid eye drop can be prescribed, but should only be untary frontalis recruitment (Fig. Aponeurotic ptosis is often accompanied by an increase in lid crease height, or a deep superior 3 Complications in the Intermediate sulcus. Postoperative ptosis can be seen frequently following upper • Mechanical ptosis can result from postoperative edema or eyelid blepharoplasty (Fig. This should resolve with conservative treat- attenuation seen in aponeurotic ptosis is present preopera- ment, including cool compresses. Lagophthalmos is usu- ally temporary and conservative management in the interme- diate postoperative period includes frequent lubrication, lid massage, and lid taping. The punctum may be everted in association with an ectro- pion, resulting in an elevated tear film and subsequent epiphora. Abnormal downward forces can result from exces- sive skin resection, scarring, imbrication of the orbital septum, edema, and hematoma. Eyelid snap-back is The brow position is elevated to compensate for the ptotic upper lids evaluated by inferiorly displacing the lower eyelid centrally. Note the change in brow position to a more normal position after The lid should normally spring back into its position against undergoing upper lid ptosis surgery (b) the globe. An abnormal result can be quantified by counting the number of blinks required for the lower lid to regain its levator attenuation. Preoperative identification of patients at risk for lower Reasons for lagophthalmos include the following: eyelid retraction is of utmost importance in prevention of this complication. Predisposing factors include the following: • Excessive skin removal • Surgical trauma to the orbicularis muscle • Globe proptosis • Tethering of the eyelids by sutures or Steri-Strips (3 M, • High myopia St. The patient is instructed to mas- evaluation should include an assessment of ocular sicca sage the lower eyelid superiorly in the medial or lateral 806 R. Although cases of skin over-resection have become less common with the popularity of transconjunctival blepharo- plasty, a role still exists for the transcutaneous blepharo- plasty. If skin over-resection is diagnosed early, skin sutures can be removed at 2–3 days postoperatively, and the wound is allowed to gap in order to granulate in the portion of the eyelid. While not ideal, this option is better than the severe bowing or ectropion that is likely to result, which will often necessitate skin grafting. Similar wound gapping can be per- formed with acceptable results in the upper eyelid.