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Techniques in
Ophthalmic
Plastic Surgery
A Personal Tutorial
SECOND EDITION

Jeffrey A. Nerad, MD, FACS

Cincinnati Eye Institute
Professor of Ophthalmology
University of Cincinnati
Cincinnati, Ohio
ELSEVIER
1600 John F. Kennedy Blvd.
Ste. 1600
Philadelphia, PA 19103-2899
TECHNIQUES IN OPHTHALMIC PLASTIC SURGERY—
A PERSONAL TUTORIAL ISBN: 978-0-323-39316-4
SECOND EDITION
Copyright © 2021 by Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the publisher.
Details on how to seek permission, further information about the Publisher’s permissions
policies, and our arrangements with organizations such as the Copyright Clearance Center and
the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Previous edition copyrighted 2010

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary. Practitioners and researchers must
always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility. With respect to any
drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product
to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on
their own experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions. To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material
herein. The Publisher

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Printed in China
9 8 7 6 5 4 3 2 1

VIDEO ’ P1 Introduction to Techniques in Ophthalmic Plastic Surgery, 2nd edition
Thank you for your interest in the second edition of
Techniques in Oculoplastic Surgery — A Personal Tutorial. This
text is for you if you want to learn the principles and techni-
ques of oculoplastic surgery that you can put into use in
your practice every day. Although the book is written from
my perspective as an oculoplastic surgeon, I am certain that
my colleagues in plastic surgery, ENT, and dermatology will
find the book useful as well.
The content is updated from texts that I wrote in 2001
and 2010. These books were written in a conversational
tone as though I were at your side to help you through each
step of the evaluation and treatment. I follow the same for-
mat here with updates and new material where appropri-
ate. Most common disorders and procedures are included—
and some less common ones, too. My greatest compliment
from a former fellow or resident is that they can hear my
voice reminding them of the important steps to do while
actually doing the operation. As your virtual preceptor, I
hope that you will find this approach equally helpful.
Because there is so much information presented, I suggest
that you start by flipping through the chapters to get famil-
iar with the content and the layout, then you can determine
where your interests are.
The book begins with an introduction to surgical tech-
nique. Being well prepared before entering the operating
room is key to your results and efficiency. You will find that
your preparedness will give you the respect and ready help
of all the OR staff. The second chapter is surgical anatomy. I
have tried to keep the anatomy very practical and have
placed clinical examples throughout. These first two chap-
ters are important — be ready to read them more than
once. Your success as a surgeon is based on your expert
technical manipulation of normal and abnormal anatomy.
My goal is that these chapters will start you on your way to
understand and perfect your operative technique.
The remaining chapters are topic oriented: ectropion,
entropion, ptosis, and the like. All chapters begin with an out-
line of what is covered, followed by a formal introduction to
the chapter topic. We move through a review of pertinent
anatomy, principles of evaluation and treatment, and finally
surgical techniques with practical tips. The chapters are writ-
ten in a hierarchal fashion that should make it easy to get the
basics and then dive more deeply into details on a second
read. Each chapter has a large amount of redundancy — this
is intentional. Look at the summary boxes and use the check-
points to make sure you actually remember what you just
read. You will find over 500 diagrams and a similar number
Preface
of photographs to help you understand and put the principles
into practice. Check out the suggested reading list for another
point of view. There are many good texts out.
For the second edition, there are many updates and addi-
tions. There is an expanded aesthetic surgery chapter.
Many of these procedures form a large part of many of
today's oculoplastic practices. You will get a new apprecia-
tion of the aging process and learn the basics of skin care,
resurfacing, peeling, and many surgical techniques. I have
included the important concepts of aesthetic forehead lift-
ing, midface, and full face and neck rhytidectomy. This is an
area where an experienced mentor is helpful. I have added
many new eyelid lesion examples, updates on the recon-
structive techniques for eyelid repair, and a section devoted
to the posterior approach to ptosis repair, among many
other changes. I hope that you will find these additions
exciting and helpful. The video section is greatly improved
with almost 100 videos dealing with the evaluation and
management of the wide range of problems in the periocu-
lar region and face. Don’t neglect to look at the videos that
introduce you to the book and also acknowledge all those
that have made contributions to my life and work.
For me, learning works best in a “layered” fashion. Start
with the big picture. Don’t try to learn it all at once. Read
and study the principles. Read again and again as many
times as it takes to get the details. After you gain confidence
in the principles and techniques, start with some easy proce-
dures. Some of the procedures can get quite complicated.
Ideally, you will have a mentor to help put what you learn
into practice. Don’t forget to collaborate with colleagues
outside your specialty. You will learn a good deal and make
some great friendships along the way.
The techniques described are not my own ideas, but
rather reflect 35 years of practice and learning from my tea-
chers, colleagues, and students. These are common
approaches to the problems that you will see in your prac-
tice. The concepts and the teaching style are my own and
the techniques described work for me. Of course, these tech-
niques are not the only ways to deal with particular pro-
blems definitely not the only ways that work but they
are ways that do work for me. Try the techniques as written.
As you get comfortable feel free to modify any part of the
operation that seems to be an improvement for you. Always
keep an open mind to learning, ask questions, understand
why something works, don’t be afraid to implement new
techniques. Put in the work and time to be a superlative sur-
geon, the master of understanding and technique.
iii
iv Preface

A couple words of personal advice. Although I am you in some way to enjoy your practice as much as I have
emphasizing the technique aspects of our practice, don’t for- enjoyed mine.
get to enjoy your patients, as well as the work you do in the Thanks again for reading this. If you have comments or
operating room. It is easy to take for granted the huge questions, feel free to write or email me at the addresses
respect and gratitude that your patients will show you. My below. You are on your way to a successful and rewarding
advice is to slow down a bit and let it soak in. You will enjoy surgical practice.
your practice more. You can be the best technician ever,
but without appreciating that taking care of your patients Jeff
means caring for your patients, you won’t be the best doctor Jeffrey A. Nerad, MD, FACS
you can be. Don’t miss the opportunity to feel the important Cincinnati Eye Institute
contributions that you make to your patients’ lives. I feel 1945 CEI Drive
very fortunate to have had a great academic career at the Cincinnati, OH 45242
University of Iowa and a terrific private practice career at jnerad@cvphealth.com
the Cincinnati Eye Institute. My wish is that this text helps

I would like to thank the many people that helped make this
book possible.
Thanks go first to my family. My parents, Frank and
Blanche Nerad, made learning fun for my siblings and me.
My daughters, Kristen and Elizabeth, and my wife, Jodi,
offered support and encouragement throughout the whole
process. Thank you very much.
So many colleagues have contributed to my education. In
many cases, I remember the exact moment that a particular
person taught me something that I use today. My formal
teachers, Rick Anderson, David Tse, John Wright, Richard
Collins, and Dick Welham, were generous in showing me
the “way” early in my career and continue to be valued
friends and colleagues. Many others have taught me
throughout my career. Special thanks to my colleagues
Robert Kersten, Jack Rootman, Jeff Carithers, and Keith
Carter. Thanks to all the residents and fellows that have
taught me so much over the past three decades. And thanks
to “too many to name” colleagues around the world that
have taught me and become long-time friends.
Acknowledgments
Many people helped with the production and technical
aspects of the current text and past editions. Special thanks to
some of my recent fellows (Jill Melicher, Rob Peralta, Blake
Fausett, and Caroline Vargason) and videographers (Randy
Verdick and Eric Redder) for the work on the new and old sur-
gical videos. Thank you to my office team for managing my
daily duties and correspondence. Thanks go to Susan Gilbert
who made the illustrations for the original text, and thanks to
the art teams at Elsevier for colorizations and new illustra-
tions. Thanks to the editorial and production teams at Elsevier
including Kayla Wolfe, Rae Robertson, and John Casey for all
the direction and hard work throughout the process of getting
this edition to you. I have included a video thanking many of
you who have helped me through my career as well.
Importantly, thanks to those of you that are reading this
new text. I am happy and grateful to be a distant preceptor
to you! I hope that this text will play a role in your future
successes. My best wishes for a long and fulfilling career.
v
Contents
1 The Art of Surgical Technique, 1 10 Diagnosis and Management of the Patient with
Tearing, 371
2 Clinical Anatomy, 29
11 Diagnosis of Malignant and Benign Lid Lesions
3 Diagnosis and Treatment of Ectropion, 93 Made Easy, 419
4 Diagnosis and Treatment of Entropion, 113 12 Eyelid Reconstruction, 465
5 Diagnosis and Management of Misdirected 13 Eyelid and Orbital Trauma, 505
Eyelashes, 131
14 Diagnostic Approach to the Patient with
6 Involutional Periorbital Changes: Upper Eyelid Proptosis, 545
Dermatochalasis and Eyebrow Ptosis, 149
15 Surgical Approaches to the Orbit, 611
7 Aesthetic Surgery of the Periocular Region and
Face, 189 16 Enucleation, Evisceration, Exenteration, and Care
of the Eye Socket, 655
8 Evaluation and Treatment of the Patient with
Ptosis, 275
9 Abnormal Movements of the Face, 339

vi

P1 Introduction to Techniques in Ophthalmic
Plastic Surgery, 2nd edition
1.1 Surgical Instruments: Using the Tools of Your
Trade Effectively
1.2 Sutures and Suturing Technique
2.1 Eyelid, Nasolacrimal, and Orbital Anatomy
3.1 The Lateral Tarsal Strip Procedure
3.2 Ectropion Repair: Lateral Tarsal Strip and
Medial Spindle
3.3 Floppy Eyelid Syndrome: Pentagonal Wedge
Resection
3.4 Full Thickness Skin Grafting for Cicatricial
Ectropion Repair
4.1 Entropion Repair, Retractor Reinsertion, and
Lateral Tarsal Strip
4.2 Spastic Entropion Repair: Quickert Sutures
4.3 Tarsal Fracture Procedure
4.4 Cicatricial Entropion Mucous Membrane Graft
5.1 Misdirected Eyelashes: Wedge Resection Upper
Eyelid
6.1 Upper Blepharoplasty: Colorado Needle
6.2 Upper Blepharoplasty: CO2 Laser
6.3 Direct Browplasty: Temporal Direct and
Complete Direct
6.4 Midforehead Browplasty
7.1 Cosmetic Botox Injection
7.2 Filler Injection for Facial Rejuvenation
7.3 CO2 Laser Resurfacing
7.4 Lower Transcutaneous Blepharoplasty
Technique
7.5 Upper Blepharoplasty and Lower
Transconjunctival Blepharoplasty
Video Contents
7.6 Pretrichial Forehead Lift
7.7 Brow Ptosis: Transeyelid Endobrowplasty
7.8 Coronal Forehead Lift
8.1 Acquired Blepharoptosis: Levator Aponeurosis
Advancement
8.2 Upper Blepharoplasty and Anterior Ptosis
Repair
8.3 Blepharoptosis Repair: Conjunctival Müller
Muscle Resection (CMMR)
8.4 Blepharoplasty and Conjunctival Müller Muscle
Resection (CMMR)
8.5 Frontalis Sling for Poor Function Congenital
Ptosis
8.6 Congenital Ptosis, Poor Function—Frontalis
Sling: Silicone Rod
8.7 Frontalis Sling Operation Using a Silicone Rod
Suspension for Apraxia of Eyelid Opening
8.8 Fascia Lata Sling: Congenital Ptosis Repair
9.1 Facial Spasms
9.2 Lateral Tarsorrhaphy
9.3 Medial Tarsorrhaphy
9.4 Eyelid Weight Implantation
9.5 Paralytic Ectropion, Facial Nerve Palsy: Cheek
Lift, Lateral Tarsal Strip, and Medial
Tarsorrhaphy
10.1 Three-Snip Punctoplasty
10.2 Canaliculitis: Three-Snip Punctoplasty
10.3 Nasolacrimal Duct Probing
10.4 Nasolacrimal Duct Probing with Silicone Stent
Placement
10.5 Lacrimal Fistula Excision
10.6 External Dacryocystorhinostomy
vii
viii Video Contents
10.7 Acquired Nasolacrimal Duct Obstruction:
Endoscopic Dacryocystorhinostomy
10.8 Epiphora and Nasolacrimal Duct Obstruction:
Endoscopic Dacryocystorhinostomy
10.9 Canalicular Obstruction: Jones Tube Placement
10.10 Canalicular Tear (Dog Bite) Repair Using Mini
Monoka Stent
10.11 Dog Bite: Bicanalicular Repair Using Crawford
Stents
10.12 Canalicular Repair Using the Pigtail Probe
11.1 Chalazion Incision and Drainage
11.2 Eyelid Lesion Biopsy Techniques
11.3 Lid Lesion Quiz: Benign or Malignant?
12.1 Myocutaneous Advancement Flap: Lower Eyelid
Reconstruction
12.2 Repair of Mohs Defect Using Split Thickness
Skin Graft
12.3 Mohs Excision Lower Eyelid Repair; Eyelid
Margin Repair
12.4 Primary Lid Margin Repair: Canthotomy and
Cantholysis
12.5 Lower Eyelid Reconstruction Using the Tenzel Flap
12.6 Hughes Flap for Lower Eyelid Reconstruction
12.7 Hughes Tarsoconjunctival Flap Take Down
12.8 Melanoma Cheek Defect: Mustarde Flap Repair
12.9 Lid Reconstruction: Hughes Flap, Mustarde
Flap, Node Dissection
12.10 Median Forehead Flap Reconstruction for Basal
Cell Carcinoma
13.1 Eyelid Trauma: Upper Eyelid Margin Repair
13.2 Chainsaw Injury: Eyelid Laceration Repair
13.3 Blowout Fracture: Floor Repair With Implant
13.4 White-Eyed Blowout Fracture: Floor Repair
Without Implant
13.5 White-Eyed Blowout Fracture: Medial Wall
Repair
14.1 Proptosis
14.2 Upper Eyelid Recession for Thyroid Eye
Disease
15.1 Anterior Orbitotomy: Optic Nerve Sheath
Fenestration
15.2 Anterior Orbitotomy: Lacrimal Gland Biopsy
15.3 Anterior Orbitotomy: Lateral Dermoid Excision
15.4 Anterior Orbitotomy: Medial Dermoid Excision
15.5 Transconjunctival Anterior Orbitotomy: Orbital
Lipodermoid Excision
15.6 Anterior Orbitotomy Using Vertical Lid Split for
a Superior Orbital Mass
15.7 Anterior Orbitotomy for Removal of Inorganic
Foreign Body
15.8 Anterior Orbitotomy for Removal of Metallic
Foreign Body
15.9 Anterior Orbitotomy for Removal of Sino-Orbital
Osteoma
15.10 Introduction to Endoscopic Orbital
Decompression and Deep Orbital Biopsy
15.11 Lacrimal Gland Tumor: Lateral Orbitotomy
15.12 Sphenoid Meningioma: Craniotomy for Orbital
Apex and Optic Canal Debulking
15.13 Eyebrow Craniotomy: Hemangioma of Superior
Orbital Fissure
15.14 Enlarging Vascular Lesion: Transcranial
Orbitotomy
15.15 Temporal Artery Biopsy
16.1 Blind Painful Eye: Phthisis; Enucleation with
MedPor Implant
16.2 Blind Painful Eye: Enucleation with MedPor Ball
Implant and Lateral Tarsal Strip
16.3 Blind Painful Eye: Evisceration
16.4 Conjunctival Squamous Cell Carcinoma with
Orbital Invasion: Exenteration
 1 The Art of Surgical Technique

CHAPTER OUTLINE Introduction 1 Forceps 12

Preparation for the Operation 1 Dissection Technique 13
Firm Plan with Contingencies 1 Retractors 13
Skin Marking and Local Anesthesia 2 Hemostasis 15
Preparing and Draping the Patient 4 Preoperative Considerations 15
Instruments 4 Tamponade 15
Cutting the Skin 5 Cautery 15
Hand Position 5 Bone Wax 17
Scalpel Blades 6 Drugs 17
Other Cutting Tools 6 Drains 17
Placement of Skin Incisions 7 Suction 17
Anxiety and Tremor 7 Suturing 18
Cutting Tissue with Scissors 8 Types of Suture Material 18
How Do Scissors Cut? 8 Types of Needles 19
Types of Scissors 8 Needle Holders 20
Cutting with Scissors (You Learned Suturing Technique 21
This as a Child) 10 The Surgical Assistant 24
Retraction and Exposure 11 Major Points 27
Fingers as Retractors 11 Suggested Reading 28
Skin Hooks 12

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.

stress some fundamental techniques, including holding and

Introduction
Welcome! I hope that this book will add to your success in
the clinic and operating room. It is my pleasure and honor
to 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 team
know what it is. If you are prepared, you will inspire the
team to follow your leadership. You will coordinate the
setup of the operating room and equipment necessary for
your procedure.
To be effective, you need to know the tools of the trade
and how to use them. In this chapter, we discuss different
types of instruments and their general and special uses. We

Chapter title is in recognition of Dr. Milton Edgerton’s excellent book by
the same name, which I recommend all surgeons read.
cutting of the skin. We describe the important instruments
used in retraction, hemostasis, suctioning, and suturing. In
the last section, we talk about the role of the assistant, who
has 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, going
into more depth each time. Scan the chapter initially to get the
flow of the material, and then go back and peruse the content
casually. Don’t labor over the details of each section; rather,
read the text several times as your abilities and interests
increase, 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 a
lot 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 a
firm plan in mind. Early in your career, it is helpful to have a
1
2 1 • The Art of Surgical Technique
set of contingency plans if things don’t go as expected. As
your surgical expertise increases, your need to make formal
contingency plans will disappear. At the early stage, or later
when you are planning a new procedure, it is helpful to
write down the steps of the operation and list the necessary
equipment and then bring the list to the operating room.
The nursing staff will appreciate your preparation and be
confident in your abilities.
You are the team leader in the operating room. Your
behavior sets the stage for how the operation goes. You set
the pace and the quality of the entire effort. If you are oper-
ating in a new setting, be sure to introduce yourself to the
nursing staff. Discuss your plans for surgery with the team.
Your preparation and willingness to include them in your
plans will improve the overall effort and give the team confi-
dence in your ability to get the job done. This approach
applies to every surgeon, from new residents to experienced
surgeons in practice for many years.
Room Setup
Part of your plan should be to know where the operating
equipment is placed. Generally, the setup is as shown in
Figure 1.1. In most cases, the position and orientation will
be the same for each procedure in a particular operating
room. For example, usually the head is away from the
door and away from the flow of traffic in the room. In
some cases, the operated eye will be placed away from the
anesthesia equipment. You, as the surgeon, will sit at
the head of the bed. Your assistant will sit at the side of the
bed 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 be
comfortable. The nursing table is placed on the side of the
operating table, opposite any anesthesia equipment and
staff.
Equipment Setup
For most operations, you will be in the sitting position. If
you are planning to move around the patient during the
operation, as in an orbital floor exploration for a blowout
fracture, you may want to stand. If so, consider step stools
to make the assistant and surgeon relatively the same
height.
Once you have decided whether to sit or stand, you
should position the operating room table. Often it is helpful
to angle the head of the table away from the anesthesia
equipment. Remember to consider where the operating
room overhead lights are when positioning the table. Adjust
your chair to an appropriate height with your feet flat on
the ground. Adjust the table height so that your elbows are
bent slightly more than 90 degrees. Make sure that the
patient’s head is at the top edge of the operating table and
the plane of the face is parallel to the floor so you will not
have to lean over the patient. Take the patient’s pillow and
place it under the patient’s knees.
Do your best to position the patient for the comfort of
both the patient and yourself. When operating on chil-
dren, your view will improve if you place a towel roll
under 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 the
head for comfort. Markedly kyphotic patients may need a
pillow under the neck and shoulders for comfort. You
may have to operate standing at this patient’s side with
the head of the bed elevated. In some cases, you can raise
the foot of the bed so that a kyphotic patient is flatter
on the table. Do your best to maintain reasonable posture.
Many older surgeons have to alter or stop their surgical
practices because of the neck aches and back pains that
result 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 Trendelenburg
position (head up, feet down) before adjusting the
table height. Once the table is at the chosen position and
height, make sure that it is locked into position.
If you are using an operating microscope, this is the time
to make adjustments to the scope and your chair. There are
several possible positions for the scope base, but the most
common is off the shoulder of the patient opposite to the eye
on which you are operating. Set the base of the scope to
allow for the full range of the microscope’s arm. Make gross
adjustments to the microscope height. Set the interpupillary
distance of the microscope heads for the surgeon and the
assistant. Set the focus of the microscope. If you are doing a
conjunctival or canalicular procedure, set the focus of the
microscope in the middle of the range. If you are doing deep
orbital surgery, set the focus at the top of the focus travel so
that you are able to adjust the focus with the foot pedal to
see deeper tissue without repositioning the operating scope
as the dissection continues into the orbit. Most procedures
are performed without a wrist rest, but don’t hesitate to use
one if it increases your steadiness. If you plan to drape the
scope, swing the microscope arm away without altering
your microscope base position and have the scrub nurse
drape the scope away from the operating field. Consider
using sterile handles or sterile baggies over the handles
rather than draping the whole scope to save time and
money. Position the microscope and cautery foot pedals in
the appropriate spot underneath the head of the table. If
you don’t do this, you may be surprised at how many times
you start the operation and reach for the cautery pedal but
find that it is not yet ready to use. Do all this before you leave
to scrub.
SKIN MARKING AND LOCAL ANESTHESIA
Many oculoplastic procedures require skin marking as a
guide to incision placement. Most incisions are placed in nat-
ural skin creases, such as the upper lid skin crease for ptosis
and blepharoplasty operations. Other skin incisions are
placed adjacent to anatomic structures so the scar will be hid-
den. You should mark the skin before any local anesthetic is
injected. 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 of
a broken applicator used as a quill. With experience,
you can draw a fine line that does not easily wash off with
prepping, but this takes some experience to keep from
making a mess. Usually, we use a thin-tipped surgical

Anesthesiologist
Patient
Anesthesia
equipment
Surgeon
Figure 1.1 Typical operating room setup for an operation on the right eye.
marker (Blephmarker 1424 Gentian Violet Twin Ultra
Fine Tip Ruler Sterile, Viscot.com, reference 1424SR-100).
Be sure to degrease the skin with an alcohol wipe before
marking.
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 mixture
is 2% lidocaine with 1/100,000 epinephrine in combina-
tion with 0.5% bupivacaine. Some surgeons choose to add
hyaluronidase to the mix, but I have not found this neces-
sary. For larger scalp and face procedures, you may want
to consider “tumescent” anesthesia. With this technique, a
large 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 develop
flaps 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
1 • The Art of Surgical Technique 3
Circ nurse
Scrub nurse
"Back"
instrument
table
Mayo
stand
Assistant
into your eyelid; you will not soon forget how it feels). Two
factors are thought to be responsible: (1) a difference in pH
and (2) the distention of the tissues during rapid injection.
To minimize the pain, try injecting a tiny amount—about
0.1 mL—into two or three places and then massage the
local anesthetic into the tissues. After a few seconds, inject
more anesthetic very slowly. This greatly minimizes the
pain. Some surgeons buffer the local anesthetic using one
part 7.5% sodium bicarbonate in nine parts 2% lidocaine
with epinephrine (2 mL of bicarbonate in 20 mL of lido-
caine). I have not found this worth the trouble, but many
surgeons swear by it. If you operate with an anesthesiolo-
gist, using appropriate sedating agents, the patient is totally
unaware of any local injections.
Remember to inject just beneath the eyelid skin. Avoid
placing the needle into the muscle to prevent a hematoma,
which may make intraoperative adjustments of the eyelid
difficult; this is especially true with anterior ptosis correc-
tion. Avoid putting the needle in the crease at the junction
4 1 • The Art of Surgical Technique
of the lateral one third and medial two thirds of the eyelid.
There is a vessel that, if torn, will guarantee a hematoma
before you start the procedure! For an upper eyelid proce-
dure, such as a blepharoplasty or ptosis repair, you should
inject 1 to 1.5 mL of local anesthetic mix.
The topical solutions that provide anesthesia are EMLA
cream and Betacaine gel. EMLA cream should be applied
in a thick coating 1 to 2 hours ahead of the procedure and
covered with an occlusive dressing (topical lidocaine 2.5%
and prilocaine 2.5%). BLT cream (20% benzocaine, 6%
lidocaine, and 4% tetracaine) is an alternative. Betacaine
gel (topical lidocaine 5%, http://www.sanofi.com) can be
applied for 20 to 30 minutes ahead of the procedure with-
out an occlusive dressing. These preparations provide
some anesthesia but do not cause vasoconstriction, so an
additional local injection with epinephrine is required for
surgical procedures. Topical agents are also useful prior to
Botox 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, but
you might find them helpful in some situations. You may
be able to avoid taking a child to the operating room for
suturing if you apply topical cream before injection of any
local anesthesia.
Most eyelid and lacrimal operations can be performed
under local anesthesia. If you choose to operate without
the benefit of an anesthesiologist, you should consider
intravenous (IV) sedation to minimize the patient’s anxi-
ety. Doses of midazolam in 0.5- to 1.0-mg increments are
reasonable to achieve some relaxation. I find it helpful to
have a midazolam drip running (1 to 3 mg/hour) rather
than give intermittent doses of the medication. Some sur-
geons prefer preoperative oral sedation with 2 to 10 mg
of oral diazepam. Additional pain relief can be given
intraoperatively using small doses of a narcotic, such as
morphine (1 to 2 mg IV). Intravenous fentanyl is useful
because of its short duration, but keep in mind that this is
a very potent opiate narcotic and a highly abused drug.
Surgical centers often do not permit the surgeon to
administer this without anesthesia staff oversight. Avoid
oversedation to the point that the patient has lost inhibi-
tions and gets restless or is too sleepy to follow your
instructions. A supportive attitude from you and the
nursing staff (sometimes called talk-esthesia or vocal
local) is helpful. I am always impressed by how many
postoperative patients comment on how helpful it was to
have the circulating nurse offer to hold hands during the
procedure. The nurse can also alert you when the patient
is feeling discomfort.
If your operating situation allows for the efficient use of
monitored anesthesia care, your anesthesiologist can medi-
cate your patient to the point at which there is no memory
of any pain from the injection and often no memory of the
entire operation. The downside of this is more staffing and
an increased cost. The majority of my eyelid and lacrimal
procedures are done with monitored anesthesia care in our
practice-owned ambulatory surgery center. If you plan to
ask for any intraoperative patient cooperation, such as eye-
lid opening for a ptosis adjustment operation, make sure
that no IV midazolam is administered until you have com-
pleted the adjustment. As you would expect, working with
the same anesthesia and nursing team on a regular basis
increases your efficiency greatly and can make your life in
the operating room much better.
PREPARING AND DRAPING THE PATIENT
In most operating rooms, the patient can be prepped while
you scrub. This gives time for the local anesthetic to take
effect. A traditional povidone-iodine scrub applied in con-
centric rings away from the planned surgical excisions,
repeated three times, provides adequate cleaning of the
skin. A surgical bonnet and a drape with a single sticky
edge (bar drape) across the forehead keep the patient’s
hair out of the operating field. If the hairline is particularly
low or close to the operating field, tape can be used to pull
the hair away from the field. For most procedures for
which the patient is awake, the entire face is prepped
under local anesthesia. If the patient is asleep, prep both
eyes whenever there is a need to obtain symmetry
between the two sides or if forced duction testing may be
required. A good general rule is to prep a larger area than
you think you will need. Most of my patients are draped
with a single split sheet (U-drape) spread over the face. It
is worth considering placing a towel over any endotra-
cheal tube before placing the U-drape so that the adhesive
on the drape does not stick to the tube (and it is always a
good idea not to pull the tube out when tearing the drapes
off the patient!).
Instruments
In the next sections of the chapter, we will discuss several
types 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 of
each of these instruments. I am going to explain the instru-
ments that I have found most useful in my practice. You
may already have your own favorite tools for specific jobs,
or you may choose to use the instruments that I have
suggested.
Particular instruments are available in different lengths
and calibers. In general, the length of the instrument is
related to the depth of the surgical incision in which the
instrument is used. Most of the eye instruments are only
4 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 are
much longer, often measuring 12 inches. An example is the
curved Yasargil scissors used in optic nerve sheath fenestra-
tion. These instruments are 9 inches long and have a finer
tip than the familiar Westcott scissors used for eye and car-
diac surgery. Ideally, for an optic nerve procedure, I use a
6-inch instrument, but none is currently available in this

scissor type so I make do with the longer instrument. The
caliber or strength of the instrument varies, depending on
the type of tissue to be manipulated or cut. Conceptually,
you want to pick the correct instrument based on length
and caliber. We talk more about the individual variations of
each 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 a
patient who has been prepped and draped, your next job is
to make a skin incision. Remember you are positioned with
your feet flat on the ground and your elbows at your side in flex-
ion slightly more than 90 degrees. Hold your hands in the
functional position (like holding a pencil), with your hand in
slight flexion at the wrist. This improves your dexterity and
strength.
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 traditional
scalpel but also to the cutting cautery needle and CO2 laser.
It is worth learning the traditional surgical techniques with
the scalpel and scissors. As your skill increases, you will
likely find that using the microdissection needle or laser
shortens the operating time. Although some surgeons use a
blade 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 area
where your index finger rests. The scalpel is supported
between 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 or
the assistant’s fingers. Let your ring finger rest on the
Figure 1.2 Holding the scalpel with the pencil grip. Note that the
hand is in the functional position in slight flexion.
1 • The Art of Surgical Technique 5
patient, stabilizing the skin or guiding your hand. Learn to
use the ring finger on your dominant hand and the thumb
and forefinger on your nondominant hand to stabilize the
skin (Figure 1.3). If the tissue is slippery, using a gauze pad
for some traction will be helpful.
It is best to start the skin incision with the tip of the scalpel
blade. As you move across the incision, lay the scalpel down
so that you are cutting with the curved part of a no. 15
blade. As the wound edges start to separate, observe the
depth of the wound. Ideally, you want to cut the eyelid skin
only and not extend the cut deep into the orbicularis. This is
difficult to do but, nevertheless, worthwhile. Controlling the
depth of any eyelid incision is critical. Remember that the
eyelid is only slightly more than 1 mm thick at the skin
crease, and you do not want to extend your incision into the
cornea! You might find initially that using a corneal protec-
tor is a useful safeguard. With experience, you will probably
find it easier not to use a corneal protector for scalpel cutting
or cutting cautery incisions, but surgeons vary on this opin-
ion. Adjust the pressure to maintain the proper depth of the
wound. As if you were driving a car, look down the road as
you pull the scalpel across the skin. All of this is happening
as you or your assistant holds steady tension on the skin.
Remember, tight skin is more easily and accurately cut
than more mobile skin. Like most instruments for eye and
eyelid surgery, the scalpel is a finger tool. As you bring your
fingers toward your palm with the scalpel tip, you may need
to reposition your hand and repeat the cutting process in
lengths of the wound (Figure 1.4). As you get more experi-
enced, you will be able to flex your fingers and move your
hand at the same time.
This is a good time to remind you about having a good
body position. You should feel relaxed and at ease as you cut.
Figure 1.3 Skin stabilization. During upper eyelid blepharoplasty, the
skinfold is stabilized and stretched with the surgeon’s fingers while
the upper eyelid is drawn downward using a lid margin traction
suture. Note that a Colorado microdissection needle is being used
for the incision. With experience, the traction suture can be
eliminated and the surgeon can use fingers to stretch the skin tightly.
( The original micropoint electrocautery needle was called the
Colorado needle. Other brands of true microdissection needles are
now available. In this text, the terms Colorado needle and
microdissection needle are used synonymously. However, this fine
tungsten microtipped needle should not be confused with the older
needle point monopolar cautery tool available in many operating
rooms.)
6 1 • The Art of Surgical Technique
A A B A
Figure 1.4 Flexion of the fingers with the scalpel blade followed by movement of the hand.
Make sure your elbows remain close to your side rather
than up high; having them up high converts the scalpel to
an arm tool rather than a finger tool. You will be making
many incisions in your life, so learn to cut away from impor-
tant structures such as your fingers and the eye. Familiarize
yourself with the several types of scalpel blades available.
SCALPEL BLADES
’ No. 11 blade: This blade has a sharp point that is good
for tight angles and curves. It is a good “stabbing” knife
for draining an abscess or a chalazion. It is not useful
for longer incisions.
’ No. 15 blade: This is the best all-purpose scalpel blade
for eyelid and facial skin; 99% of your eyelid surgery
with a scalpel will be done using a no. 15 blade.
’ No. 10 blade: The no. 10 blade is shaped like a no. 15
blade except it is bigger. This blade is used primarily for
thicker skin incisions. It is not used for periorbital
incisions but can be helpful in facial flaps.
’ Beaver blades (www.bvimedical.com): The no. 66
Beaver blade (376600) is a special-purpose right-angled
blade. Its primary use is for making cuts in tight spaces.
It is especially useful for nasal mucosal incisions in
dacryocystorhinostomy procedures. Angled keratomes
designed for anterior segment surgery work in a similar
fashion (Figure 1.5). Other useful blades are the no. 64
blade (376400 rounded tip, sharp on one side) and the
no. 76 blade (376700, a mini no. 15 blade), both of
which are useful for the delicate shaving of tissue off
the sclera or cornea. The needle blade 375910 is good
when you need to make a microincision. Beaver
handles come in a variety of lengths, the most common
being 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. The
microdissection 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 cauterizing
the thin eyelid tissues. The needle is made of tungsten and
has an extremely fine tip. Tissue in contact with the tip is
vaporized. Getting used to this instrument takes some prac-
tice. Cutting the tissue should be done with superficial light
passing over the tissue in a “painting” motion and the nee-
dle slightly angled as if you are using a paintbrush. If you
B A B C
find that carbon is building up on the tip of the instrument,
you are moving too fast, cutting too deep, or have the power
turned up too high. The trick of using this tool is cutting
only at the very tip so that there is little thermal damage to
the surrounding tissues. You learn that “pulling” the layers
of tissue apart is essential for this tool and gives a very clean
dissection with little collateral damage to the adjacent tis-
sues. Using a “blend” mode setting on the cautery machine
provides cutting and cautery. Try this for the dissection of
an upper eyelid blepharoplasty skin muscle flap. Once you
get used to this “bloodless” field, you will have trouble going
back to scissors. You should use a smoke evacuator to elimi-
nate the hazardous smoke produced by this tool. The patient
requires grounding, as with the use of any unipolar cautery
equipment. 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 and
causes pain for many patients under local anesthesia. The
tip works on the dry eyelid skin but works best on tissues
deep to the skin. For this reason, some surgeons prefer using
a blade for the initial skin incision because the edges of the
wound are cleaner. They switch to the needle for any deeper
work. You may find the Colorado needle with a foot pedal
useful, but I prefer the hand switch on the cautery handle
itself. Several companies make a microdissection needle
(e.g., Stryker makes the Colorado microdissection needle,
www.stryker.com, and Medtronic makes the Valleylab
tungsten microsurgical needle E1650, www.medtronic.
com). The shortest-length needle is the easiest to work with
on 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, with
excellent cautery of capillaries and small veins. The
UltraPulse CO2 laser was introduced years ago and remains
a workhorse in my practice. The current model is the
UltraPulse Encore made by Lumenis (www.lumenis.com).
These lasers remain the gold standard for laser incisional
and resurfacing work. As when using a microdissection
needle, large vessels are often cut with the laser rather than
cauterized, 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 you
have a CO2 laser available, you should try it as a cutting
tool. You must emphasize the pulling apart of the tissues
with your forceps, even to a greater degree than with a
microdissection needle. There is no touch or feel involved in
the cutting. It is all visual, so technique is very important.
Once you learn it, you love it. Patients have less discomfort
with the CO2 laser than with the Colorado microdissection

A B
C hands become “silkier” when they have taken a beta-
Figure 1.5 Surgical cutting instruments. (A) Colorado microdissection
needles. 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.
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 must
wear protective goggles. Smoke evacuation is necessary.
Care with oxygen and the use of wet drapes are important
to prevent fire. Most procedures in this text use the microdis-
section needle, but I suggest you try the laser, especially for
upper blepharoplasty. The skills that you learn using the
microdissection 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 wrinkle
lines (Figure 1.6). The upper lid skin crease is a natural place
to make incisions in the upper lid. The upper lid skin crease
is often carried laterally into a laugh line. If you are not
familiar with the wrinkle lines of a certain area, ask the
1 • The Art of Surgical Technique 7
patient to contract the facial muscles in that area. Seeing
the wrinkles and folds in the skin shows you where to place
your incisions. You can anticipate these lines. The natural
skin creases occur perpendicular to the direction of the mus-
cle fibers causing the creases. By contracting your frontalis
muscle 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 them
near 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 to
the lower lid lashes (subciliary incision). This incision can
also be carried laterally into a laugh line. Similarly, an eye-
brow incision can be hidden by placing it adjacent to the
upper or lower margin of the eyebrow hairs. Incisions can be
placed 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 include
pretrichial hairline incisions, preauricular skin incisions,
and incisions along the alae of the nose. Older-style incisions
such as the Stallard-Wright lateral orbitotomy incision and
the Lynch incision have been largely replaced by incisions
that leave a better scar.
ANXIETY AND TREMOR
Every surgeon has a tremor to some degree or another. This
tremor is worse when you are anxious, are tired, or have
drunk too much coffee. If you find that your tremor is both-
ersome, try to eliminate these factors. I occasionally hear of
a resident who takes a beta-blocker before performing an
operation. This can serve as a confidence booster but is
likely not necessary once you learn to relax during surgery,
although I do know experienced surgeons that feel their
blocker. A big part of being anxious when learning surgery
is the feeling that you will look bad to your teacher or others
observing. Consequently, you get more nervous and your
tremor increases. Don’t forget, everyone in the operating
room is on your side, doing everything they can to help you
do 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 deserved
empathy, and your tremor will settle down a bit. Take a few
deep breaths. Make sure that your chair and the
table height are appropriate. Try to relax your forearms and
loosen your grip on the instruments. If this does not work,
consider a wrist rest. I have yet to see a student who had a
tremor that kept him or her from being a successful surgeon.
CHECKPOINT
• Remember to have a plan when you enter the
operating 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 pace
for the operation.
• You must have a plan for the operation and some
contingencies if things don’t go as planned. You would
be surprised how many residents come to the operating
room expecting to be “shown” what to do. As a
resident, the more you prepare before entering the
8 1 • The Art of Surgical Technique

O G

N
F

J
P
H

L
M

B
E

K
C

D
I

Figure 1.6 Facial incisions are typically hidden in natural skin creases or placed next to anatomic structures for camouflage. A, Upper lid crease
incision 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, Gingival
upper buccal incision. L, Forehead furrow incision. M, Suprabrow incision. N, Pretrichial incision. O, Transcoronal forehead incision. P, Endoscopic
browplasty incisions.

operating room, the more you will get to do and the

faster you will learn.
• Get the patient, operating table, your stool, and your
body in a comfortable position before starting. Have all
the equipment prepared before you make a skin
incision.
• Why should you mark the skin and inject the local
anesthetic before scrubbing?
• Do you need to write down the names of the special
instruments, sutures, or equipment you will be using?
• Let the operating room nurses know what you are
planning, especially if you anticipate any change from
the routine.
• Practice stabilizing and cutting the skin on pieces of
chicken at home. It is not the perfect model, but it can
be helpful. Practice everything you can at home,
including cutting, suturing, and tying. Operating room
time is very valuable.
• Learn to be comfortable and relaxed in the operating
room. As a surgeon, it is your home and workplace for
a big part of your career.
Cutting Tissue with Scissors
HOW DO SCISSORS CUT?
Scissors cut by the shearing action of the blades crossing so
close together that tissue between the blades is separated in
a 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. Some
surgeons do, however, use scissors to cut the thin skin of the
eyelid. Most surgeons reserve scissors for the dissection of
deeper tissue planes.
TYPES OF SCISSORS
In the Storz instrument catalog (storzeye.com, now a part of
Bausch and Lomb), there are more than 50 pages showing
over 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 you
can make a sensible choice in selecting the right scissors for
 1 • The Art of Surgical Technique 9

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 the
wound in which you are working. Most of the instruments
on the eye tray are 4 inches long. This size goes with the
scale and depth of the usual ocular procedures. Longer Figure 1.7 Blades of the straight Mayo scissors compared with those
instruments would be less steady and bump into the of the curved Stevens tenotomy scissors. Notice that the length and
microscope. You will use many 4-inch instruments in caliber of the scissors are also different.
oculoplastic surgery. Plastic surgery instruments are usu-
ally 6 inches long and fit the normal hand size better, for
instance, a Metzenbaum scissors. In most cases, the longer
neurosurgical instruments are not useful. For orbit sur-
gery, on occasion, you may use a longer neurosurgical
scissors 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 delicate
Westcott scissors to cut through the thick dermis of the
cheek. Similarly, you would not use the tough Mayo scissors
to cut eyelid skin. Remember it is the blade tip size, not
the length of the instrument, that you should consider for
the 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 tissue Figure 1.8 Dissection of levator aponeurosis from Müller’s muscle
planes. Sharp scissors are used to cut through tough tis- using curved Westcott scissors. Note how pulling the tissues apart
sues such as scar tissue. A sharp-tipped Westcott scissors creates bands of tissue that are easy to see and cut. The convex side
works better than a blunt-tipped Westcott scissors to open of the scissors blades should be against the tissue that is the
strongest, in this case, the aponeurosis.
an eyelid cyst. Facelift scissors have slightly sharpened
rounded tips to facilitate flap dissection in the subcutane-
ous plane.
Scissors Blade Design tissue bands are seen stretching between the tissue planes
Scissors blades are straight or curved (Figure 1.7). Most (learning to “pull” the layers apart is the most important
straight scissors are used for cutting sutures and bandages surgical technical tip I can give you; more on this later).
and are sometimes called suture scissors. It is easier to cut The convex surface of the scissors can slide up the fibrous
a straight line with straight scissors than with curved scis- bands and rest against the aponeurosis. Cutting can be
sors, and vice versa. Remember to use the curve of the performed without buttonholing the aponeurosis
scissors blade to your advantage (the curve of the scissors (Figure 1.8). This technique is useful for separating any
should follow the curve of the eyelid crease, for example). tissue planes. Another good example is separating
Curved scissors are useful for tissue dissections. The Müller’s muscle from the conjunctiva.
curved angle of the blade lifts the tissue planes apart as the
tip cuts the reflected tissue, which is placed on stretch. Scissors Cutting Motion
The curve of a scissors blade is easy to palpate through tis- Scissors are composed of opposing blades held together by a
sues. You will learn to protect tissues against the convex central pin. Most scissors close and open with opposite hand
surface of the curve. An example of this technique is sepa- motions, stabilized by one or more fingers in the ring holes
rating the levator aponeurosis muscle from the underly- (often called ring scissors). You can control the force when
ing Müller’s muscle. As the two layers are pulled apart, fine opening the blades, as well as the force when closing the
10 1 • The Art of Surgical Technique
blades, with your hands. This allows you to use the scis-
sors tips as a dissecting tool as you spread open the tissue
planes by opening the scissors. Spring scissors open with
the recoil of a spring mechanism in the handle of the scis-
sors. Westcott scissors are an example of this type. These
scissors are generally used for fine tissues where minimal
hand motion is important (finger tools). The spring
action determines the force of the opening of the blades.
Stevens tenotomy scissors are ring scissors with slender
curved blades; they are common 4-inch scissors used fre-
quently in ophthalmic procedures (see Figure 1.7). Iris
scissors are a type of delicate, sharp-tipped ring scissors
designed with short blades that are either curved or
straight. Although the usage is technically incorrect, the
term iris scissors has almost become generic and has been
applied to any pair of straight scissors used as suture cut-
ting scissors.
Westcott scissors can be used as a spreading tool useful
for separating delicate layers, for example, separating the
conjunctiva from Tenon’s capsule, orbital septum from orbi-
cularis muscle, Müller’s muscle from levator aponeurosis,
conjunctiva from lower eyelid retractors, or any adjacent
delicate tissues from each other. Remember that dissection
is more about pulling layers apart and using the convex side
of the blades to tease the tissues away from each other than
it is about cutting the tissues.
Scissors cut by a shearing action. Most ring scissors are
designed as right-handed cutting tools. Imagine holding a
pair of scissors in your hand. Push your thumb away from
the palm and pull your fingers toward your palm. This
action squeezes the blades of the scissors more tightly
together, increasing the cutting power. You may recall
doing this as a child playing with dull scissors. You quickly
learn that squeezing the blades together increases the cut-
ting power. Try doing this with your left hand; there
is much less shearing action. This is why left-handed
children (and techs and surgeons, as well) sometimes
have trouble cutting with right-handed scissors. Try
squeezing the blades together the next time you use a pair
of scissors. Compare cutting sutures or tissues with your
left hand instead of your right hand; you will appreciate
the difference.
CUTTING WITH SCISSORS (YOU LEARNED THIS AS A
CHILD)
Spring scissors, or Westcott scissors, are held as finger tools,
like a pencil. As with any scissors, you should gently squeeze
the blades together in a continuous action. As the scissors
cut, watch the tissue separate. Avoid clicking or snipping the
scissors closed in one quick motion (close the scissors like you
may have been taught to slowly squeeze the trigger of a gun
or a camera shutter release button). Quick motions do not
allow you to evaluate the depth or length of the scissors’ cut
as you proceed. Observing how the tissues spread apart as
you cut them is the very best way to stay in the correct sur-
gical plane.
If you watch less-skilled surgeons or nurses cut your
sutures you see that they often snip away at them. This type
of cutting is too inaccurate for tissues.
As you proceed with cutting tissue, do not close the
blades completely to the tips. You lose your place in the
Figure 1.9 Holding scissors. Left, Ring scissors (a finger-and-hand
tool). Right, Westcott scissors, the most common spring scissors used
in eyelid surgery (a finger tool).
wound if you close the scissors. Again, remember when you
first learned to use scissors as a child. Initially, every time
you cut a piece of paper, you would close the scissors blades
completely. It was difficult to make a straight, continuous
smooth line. You had to start over each time you cut. As
you learned to use the scissors better, you found that you
could more effectively cut a continuous line by closing the
scissors halfway to two thirds of the way and then advanc-
ing the blades forward. This is the same technique that you
should use in cutting tissue. As the blades cut approximately
halfway closed, push the blade forward in the same plane and cut
again. Do not cut with the full closure of the blade until the
end of the incision.
Remember when cutting with curved scissors to position
the curve of the scissors along the curve of the incision.
Many of the incisions that you make, such as the skin crease
incision, are curved.
When using a ring scissors, rest your middle finger in one
ring and your thumb in, or on, the other ring. Use this grip
with the index finger providing three-point fixation of the
scissors (Figure 1.9). These larger scissors are useful as a
finger-and-hand tool. You will find a comfortable thumb
and finger position, often not totally within the ring. The
same cutting motion that is described above should be
used with this type of scissors. You might want to practice
this technique on a piece of paper to make sure that you
have the idea. You may be using scissors in more than one
way already. Dr. Edgerton’s book nicely describes the
function of scissors. Scissors can be used for cutting
sutures 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 lateral
sweeps or pull wedges. Small vessels may be squeezed
closed with the shearing action of scissors. Palpation of
the curved blade of scissors can be used to help guide a
deep tissue dissection.
CHECKPOINT
• Compare two types of scissors that you may be familiar
with: straight Mayo scissors and Stevens tenotomy scissors
(see Figure 1.7). Mayo scissors come in many variations,
 1 • The Art of Surgical Technique 11

A B

Figure 1.10 Uses of scissors. (A) Shearing cutters. The normal cutting action of the scissors is shown with Westcott scissors trimming redundant skin
and muscle off a lower blepharoplasty flap. (B) Push cutters. The blades are open halfway (top), and the tissue is cut by pushing the scissors against
the 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 pull
wedges. 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 (dull
side). This can be used to create a dissection plane, for example, between the orbicularis muscle and the orbital septum. Scissors are typically used
in this fashion to open an abscess pocket.

so look at the scissors pictured. This variation is almost
7 inches long and has thick straight blades with fairly
pointed tips. The Stevens scissors are just over 4 inches
long and have thinner curved blades with blunt tips.
Which scissors would be best for cutting sutures in a
deep abdominal wound? The Mayo scissors, of course.
The straight, thick, pointed blades are not well suited for
tissue plane dissection. The shorter, curved, blunt-tipped
blades of the Stevens scissors are ideally suited for the
tissue plane dissection of the relatively superficial layers
of the eyelid.
• Think of which layers of the eye or eyelid would be
appropriate for Westcott scissors. Would you choose
sharp or blunt Westcott scissors for a conjunctival
peritomy? The soft conjunctival and episcleral tissues
would tear if sharp-tipped scissors were used.
• Remind yourself how to cut tissue using a plain piece of
paper. Draw a straight and a curved line. Try cutting the
line in “snips.” Now try cutting the line with smooth
continuous strokes, not closing the blades completely.
Which is easier, more accurate, and faster? Cut the
straight line with a curved scissors. Cut the curved line
with the curved scissors using the curve of the blades
with the curve of the line. Now cut the curved line with
the scissors blades turned against the curve. You should
be getting the idea that learning how to use your tools
correctly 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
12 1 • The Art of Surgical Technique

ocular surgery is done with a lid speculum. You will learn

to use a variety of tools to hold the tissues. You are already
familiar with the best and gentlest retractor of all, your fin-
gers. All of the fingers on your nondominant hand can be
used to support or stretch the tissues. As you are working,
you can hold a cutting tool in your dominant hand with
your thumb and first and second fingers and, at the same
time, use the ring and small fingers as retractors (visualize
holding a blade with the pencil grip and stretching the tis-
sues with your other fingers, and then try to do this). A
finger 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 is
one of the oldest surgical instruments and, when used cor- Figure 1.11 Skin hooks (left to right): Large double-pronged (Joseph)
rectly, one of the gentlest retractors. Skin hooks are avail- skin hook, lacrimal rake, small double-pronged skin hook, small
able in different sizes and with varying numbers of prongs. single-pronged hook (Tyrell).
The most useful skin hook for eyelid surgery is the Storz
double fixation hook, a small double-pronged hook (Storz
E0533; Figure 1.11). There are also small single-pronged
hooks that can be used for very delicate tissues (Tyrell iris
hook, Storz E0548) and rake-type skin hooks with multiple
prongs that are used for lacrimal surgery (Knapp lacrimal
sac retractor, Storz E4538). A large double-pronged skin
hook, known as the Joseph double hook (Storz N4730), is
useful 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 a
good all-purpose, soft tissue retractor for facial proce-
dures. Obviously, you must be quite careful not to pull the
hook toward the eye where inadvertent puncture of the A
globe could occur.

FORCEPS
The most common type of instrument for holding tissue is a
forceps. All forceps work the same, using a pinching action
of the fingers to grasp tissue. Forceps differ in length, caliber,
and tip. Length and caliber differ for the same reasons as all
instruments in general. The tips of forceps can either be
smooth or have teeth.
Smooth forceps generally cause more trauma than for-
ceps with teeth. Because there is low friction on the tip of
smooth 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 occasion
forceps 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 and
small serrations on the inner surface of the blades. These
variations increase the friction of the forceps and reduce the
pressure required to grasp the tissue.
Jeweler-type forceps are the smooth pointed forceps
that you are probably already using to remove delicate
sutures (Storz E1947 1). Jeweler forceps do not grasp
tissue well.
Forceps with teeth offer a better grip with less crushing of
tissue. You should use forceps with teeth whenever possible.
Several types of forceps with teeth are available. The most
common form has two teeth on one blade opposing a single
B
Figure 1.12 Forceps. (A) From top down: Adson forceps (large forceps
with teeth, for cheek and scalp), forceps without teeth (smooth), and
Paufique forceps with teeth (the most common forceps that you will
use). (B) Forceps tips. Left to right: Adson forceps, smooth forceps,
and Paufique forceps.
tooth on the other blade. In general, forceps with multiple
small teeth are more delicate than forceps with fewer and
larger teeth. As you grasp the tissue with forceps you should
use gentle pressure to close the tips. The teeth should not
leave 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 skin
hook to lift and sometimes unroll a skin edge. This blade is
known as a lifting jaw. When grasping tissue, select the
layer of tissue that is the least susceptible to injury. It is
better to grasp the dermis or subcutaneous fat than the
skin edge directly.
 1 • The Art of Surgical Technique 13

Box 1.1 Dissection Technique That You Must Know

’ Most surgery is not cutting; rather, it is separating tissue
planes.
’ Grasp the tissue layers that you want to separate (don’t hold
the skin when you are separating the muscle from the
septum).
’ 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 close
the blades.

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

The Paufique forceps are great for most periocular work.

They have small teeth that grasp delicate tissues, but the
blades 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 with
teeth. Useful more delicate forceps include the Castroviejo
suturing forceps, more familiarly known as point 1 2, point
3, 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 proximal
to the teeth so the suture will not slip with tying. Heavier
forceps useful in the cheek, scalp, and lower face include
Figure 1.14 Jaffe eyelid speculum in place. The speculum can be
Adson and Brown Adson forceps (Storz N5405 and used to open the surgical wound (as shown here for a lacrimal gland
N5420). biopsy), or it can be used to elevate an eyelid away from the
It is worthwhile to page through the Bausch and Lomb operating site. It is a useful tool in almost every eyelid procedure.
Storz ophthalmic and ENT/plastic surgery catalogs (www.
bauschinstruments.com). You will be amazed at the variety
of instruments available.
to sharply incise the tissues. Have an experienced surgeon
check your dissection technique to confirm that you are cor-
DISSECTION TECHNIQUE
rectly pulling the tissues apart and separating the planes
Most surgery is not cutting but rather separating tissue with the cutting tool. This concept of dissection is so impor-
planes. This concept may be the most important in this text. tant. Read this paragraph again and make sure that you
The surgeon and assistant should pull the tissues apart as understand the principle. Consciously try it next time you
the surgeon separates the tissues with the cutting tool. For are in the operating room.
example, to separate the orbicularis muscle from the orbital Remember to avoid “snips,”; close the scissors slowly.
septum, the surgeon should hold the scissors in the domi- Watch how the tissues open. This can be one of the most
nant hand and grasp the muscle with the forceps in the elegant and rewarding of surgical techniques (Box 1.1).
nondominant hand. The assistant should grasp the septum
with another forceps. Working together, the two pairs of
forceps pull the orbicularis muscle off the septum. You will
RETRACTORS
see small fibrous bands that are easy to separate with the There are three types of retractors:
scissors, Colorado needle, or laser (Figure 1.13). In a sense,
your nondominant hand shows your dominant hand what ’ Self-retaining retractors
to do. It is easy to operate with an experienced surgeon as ’ Handheld retractors
your assistant because the layers are pulled apart for you. ’ Suture retractors
Use this technique whenever possible. There are a few
planes in which using this technique is not possible. For The Jaffe eyelid speculum is an excellent self-retaining
example, in the subcutaneous plane of the cheek, you have retractor for eyelid surgery (Figure 1.14). This speculum
14 1 • The Art of Surgical Technique

Figure 1.15 The Desmarres lid retractor is used similarly to the Jaffe Figure 1.16 Orbital retractors (top, left to right): malleable retractors
lid speculum but must be handheld. This retractor can be placed over and Sewall retractors. (Below) Neurosurgical cottonoids.
a Jaffe lid speculum for extra retraction, a useful combination. Here,
the Desmarres lid retractor is opening a skin crease incision to drain a
superior orbital abscess.

was originally designed for cataract surgery to retract the

eyelids independently without any pressure on the globe. I
use this retractor in almost every lid procedure (www.katena.
com, K1 8000, sold as a pair). Self-retaining retractors are
rarely used in orbital surgery because it is difficult to position
the retractors adequately in the orbit. The constant pressure
on the tissue with a self-retaining retractor can limit circula-
tion to the eye. There are self-retaining retractors made for
lacrimal surgery, but I have not found these instruments to
be satisfactory.
Handheld retractors are useful but require a good assis-
tant. The well-trained assistant will move the retractors
as the surgery proceeds from one area to another (good
assistants “dance” with the surgeon as they move across
the surgical field). When maximum retraction is not nec- Figure 1.17 Use of 4-0 silk suture retractors for exposure of an
essary, the assistant eases the pressure on the retractor to external dacryocystorhinostomy wound.
improve 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 shape
of the Desmarres lid retractor is helpful for atraumatically
retracting the tissues. Useful orbital handheld retractors length for deep orbit cases. The familiar nasal speculum is a
are the malleable retractors and the Sewall orbital retrac- type of handheld retractor.
tors. The flat-bladed malleable retractors are available Sutures can be used as retractors. No manipulation by a
through a number of companies and come in straight and surgical assistant is necessary. As many sutures as neces-
tapered varieties (symmetrysurgical.com and surgicalinstru- sary can be placed to provide good tissue exposure (4-0
ments.com are good sources). Tapered malleable retractors silk). Handheld retractors can be placed on top of the suture
are helpful in deep wounds but require special ordering. retractors to give extra retraction when necessary. As with
Sewall retractors are commonly used to retract orbital tissues. any other static or self-retaining retractor, if problems with
A disadvantage of both malleable retractors and Sewall circulation are anticipated, suture retractors should be
retractors is that towing-in of the retractor may damage tis- avoided or frequently released (Figure 1.17). Small hooks
sues, especially those deep in the orbit (experienced orbital on elastic bands can be used as retractors, as well. The
surgeons fear the towed-in retractor as a cause of blindness hooks can be easily repositioned as the need for a different
more than any cutting instrument). You will find that exposure comes up (http://www.medline.com/product/Lone-
orbital exposure is improved by lining the wound with Star-Retractor-Hooks-by-Cooper-Surgical/Z05-PF65677).
neurosurgical cottonoids (similar to the lap sponges you used These hooks are best for larger facial or neurosurgical
to pack off the bowel as a general surgery student) dissections. You need to be extra careful with hooked instru-
(Figure 1.16). I prefer cottonoids of 1/2-inch width and 3-inch ments around the eye.

Hemostasis
PREOPERATIVE CONSIDERATIONS
Achieving hemostasis is another new technique for most
ophthalmic surgeons. You need to master some simple tech-
niques for controlling bleeding if you are going to do eyelid
surgery safely. Effective hemostasis technique begins with
using an injection of local anesthetic with epinephrine
(1/100,000) in every operation on the face. You should
always inject the local anesthetic before prepping the
patient and scrubbing, allowing about 10 minutes to pass
to achieve maximum hemostasis.
Your time in the operating room will be shorter, and your
patients will suffer less postoperative bruising, if you remind
them to stop taking anticoagulant medications before surgery.
General recommendations are as follows. Warfarin should
be stopped 5 days preoperatively with the consent of the
patient’s internist. Aspirin-containing products and other
platelet aggregation inhibitors (e.g., clopidogrel, ticagrelor,
or Aggrenox [ASA and dipyridamole]) should ideally be
stopped 10 days before surgery. Nonsteroidal antiinflamma-
tory medications should be stopped 3 to 5 days before sur-
gery. There are many newer anticoagulant medications
used as alternatives to warfarin. It is best to have your
patient consult with the primary care doctor before disconti-
nuing these medications. In some cases, bridging therapy
with enoxaparin may be required. Under some circum-
stances, operating on a patient who is anticoagulated may
be necessary, but to minimize the chances of hemorrhage,
you should stop anticoagulants whenever reasonable. That
being said, at times I do perform procedures for a patient
who is still taking anticoagulants. Obviously, trauma
patients 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 and
orbital surgery. Damaging hemorrhage after these operations
is rare and consequently difficult to study in a randomized
fashion. Studies in the neurosurgical and dermatologic litera-
ture suggest a less strict approach to discontinuing anticoagu-
lants. You should consider any negative systemic effects of
discontinuing anticoagulants, prior to making any recom-
mendations to your patients. In most cases, it is best to have
the patient consult with his or her primary care doctor about
the safety and duration of discontinuing anticoagulants. As
many as one third of your adult patients are taking one or
more of these medications. This is an evolving discussion and
likely will continue to change over the next several years. The
bottom line is that a decision regarding anticoagulants should
be made on an individual basis in consultation with the
patient’s primary care physician.
Most patients do not consider aspirin and other over-the-
counter medications as being important when you ask
what medications they are taking. You must ask specifically
about these medicines. A long list of herbal remedies can
affect coagulation, especially when used in combination
with other anticoagulants. Among others, the three G’s
(garlic, ginseng, and ginkgo) should be stopped before an
operation. 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.
1 • The Art of Surgical Technique 15
TAMPONADE
An easy way to temporarily control bleeding is tamponade.
Your finger, a gauze pad, or a cotton swab compressing the
bleeding tissue against bone will stop most bleeding epi-
sodes. Similarly, you can obtain hemostasis by pinching the
tissue between your fingers or in a forceps. This is usually a
temporary measure, but it will minimize blood loss and facil-
itate your attempts to use cautery. An example of this is the
bleeding that occurs after a wedge resection of the lid. The
marginal artery usually bleeds. By holding the lid margin
between 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 wound
may be packed with a gauze sponge to control bleeding. As the
packing is removed, you may be able to isolate individual
bleeding spots.
Most arteries encountered in oculoplastic surgery do not
require clamping and tying to gain control of bleeding.
However, placing a small hemostat on a bleeding artery
may facilitate your attempts to use cautery. For larger arter-
ies, suture ligatures or vascular clips can be used, but this is
usually necessary only in large orbital procedures. You can
avoid bleeding in enucleation surgery by clamping the optic
nerve before cutting it. This requires some practice but
leaves a dry orbit after the removal of the eye. The stump of
the 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 small
areas of bleeding. In general, these are too inefficient for any lid
surgery other than the smallest procedures, such as lid biopsies
or chalazion incision and drainage. There are several brands
available. The high-temperature model is best for periocular
tissues. You can control the temperature of the heated wire
somewhat by turning the cautery unit off and on. If you
depress the finger switch on continuously while you apply cau-
tery, the tip gets very hot (more than 2000 F) and will burn
through the tissue, often causing more bleeding. On occasion, I
use the hot tip as a cutting and cautery tool for dissection of
delicate vascular tissues, as in the separation of Müller’s muscle
and the levator aponeurosis muscle, and it works nicely.
Remember to turn off any supplemental oxygen when using
this 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 little
spreading of tissue damage. Normally, the tissue is wet enough
to conduct the current between the cautery tips (this type of
cautery is also referred to as a wet field cautery). Many sur-
geons accustomed to doing ocular surgery have a difficult time
using bipolar cautery for eyelid surgery. The main problem is
16 1 • The Art of Surgical Technique
holding the cautery tips too closely together, preventing ade-
quate amounts of tissue from being cauterized. The current
has to flow through the tissue held between the cautery tips to
affect coagulation. Using a bipolar cautery with nonstick tips
(Weck Biceps coagulator with nonstick tips) works well. Like
other instruments, bipolar cautery forceps are made in different
lengths with different tips (the jeweler forceps tip is a good size
for eyelid operations).
You must become adept at bipolar cautery to do eyelid
surgery. Consider these three steps:
’ Exposure
’ Tamponade
’ Cautery
Your assistant should provide exposure of the bleeding area
with 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-tipped
applicator and the bipolar cautery tool. Bipolar cautery technique
is easiest if the surgeon, rather than the assistant, applies the tampo-
nade (the roles can be reversed, but the same person using the
cautery tool should provide the tamponade). The surgeon
places the bipolar tips in proximity to the cotton-tipped applica-
tor. The applicator is rolled away from the bleeding site, and
cautery is applied immediately. If bleeding is brisk, you may be
able 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
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.)
cautery is the microdissection or microsurgical needle dis-
cussed above. When placed on the blend mode this needle
provides simultaneous cutting and cautery and reduces the
bleeding of soft tissues dramatically. Keep in mind that there
is some collateral tissue damage when using a unipolar sys-
tem, so the power settings should be as low as possible for
coagulation (on our machine, 12 cut/12 cautery/12 bipolar
blend mode). Your hands usually move more slowly when
you are a beginner. You might consider using a slightly
lower setting on cut and cautery to minimize the spread of
the 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 (or
microsurgical) needle should not be confused with the
broader needle of other unipolar systems. The tungsten tip
of the microdissection needle is much finer and causes less
thermal damage to the surrounding tissue. Unipolar cau-
tery with a wider flat blade is used only when all other
attempts to stop bleeding fail. Remember that teamwork is
necessary for efficient hemostasis techniques. A helpful
assistant can make a big difference.
In my opinion, a smoke evacuation system is necessary
when using this instrument (Figure 1.18). The smoke plume
can contain toxic gases and vapors (such as benzene, hydrogen
cyanide, and formaldehyde), bioaerosols, dead and live cellular
material (including blood fragments), and viruses. Breathing
the smoke can cause respiratory symptoms. No reported infec-
tions due to smoke inhalation have been confirmed so far. In
vitro studies have shown a mutagenic potential.
Surprisingly, many operating rooms do not routinely use
these 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 to
vacuum the smoke. As an alternative, vacuum attachments
 1 • The Art of Surgical Technique 17

that fit directly on the cautery handle can be used. Although I intraarterial embolization of large vessels to minimize bleed-
find that these can be a bit bulky, they do make the smoke ing encountered during surgery is very helpful.
evacuation process easy (see Figure 1.18).
DRAINS
BONE WAX
Suction drains can be used postoperatively to increase
You will encounter bleeding from small perforating vessels hemostasis and decrease swelling and the risk of infection. If
in bone. Bipolar cautery will not stop this bleeding. Unipolar you are performing surgery involving large flaps, active suc-
cautery can be used to provide hemostasis in bone because tion devices (grenade type) attached to a Jackson Pratt
the current spreads directly into the bone. As a better alter- drain are helpful. Some surgeons use passive drains, such as
native, you can use small pieces of paraffin or bone wax to Penrose or rubber band drains, routinely for orbital surgical
plug the bleeding sites. The surrounding bone must be dry procedures. I rarely use drains with periocular procedures.
to get the wax to stick. For large reconstructive facial flaps and facelift procedures,
Placing a small amount of bone wax on a Freer elevator drains can be helpful. Remember that a drain is not a substi-
and spreading it over the bleeding bone works well. A good tute for intraoperative hemostasis.
alternative in deeper surgical wounds is to put a tiny ball of
wax on the end of a cotton applicator and push/twist the
applicator onto the bleeding bone. For larger, easily accessi-
ble areas, bone wax on your finger works well. Suction
Suction is a useful technique to clear unwanted blood, irri-
gation fluid, or other fluid from the surgical site to increase
DRUGS
exposure of the operative wound. Three types of suction tips
We have already talked about the preoperative use of epineph- are used in oculoplastic surgery (Figure 1.19):
rine in the local anesthetic (1/100,000 or 1/200,000) to
decrease bleeding. You will notice the effect of the epineph- ’ Flexible suction catheter
rine on the surgical site by the blanching of the injected ’ Yankauer tonsil suction tube
area. Similarly, injections can be used intraoperatively for ’ Frazier and Baron suction tubes
additional vasoconstriction. Initially, the hydrostatic pres-
sure effect of the injected fluid into the tissue helps control The flexible suction catheter can be used to suction blood
capillary bleeding, as well. You can apply 0.05% oxymeta- and irrigation fluid out of the nostril when you are perform-
zoline or 5% cocaine solution topically to the nasal mucosa ing tear duct surgery. It is also useful to pass this catheter
to cause vasoconstriction. Agents such as Gelfoam, Avitene, down the nasopharynx to remove fluid before extubation.
and Surgicel can be used to promote clotting, increasing The Yankauer tonsil suction tube is an all-purpose suction
platelet activation. Surgicel is now available in a powdered tip used primarily in wide surgical wounds when a large-
spray, which is useful when you encounter nasal mucosal bore general suction device is needed, but it can be used in
bleeding. Thrombin (topical Thrombogen) works a step later the throat, also. The Frazier suction catheter is the most
in the clotting cascade, stimulating the conversion of fibrin- useful suction device for oculoplastic surgery. This metal
ogen to fibrin. A small piece of Gelfoam soaked in thrombin angled catheter (9 French) provides directed and accurate
solution as a packing material is an excellent way to stop suction to individual bleeding sites. A small version of the
recalcitrant bleeding from the nasal mucosa (because it Frazier suction catheter is called the Baron catheter (avail-
enhances platelet aggregation and fibrin formation). able as a 3, 5, or 7 French). Most suction catheters have a
If you start constructing bigger flaps or doing reconstruc- port that can be occluded to increase the pressure. For mild
tive craniofacial work, you will become familiar with pro-
ducts that can be “lifesaving.” To stop troubling bleeding
or cerebrospinal fluid leaks, FLOSEAL and TISSEEL (www.
baxter.com) are especially helpful. FLOSEAL contains
bovine thrombin suspended in gelatin granules, so the
mechanism is similar to the Gelfoam/thrombin combina-
tion. The mix sticks to wet tissue and does not swell to the
degree that Gelfoam does. TISSEEL (a fibrin glue) contains
human fibrinogen, bovine thrombin, and an antifibrinolytic
agent (to stabilize the clot). FLOSEAL tends to be more useful
for cranioorbital applications, but you should know about
both. Stammberger Sinu-Foam (carboxymethylcellulose
fibers mixed with saline in a syringe) and similar products
are designed for endoscopic sinus surgery to control bleed-
ing, prevent adhesions, and improve mucosal healing. Your
neurosurgical and ENT colleagues can give you tips on how
to 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 will Figure 1.19 Suction types (top to bottom): Yankauer tonsil suction,
Frazier suction tubes, Baron suction tube, and flexible suction catheter.
find that when removing vascular tumors, preoperative
18 1 • The Art of Surgical Technique
bleeding, this port does not need to be occluded. When more
bleeding is present, the port may be occluded to give more
suction. When dealing with tissues that are easily sucked
into the catheter tip, such as orbital fat or brain, you should
suction over a gauze pad or neurosurgical cottonoid to clear the
fluid 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. You
might find that clamping the suction tubing when it is not
in use makes the operating room quieter.
The rigid suction tubes can also be used to provide gentle
retraction 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 and
surgeon each holding one.
CHECKPOINT
• What is the best retractor?
• How are forceps with teeth like retractors? Which is
gentler: forceps with teeth or smooth forceps?
• Try the Jaffe lid speculum on the next ptosis procedure
you perform (your operating room may have to order
one for you).
• Review the different types of self-retaining and handheld
retractors. When you place suture retractors, try placing
them at the intersection of the thirds on each side of the
wound.
For cautery with an assistant, there are four hands avail-
able. The assistant’s hands provide retraction, usually with
two pairs of Paufique forceps or skin hooks. The surgeon’s
hands 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-tipped
applicator away to expose the exact point of bleeding.
• Coagulate the vessel (making sure you have enough
tissue between the blades).
Ask the operating room nurses what types of suction
tips 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 the
part number of each suture needle. They are there for
your reference later. Skip over the details. Learn the main
points 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 no
removal is required. Common absorbable sutures are made
of gut (fast-absorbing, plain, and chromic), polyglactin 910
(Vicryl), polyglycolic acid (Dexon), poliglecaprone 25
(Monocryl), or polydioxanone (PDS). These sutures vary in
degradation time from 5 days to a few months. Permanent
sutures do not degrade in human tissue. Examples include
nylon, polyester, polypropylene (Prolene), and stainless steel
sutures. 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 tissue
reaction and are easier to pull out than multifilament
sutures. Braided sutures are easier to handle than monofila-
ment sutures (said to have a better “hand”). Multifilament
sutures have a higher coefficient of friction and therefore
maintain tension on a wound and hold a knot better than
monofilament sutures. You need to use the 3-1-1 tie with
monofilament sutures, but you can usually use a 1-1-1 tie
with braided sutures. Silk sutures (permanent multifilament
braided sutures) are considered the gold standard in terms
of handling and tying. Manufacturers sometimes combine
characteristics to make a more versatile suture. An example
of this is braided nylon sutures, which are permanent
sutures with little tissue reactivity; they have a better hand
than monofilament nylon.
Natural fibers, including silk and gut, are available.
Chromic sutures are gut (collagen) sutures that have been
treated for greater resistance to absorption. Fast-absorbing
gut sutures are used on the skin and are reabsorbed in 5 to
7 days. Synthetic sutures include nylon, polyester, Prolene,
and expanded polytetrafluoroethylene (PTFE or Gore-Tex).
Wire sutures, usually stainless steel, are used in some types
of fracture and telecanthus repairs. Skin staples can be used
in the scalp where a less precise closure is necessary.
You might notice that we have not mentioned glue so
far. Surgical skin adhesives can be useful but really have
not caught on much at this point. Dermabond Advanced
(Ethicon) is an alternative for sutures. You can use it on small
lacerations in children and avoid the local anesthetic. I have
used it on external dacryocystorhinostomy incisions and
functional skin crease incisions with good success, and it is
used in many other areas of surgery. It is helpful to put oint-
ment on the skin around the wound where you do not want
the glue to adhere. I expect we will see more use of surgical
glues in the coming years. You may want 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 good
materials from which to choose. If you are interested in detailed
closure choices, read on. If not, skip to the section on needles.
These are the common suture choices for me. In the last
5 years I have moved away from absorbable sutures for
most cases. Absorbable sutures tend to scar more, often
untie or break, and frequently are not entirely gone at 1
week, causing the patient some consternation. Sometimes
suture tracks form. The benefit of absorbable sutures is that
they do not have to be removed (and patients don’t like to
have sutures removed), and no need for removal means sav-
ing some time postoperatively in the office, but using
Prolene sutures makes removal easy. The suture material is

slick, and it is easy to pull out an entire running suture. I
often put two extra interrupted sutures in the skin crease
prior to placing a running closure. The blue color of these
sutures makes them easy to see, especially around the eye-
brow hairs. In cases where you are trying to end up with
the least possible amount of scarring, a subcuticular
Prolene suture removed at 5 to 8 days is a nice option (see
below). For subcutaneous closure, I use PDS sutures (or
sometimes Vicryl). There is a tendency for Vicryl sutures to
“spit” (that is, sterile abscesses may rise to the surface as the
sutures become absorbed). The monofilament absorbable
sutures, PDS and Monocryl, do not do this, but they require
more careful knot tying because they are slipperier. Clear
sutures do not show through thin skin but are more difficult
to place. Silk sutures (4-0) placed with a cutting needle are
my main choice as a tissue retraction suture.
TYPES OF NEEDLES
Several types of needles are available. Needles have the same
parts but vary by shape, size, and point (Figure 1.20) as follows:
Shape
’ 3/8 circle
’ 1/2 circle
’ 1/4 circle
3/8
Point
1/2
1/4
A B
C
Taper Conventional cutting
Figure 1.20 (A) Needle shapes. (B) Needle parts. (C) Needle points.
1 • The Art of Surgical Technique 19
Size
Point
’ Tapered
’ Cutting
’ Reverse cutting
’ Conventional cutting
’ Spatula
The most common shape is the 3/8-circle needle (see
Figure 1.20B). These needles are used for all general-purpose
suturing. 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 a
half-circle needle in oculoplastic surgery is to attach the lat-
eral tarsal strip to the periosteum (4-0 Mersilene, braided poly-
ester, Ethicon 1779G, double-armed S-2 spatula needle). 4-0
Polydek with a half circle is another good choice (Teleflex
Deknatel, 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 lateral
orbital rim and the orbital tissues. The 4-0 Mersilene and
Polydek sutures are permanent and do not cause as many
suture granulomas as 4-0 Vicryl sutures. I use a double-
armed suture that nicely “tucks in” the strip against the
periosteum. The mucosal flaps of an external dacryocystorhi-
nostomy can be closed with a short half-circle needle (only
Swaged
end
Body
Reverse cutting Spatula
20 1 • The Art of Surgical Technique
8 mm) and a chromic gut suture (Ethicon 798; 4-0 chromic
gut G-2 half-circle cutting needle). The 6-0 chromic needle
would be a better choice, but the available 11-mm needle is
too 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 pass
through tissue. Two types of needle points are available:
taper and cutting (see Figure 1.20C). Taper-point needles
come to a sharp point and push through tissue. There is no
cutting edge of the needle. Taper needles are used in delicate
tissues such as bowel (and conjunctival blebs). In oculoplas-
tic surgery, taper needles are used for bridle sutures under
extraocular muscles to minimize injury to the muscle if
penetrated.
Most needles you use are cutting needles. Cutting needles
have sharpened edges along the curvature of the needle.
Rather than push through the tissue, these needles cut the
tissue, facilitating penetration of the needle through
the 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 are
on the outer curvature.
The conventional cutting needle, when viewed on end, is a
triangle pointed upward. The sharp edge of the cutting needle
is on the inner curvature. Typically, a conventional cutting
needle creates a bigger hole in the tissue than a reverse cut-
ting needle. The natural motion of passing a needle tends to
pull the needle superiorly out of the wound. If the cutting
blade is facing upward, the needle tends to cut superiorly as
well as along the needle pass. The reverse cutting needle
easily pushes through the tissue without enlarging the nee-
dle tract.
Several variations of cutting needles are available. The
most common variation is the spatula needle (see
Figure 1.20C). The spatula needle is designed to pass
through tissue in a lamellar fashion. Spatula needles are
useful when you want to pass a suture in a lamellar fash-
ion through thin tissues, such as the sclera or tarsus. You
have likely used a 5-0 Vicryl spatula needle to reattach an
eye muscle to the sclera. Many surgeons use a spatula
needle to reattach the levator aponeurosis to the tarsus
when performing a ptosis operation (more on that in a
couple of sentences).
Many other variations of taper and cutting needle points
are 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 the
same size and shape. Try to pass a tapered 4-0 silk suture
through the lid margin as a traction suture. Repeat the
same needle pass with a 4-0 silk suture on a reverse cutting
needle. There is an amazing difference in the way the needle
is passed.
The size of the needle corresponds to the size of the suture.
This choice largely depends on how much strength is
required to keep the tissues sewn together. Thicker tissues
under greater tension require larger sutures. Often, the
choice of needles and suture size is a process of elimination.
A smaller suture would break and a larger suture seems
too big.
The next time you are in the operating room, ask the
nursing staff to show you the suture packs. There is a dia-
gram of the needle shape and point on each package. You
are guaranteed to be overwhelmed if you browse the
Ethicon suture catalog online. It has some good illustrations
showing comparisons of needle sizes and shapes that are
useful when you are looking for a new suture and needle.
You might find it interesting to look at some of the needle
and 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, is
impressive but often taken for granted.
NEEDLE HOLDERS
Two types of needle holders are used in oculoplastic
surgery:
’ Spring handle (Castroviejo needle holder)
’ Ring handle (Webster-type needle holder)
The most common needle holder is the Castroviejo needle
holder. This spring-action needle holder is excellent for the
delicate work of oculoplastic surgery. The Castroviejo needle
holder is held with the traditional pencil grip because it is a
finger tool (Figure 1.21). The index finger and thumb con-
trol precise movements for delicate suturing. I prefer the
locking variation of the Castroviejo needle holder. It should
not be used for needles larger than 4-0, however.
The traditional plastic surgery ring handle needle holder
is used for 4-0 or greater sized needles. The most commonly
available ring handle needle holder is the Webster needle
Figure 1.21 Holding the needle holder. Left, The pencil grip of the
spring (Castroviejo) needle holder. This is the most common needle
holder that you will use. Right, The thumb/ring finger grip of a ring
handle (Webster) needle holder.

holder. This type of needle holder is held with the thumb/
ring finger grip. The index finger serves to direct the tip of the
needle holder. This grip allows the needle holder to be used
with 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 you
look at a larger needle, you will notice that there is a flat
platform that ends where the suture is swaged onto the nee-
dle (see Figure 1.20A). If you hold the needle on the round
part 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 have
selected the appropriate size, curve, and point of the needle
and have positioned it properly in the needle holder. You
are holding the needle holder with either the pencil grip for
delicate 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 is
away from the site of the next needle pass. Always suture
with 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 you
control the tissues, that is, get the tissues to act the way that
you want them to act. Grasp the tissue lightly with the tooth
of the forceps very close to where you want to place the nee-
dle point. Place the point of the needle directly adjacent to the
forceps and drive the needle through the tissue following
the curve of the needle, pushing the needle toward your
chest. Take note of the depth at which the needle emerges
from the wound. Grasp the near side of the wound and place
the tip of the needle at the same depth. Continue passing the
needle until the needle holder touches the skin and the pass
is complete. Regrasp both wound edges directly adjacent to
the needle and begin to pull the needle out of the wound. Do
not grasp the tip of the needle. Advance the needle until you
can regrasp it three fourths of the way back, so you can load
the 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 the
forceps and pull it out. As the needle is being pulled out, you
use your needle driver to reload the needle. My preference is
the former method. You might try both. The important part
is not to spend a lot of time reloading the needle. Practice
reloading 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 suture
through the skin of an orange or apple. You will save lots of
time in the operating room by learning more and getting
more experience ahead of time. Then, in the operating
room, you can learn the things that only operating room
experience can teach you!
Recently, I have begun using a helpful long-time suturing
technique. Hang a single-prong iris skin hook from the end
of the wound. This puts the wound under some tension, sta-
bilizes the edges for suturing, and helps with spacing. The
technique works well for upper eyelid skin crease incisions.
1 • The Art of Surgical Technique 21
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 dead
space, provide wound stability, and remove tension from
the final skin closure. Deep sutures are not required on the
eyelid skin but are used in the periocular area. Deep suture
passes may be placed through periosteum, muscle, subcuta-
neous fat, or the dermis of thicker skin. Any dead space
should be closed with deep sutures to prevent hematoma
formation. Deep sutures may be used to anchor skin and
muscle flaps and provide fixation and usually some degree
of anatomic overcorrection. Long-lasting absorbable suture
material (such as PDS, Vicryl, Dexon, or Monocryl) is usu-
ally used for buried sutures. My personal preference is PDS
suture for most subcutaneous closures.
Superficial sutures are placed on the skin. Superficial
sutures may be either interrupted or running (continuous).
Interrupted sutures provide accurate wound alignment and
appropriate eversion of the wound edges. When repairing a
complex laceration, you can use interrupted sutures ini-
tially to tack together the wound in an anatomically correct
alignment. When you are suturing a long wound, a good
place to start is to divide the wound into halves with inter-
rupted sutures. This prevents misalignment of the wound
edges 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 because
slightly more inversion of the wound may occur. Running
sutures are faster to place and easier to remove than inter-
rupted sutures. Generally, I use a continuous running
suture with 6-0 Prolene to close eyelid incisions. Often, I
place two interrupted sutures at the junction of the thirds of
the wound to fix the skin crease at the top of the tarsus. I
also place an interrupted suture at the most lateral end of
the wound to prevent the bunching that can occur when a
running suture is tied. This was a common complaint of my
patients until I started adding this single interrupted suture
to the running closure.
Some surgeons close the skin crease using a “subcuticu-
lar” suture. This suture enters the end of the wound, and
the trailing end is tied on itself. The needle is passed in and
out of the wound edges in a plane parallel to the skin sur-
face. The suture travels through the most superficial portion
of the orbicularis muscle (“subcuticular” here is really a
misnomer; there is no subcutaneous layer of the eyelid
skin). At the end of the wound, the needle is brought
through the skin and the suture is tied on itself. After about
1 week, the knot at one end of the wound is cut and the
suture is pulled out. Prolene suture, 6-0, is ideal for this clo-
sure as it is slippery and easy to pull out. Remember that
Prolene requires a 3-1-1-1 tie to ensure a secure knot.
For wounds outside of skin crease lines, it is best to use
interrupted sutures to give better wound eversion, prevent-
ing a depressed scar. Two types of interrupted sutures are
used to close the surgical wound:
’ Simple suture
’ Vertical mattress suture
Simple suturing is the most commonly used interrupted
suturing technique (Figure 1.23A). When correctly placed,
22 1 • The Art of Surgical Technique

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)
 1 • The Art of Surgical Technique 23

’ 6-0 Prolene: eyelid skin closure (used as single arm), posterior ptosis (Ethicon 8726 C-1 13-mm 3/8-circle taper, double-armed), another
favorite 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.

My new favorite suturing technique for forehead and

A B
C D
Figure 1.22 Passing the needle through the wound. (A) Pass the
needle to enter perpendicular to the skin. (B) The needle should leave
and enter the wound edges at the same depth. (C) Use the Paufique
forceps to grasp both edges of the wound. Advance the needle with
the needle holder, first pushing the needle in and then pulling the
needle out. Take care not to grasp the tip of the needle to avoid
dulling. (D) When the needle is advanced enough, reload it before you
remove it from the tissue. You are then ready for the next needle pass.
simple sutures provide good wound alignment and eversion
of the wound edges. When a greater amount of wound ever-
sion is necessary, vertical mattress sutures can be used (see
Figure 1.23B). The far far, near near suture pass is espe-
cially useful to provide wound eversion of the lid margin
when you are repairing a lid laceration. In skin creases, a
simple running suture is used (see Figure 1.23C).
other periocular incisions is the running vertical mattress
suture (I first saw it in the newest version of the textbook
Eyelid Surgery: Principles and Techniques by C. McCord, Jr.,
and M. A. Codman). After tying the first interrupted
suture, take a wide deep bite and move backward and
place a narrow, more superficial suture, and then repeat
alternating the wide deep and (moving backward) narrow
superficial sutures. This is a great way to get the eversion
benefits of a vertical mattress suture with the speed of a
running 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 the wound, it can be excised
at the expense of a slightly longer scar (see Figure 1.24B).
Tying the Suture
Most sutures passed in oculoplastic surgery are tied with an
instrument tie. There are some simple tricks that you should
learn to make your knot tying secure and efficient
(Figure 1.25A). Imagine passing a suture through the wound
edges. As you withdraw the needle, the two arms of the suture
make a V. Place your instrument in the V and wrap the needle
end of the suture around the needle holder twice (see
Figure 1.25B). Grasp the end of the suture with the needle
holder (see Figure 1.25C) and pull your instrument toward
you (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 the
wound edges. You have created a new V in the suture arms.
Repeat the wrapping of the needle holder and now reverse the
pull of your hands with the needle holder being pulled away
from you (see Figure 1.25E). Make sure that the knot lies down
squarely 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, grasp
one end of the suture with your forceps (held in your non-
dominant hand) close to the end of the suture. Orient the
suture to be parallel to the needle holder (sometimes using a
gentle twist or pulling the suture). Now wind the suture
around the needle holder (not the needle holder around the
24 1 • The Art of Surgical Technique
A
B
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.
suture). Because the needle holder and the suture are paral-
lel, there will be very little “spring” in the suture and little
tendency for the suture to unwind from the needle holder.
Be sure that you understand this. The second point to
remember is that before you wind the suture around the
needle holder, place the needle holder close to the end of the
suture you are about to grasp to complete the tie. Avoid the
tendency to bring the needle holder to the end of the free
suture once the suture is wrapped around the needle holder
(the videos accompanying this text should be helpful for
you). Practice with large sutures until you have this tech-
nique mastered, and then practice with smaller sutures. As
you get better, concentrate on how to minimize your hand
movements, making each tie look “easy.” If you play violin
or guitar, you know that minimizing your finger movements
is the only way that you can play a rapid rhythm. Learn to
operate quickly, not by hurrying but by moving your hands effi-
ciently. If each step takes twice as long as necessary, the
whole operation will be twice as long as necessary.
D
E
The Surgical Assistant
The job of the surgical assistant is to anticipate and facilitate.
It is said that good surgeons make surgery look easy, but the
fact that good assistants make surgeons look good is seldom
appreciated. If you are just learning surgery, you may not
be aware of how important a good assistant is. Every day
you may be operating with experienced surgeons assisting
you. For you to appreciate the value of the assistant, try
operating 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 an
assistant relates directly to your abilities as the primary
surgeon. An experienced teacher can easily identify stu-
dents with excellent surgical potential by the way they
assist in surgery. Don’t underestimate your value as an
assistant or your ability to learn while assisting.

Figure 1.24 (A) The “halving” method for closure of surgical wounds. (B) Dog-ear excision of redundant tissue.
CHECKPOINT
• Do you remember the main differences between mono-
filament and multifilament sutures for handling and
tying?
• Which has the better “hand?” What type of suture is
the gold standard for handling?
• What are the main needle types and shapes? What is
the most common needle point for sewing skin?
1 • The Art of Surgical Technique 25
• Practice suturing using the pencil grip for the
Castroviejo needle holder and the thumb/ring finger
grip for the Webster needle holder.
• Explain the in-the-V technique for suturing to a
colleague also learning to suture. Try the refinements
suggested to make your ties smoother (Box 1.3)
• Can you make smaller movements to increase your
efficiency?
26 1 • The Art of Surgical Technique

“V”

A B C 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 the
suture 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 the
needle holder to minimize your movements). (D) Pull the needle holder toward you and the suture end away from you. Notice that the knot should
lie 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 suture
end and pull your hands in the opposite direction. (F) Repeat a third time, pulling your hands in the opposite direction again. (G) Each time, watch
the 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)

 1 • The Art of Surgical Technique 27

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

Major Points ’ The scissors you will use most often are Westcott spring scissors
’ Being prepared demonstrates your competence and instills confi- and Stevens iris-type scissors. Use the curve of the scissors blade
dence in the operating room team. to your advantage. Make cutting a continuous motion. Avoid
’ Have the room setup in mind before you enter the operating room. “snipping.”
’ Oculoplastic surgery requires skill in retracting tissues. Types of
Set your operating stool height first, then the operating table, and
finally the microscope. Adjust the interpupillary distance on the instruments used to retract tissues are the following
’ Your fingers
eyepieces and set the focus of the scope. Position the necessary foot
’ Forceps
pedals before you scrub.
’ Skin hooks
’ Use a local anesthetic with epinephrine on all patients. Mark and
’ Retractors
inject the skin before preparing the patient.
’ Use forceps with teeth whenever possible. Learn to pull the tissues
’ Learn as much as you can about the tools of your trade
’ Scalpel blades and other cutting instruments apart as you dissect with any cutting tool. To separate the
’ Scissors orbicularis muscle off the orbital septum, grasp the muscle with
’ Forceps one forceps and the septum with another forceps (using an
’ Retractors assistant). Gently pull the layers apart as you separate them with
’ Cautery the scissors. Most surgery is not cutting, but it is, rather,
’ Suction separating tissue planes.
’ There are three types of retractors
’ Needle holders
’ Self-retaining retractors
’ Sutures
’ Handheld retractors
’ Spread and stabilize the skin before any incision. Be aware of
’ Suture retractors
your body position. Always inject or cut away from the eye or
’ The most useful self-retaining retractor is the Jaffe lid speculum.
your fingers. The no. 15 scalpel blade and the microdissection
needle are the most useful cutting tools. Handheld retractors, including the Desmarres vein retractor (for
’ Hide incisions in wrinkle lines or natural skin creases, when eyelids) and the Sewall and malleable ribbon retractors (for
possible. orbital retraction), are very important tools; 4-0 silk sutures are
’ Scissors vary in the following characteristics excellent suture retractors.
’ Intraoperative hemostasis begins with stopping aspirin and
’ Length
’ Caliber nonsteroidal antiinflammatory medications well in advance of
’ Tip sharpness surgery. Inject local anesthetic with epinephrine 10 minutes
’ Blade design before making any incision. Learn to tamponade tissues.
’ Learning an effective bipolar cautery technique is a must.
’ Cutting motion
Consider these three steps
28 1 • The Art of Surgical Technique
’ 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 multifilament
sutures, but working with them is more difficult. Multifilament
sutures hold tension and maintain a knot better than
monofilament sutures.
’ Needles vary by shape, size, and point. Half-circle needles are best
for tight spaces (lateral canthoplasty). Reverse cutting needles are
used on the skin. Spatula needles are used for most lamellar
passes 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 the
thumb/ring finger grip for the Webster needle holder.
’ Sutures may be continuous or interrupted. Continuous sutures
are used in natural skin creases or wrinkle lines (upper lid skin
crease). Two types of interrupted sutures are used to close the
surgical 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 as
the primary surgeon. To be a good assistant, you need to be a
part of the operation. Don’t wait to be told what to do. Learn to
“dance” with the surgeon. Don’t underestimate your value as an
assistant 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 an
assistant, you should be entirely familiar with the steps of the
operation and any changes that the surgeon may have in mind
for a particular patient. You can’t anticipate if you don’t know
the steps of the operation.
’
Your job as an assistant starts with the room and equipment
setup. You may be the person to administer the local anesthetic
or prep and drape the patient while the surgeon scrubs. Once in
the operating room, you need to position yourself where you can
see what is happening and be a part of the operation. You would
be surprised at the number of surgical students who don’t do well
as assistants, claiming that they can’t see the operating field. If
you can’t see, move so you can see. If you can’t get in a
reasonable position to see, let the surgeon know so the situation
can be changed. To be a good assistant, you need to be a part of
the operation. If the lighting is poor, adjust the operating room
lights. If there is bleeding, provide exposure and tamponade.
Perhaps you can offer suction. As the dissection proceeds, move
with the surgeon, constantly adjusting your retractors to provide
the best exposure possible. If you can’t see the area of interest
well, it is likely the surgeon can’t either. As the dissection
continues, provide gentle countertraction to facilitate the cutting
of tissue or spreading of the tissue planes. If you don’t know how
to help, ask what you can do to help.
’ If you see the surgeon passing a suture, have a suture scissors
ready to cut the ends of the suture. Use scissors with a straight
blade and sharp tips. Hold the scissors with the tripod or thumb/
ring finger grip. This allows you to stabilize the scissors with your
index finger. Sometimes, it is helpful to rest the scissors on your
nondominant index finger as if you were using a pool cue. The
surgeon should pull the suture to the side (not straight toward
you) so that you can see the full length of the suture. It is difficult
to 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 a
few inches to the knot. Exerting a slight bit of pressure against the
suture helps control your movement. This gives you both visual
and proprioceptive input as to where to close the scissors. Try to
cut with the scissors tips to improve your accuracy. Remember to
close the scissors slowly rather than snip the suture.
’ Your efforts practicing as an assistant will help you to become a
good surgeon. Take advantage of the opportunity to learn. Be
interested. Ask questions. Develop a passion for the operating
room. 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 as
an assistant.
Suggested Reading
Albert 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. Available
at: http://www.eyerounds.org/video/plastics/index.htm
Christie DB, Woog JJ. Basic surgical techniques, technology, and wound
repair. In: Bosniak S, ed. Principles and practice of ophthalmic plastic and
reconstructive 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 and
Wilkins; 1988.
Korn BS, Kikkawa DO. Video atlas of oculofacial plastic and reconstructive
surgery. 2nd ed. Philadelphia: Elsevier; 2016.
Linberg JV, Mangano LM, Odom JV. Comparison of nonabsorbable and
absorbable sutures for use in oculoplastic surgery. Ophthalmic Plast
Reconstr Surg. 1991;7(1):1 7.
McCord Jr C, Codner MA. Basic principles of wound closure. In: McCord
C, 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 oculoplastic
surgery. Boston: Butterworth-Heinemann; 2003:23 29.
Tanenbaum M. Skin and tissue techniques. In: McCord CD, Tanenbaum
M, Nunery WR, eds. Oculoplastic surgery. 3rd ed. New York: Raven
Press; 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.
 2 Clinical Anatomy

CHAPTER OUTLINE Introduction 29 Lacrimal Drainage System 57

Periocular Anatomy 30 Nasal Anatomy 59
Skin Creases and Folds 30 Anatomy of the Paranasal Sinuses 61
Eyebrows 32 Ethmoid Sinus 62
Eyelids 34 Frontal Sinus 64
Orbital Bones 35 Maxillary Sinus 65
Orbital Rim 35 Sphenoid Sinus 66
Orbital Walls 37 Innervation to the Periocular Area 66
Muscles That Close the Eyes 41 Sensory Innervation 66
Orbicularis Muscle 41 Innervation to the Muscles
Corrugator and Procerus Muscles 41 of Facial Expression 68
Underactive Muscles: Facial Nerve Innervation to the Extraocular
Palsy 41 Muscles 70
Overactive Muscles: Orbicularis Autonomic Innervation 72
Myokymia, Facial Tics, Arterial Supply to the Orbit and
Essential Blepharospasm, Periocular Tissues 72
and Hemifacial Spasm 41 The Basics 72
Canthal Tendons 43 External Carotid Artery 73
Lateral Canthal Tendon 43 Internal Carotid Artery 74
Medial Canthal Tendon 43 Rich Anastomoses of the Internal and
Muscles That Open the Eyes 45 External Carotid Arteries 76
Levator Muscle 45 Venous Drainage of the Orbit and
Müller’s Muscle 46 Periocular Tissues 78
Ptosis of the Upper Eyelid 47 Lymphatic Drainage 79
Frontalis Muscle 48 Facial Anatomy 80
Lower Eyelid Retractors 49 Layers of the Face 80
Preaponeurotic Fat and the Skin 81
Orbital Septum 51 Subcutaneous Fat 81
Preaponeurotic Fat 51 Muscles of Facial Expression and
Orbital Septum 51 Function 83
Conjunctiva 53 Superficial Musculoaponeurotic
Bulbar, Palpebral, and Fornix System (SMAS) 83
Conjunctiva 53 SMAS Equivalents—the Galea and
Diseases of the Conjunctiva 53 Temporoparietal Fascia 83
Anterior and Posterior Lamellae SMAS and Associated Fat Pads 86
of the Eyelid 53 Retaining Ligaments 87
Lacrimal System 54 Major Points 89
Tear Film 54 Suggested Reading 91
Lacrimal Gland 55

VIDEO ’ 2.1 Eyelid, Nasolacrimal, and Orbital Anatomy

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

down in the details before you know why a particular ana-

Introduction tomic feature is important in taking care of your patients.
Expertise in oculoplastic and orbital surgery starts with One way to learn anatomy is to understand how the anatomy
anatomy. Learning anatomy can be very difficult— makes the normal tissues function (e.g., a certain amount
remembering it is even harder. It is easy to get bogged of horizontal tension or “tightness” is required to hold the

29
30 2 • Clinical Anatomy
normal lower eyelid up against the eyeball). The next step is
to understand how an anatomic and functional abnormality
may be related to a clinical problem (e.g., with age, the canthal
tendons lengthen, which causes the normal lower eyelid
tension to be lost, allowing eversion, or ectropion, of the
lower eyelid). It is not difficult to move to the final step:
understanding how to repair the anatomic abnormality and
restore the function (e.g., tightening the lower eyelid by
removing some of the redundant tendon shortens the lax
lower eyelid to correct the ectropion). These clinical ana-
tomic correlations are not just useful teaching tools—they
are the basis for most reconstructive procedures. A real
understanding of anatomy comes when you start to apply
what you have read to the case on which you are working.
This is one of the fun parts of operating (Box 2.1).
Throughout this chapter and in the remainder of the
book, the anatomy is applied to the clinical problem, and
vice versa. Periocular and orbital anatomy is complex.
There are many levels of understanding of anatomy, some
of which cannot be achieved without seeing the structures
in the “living flesh” and actually performing the surgery.
While reading this chapter, try to get the big picture.
Understand the principles. There is a tremendous amount of
information here, and if you are a beginner and unfamiliar
with periocular anatomy and clinical oculoplastic surgery,
it can be overwhelming. I have read over this chapter
more than 30 times in preparation for the final text, and I
am overwhelmed myself at the amount of material. In fact,
this is the longest chapter in the book. Please scan the
chapter a few times before diving in deeper for the details.
Remember to learn in layers. You continue to discern
nuances in anatomy throughout your entire surgical
career.
In subsequent chapters, the anatomy pertinent to the
clinical problem or procedure being discussed is presented
again, so you don’t need to worry about learning it all the
first time through. This repetition may be unnecessary for
some, but most of us can use it when it comes to remem-
bering anatomy. I expect that by the time you finish this
book, this material will seem very easy. Remember, it is
the application of the anatomy to the clinical problem
that makes you a successful reconstructive surgeon. A
photographic memory helps in learning anatomy, but
that alone is not enough to get the job done for your
patients.
The anatomy covered in this chapter and throughout
the book is the essential material that you need to get a
good understanding of eyelid, lacrimal, and orbital surgery.
Obviously, we cannot cover all of the anatomy in a text like
this. I have not discussed ocular anatomy, neuroanatomy,
Box 2.1 Steps in Learning Clinical Anatomy
’ Understand how the anatomy makes the normal tissues function.
’ Understand how an anatomic and functional abnormality is related to a clinical problem.
’ Understand how to repair the anatomic abnormality and restore the function.
’ Your real understanding comes when you apply what you have learned in books to the operation you are doing.
or much of the anatomy related to the extraocular muscles
or deep anatomy of the face and neck. There are many
good textbooks on periocular, orbital, and head and neck
anatomy (see the Suggested Reading at the end of this
chapter); please refer to these as necessary. My hope is that
the anatomy described here is presented in a way that is
useful for learning the principles of oculoplastic and orbital
surgery.
This chapter starts with a description of the external
features of the periocular area to give a point of reference
for the deeper tissues. Rather than discuss the anatomy
from anterior to posterior, as is often done, we look at the
anatomy from a more functional approach. The orbital
bones are covered next, because it is helpful to learn
about the soft tissues relative to the bones. Most of the
eyelid and orbital tissues either attach to or pass through
openings in the orbital skeleton. Next, the muscles that
close the eyes are discussed, followed by a section on the
muscles that open the eyes. After that, the nerves, vessels,
and lymphatics are covered. Lastly, the support system of
the facial tissues is explored. These principles will become
important as your surgical adventures move out of the
orbit and lids into the periocular and facial regions. We
use the clinical examples as a way to learn the anatomy.
In the chapters that follow, we spend more time on the
clinical problems themselves. The video for this chapter
offers a tour of some of the surgical anatomy that you will
see in your daily practice. It gives you a taste of what is
to come!
Periocular Anatomy
SKIN CREASES AND FOLDS
Several lines on the skin serve to anatomically define the
periocular and facial anatomy. The upper eyelid skin crease
separates the upper eyelid skin fold from the flat pretarsal
component of the upper eyelid (Figure 2.1). The upper eye-
lid crease is an anatomic landmark that is commonly
referred to in oculoplastic surgery. Incisions hidden in this
crease for upper eyelid ptosis repair or blepharoplasty and
other procedures are among the most common incisions
used in oculoplastic surgery.
The eyelid skin above and below the crease is the thin-
nest in the body. The skin must be thin to allow for the
spontaneous quick blinking movements of the eyelids. A
lower eyelid crease is common in children (Figure 2.2) but
is usually not visible in adults. The eyelid skin becomes
thicker as you move further away from the eyelid margins
 2 • Clinical Anatomy 31

Galea

Frontalis m.

Corrugator m.
Peak
of brow
Forehead Procerus m.
Peak of furrows
upper lid Levator labii superioris
alaeque nasi m.
Upper lid
skin crease Nasalis m.

Lateral Orbicularis
canthus Medial oculi m.
canthus
Lower lid Levator labii
skin crease superioris m.

Malar fold Zygomaticus minor m.

Nasojugal fold
Zygomaticus major m.
(”tear trough”)

Risorius m.
Midface
groove Orbicularis oris m.

Melolabial Depressor anguli

fold oris m.

Depressor labii
Marionette
oris m.
line
Platysma m.

Mentalis m.

Figure 2.1 Surface landmarks of the periorbital area. The facial wrinkles are oriented 90 degrees to the underlying muscle.

toward the brow and cheek. The nasojugal and malar folds
separate the thin lower eyelid skin from the thicker skin of
the cheek. In younger patients, the inferior orbital rim
contour is not visible or easily palpable. With age, the
malar fat pad (and the deeper suborbicularis oculi fat
[SOOF]) descends and deflates and the rim becomes more
noticeable, both visually and by palpation (compare
some of your 20-year-old patients with your 50-year-old
patients in this regard). As the nasojugal fold becomes
deeper it is often termed the tear trough. Thinner patients
show more “hills and valleys.” As thinner patients age, a
hollow diagonal furrow or groove forms, separating the
malar fat from the nasolabial fold (the midface groove).
These “valleys” correspond to areas where the soft tissues
are more tightly bound down to the underlying facial soft
tissue or bone. In this case, the tethering is by the zygo-
matic cutaneous ligaments, or the connective tissue that
more tightly attaches the skin to the underlying muscle
here than at the surrounding areas; this causes the hol-
low that forms. The melolabial fold extends inferolaterally
from the ala of the nose to the corner of the mouth. Subtle
facial asymmetry resulting from paralysis of the facial
nerve is often evident in the melolabial fold, where the
fold is softer or absent. This fold is also known as the naso-
labial fold. A hollow or line develops from the corners of
the mouth, slanting laterally to the mandible, and is
known as the marionette line. Associated with the devel-
opment of marionette lines, you see jowling of the cheek
posterior to the marionette line. As these tissues descend,
the smooth mandibular border that is associated with
youth is lost.
As you learn the anatomy of the face, you start to become
aware of what makes your patients look “old.” The youthful
face has long, smooth contours with graceful transitions
32 2 • Clinical Anatomy
A B
Figure 2.2 Features of the youthful face. (A) The round, long, smooth curves of the full baby face with graceful transitions from one part of the face
to another. (B) The lower eyelid crease, usually seen only in children.
from one area to the other. For example, the cheek and
lower eyelid blend together without an obvious division. The
landmarks that we have been discussing appear with age,
separating the anatomic areas of the face in hills and valleys
belying the patient’s age. Later in the book, you learn techni-
ques using Botox, filler, and surgery that push the clock back
a bit, re-creating those smoother contours of youth.
Skin creases (rhytids or wrinkles) form as a result of the
movement of the underlying muscles of facial expression.
The most familiar of these creases are the “crow’s feet”
arising at the lateral canthus caused by contraction of the
orbicularis muscle. The direction of these wrinkles can be
predicted by recognizing that they always form perpendic-
ular to the underlying muscle fibers (see Figure 2.1 and also
see Figure 2.16). This explains the radial orientation of
the crow’s feet lines to the circular orientation of the orbi-
cularis muscle. Other prominent creases caused by
underlying muscle contraction include the horizontal
forehead furrows (from the frontalis muscle). The hori-
zontal and diagonal lines of the glabella are caused by the
contraction of the procerus and corrugator muscles,
respectively. These lines suggest redundancy in the tissue
perpendicular to the lines. That redundancy represents
lax tissue that is “tightened” to reverse aging changes.
The same redundancy is what you are looking for when
you are trying to close a tissue defect after excision of a
facial skin cancer. You also learn to hide incisions in these
creases so that the resulting scar is not easily seen. We
will discuss how Botox and other neuromodulators can
be used to improve facial wrinkles by relaxing the under-
lying muscles.
EYEBROWS
The brows, technically a part of the scalp, are divided into
three anatomic parts:
’ Head
’ Body
’ Tail
The orientation of the brow hairs varies in each part of
the brow. The brow hairs in the head of the brow tend to
be vertical. As you move toward the tail of the brow,
notice that the hairs tend to lie flatter or slightly down-
ward. It has been suggested that incisions made within
the brow hairs should be oriented parallel to the shafts of
the hairs to minimize the number of follicles damaged.
This seems reasonable but makes closure of the wound
more difficult.
The eyebrows are an important feature of an individual’s
facial appearance and are primary indicators of facial expres-
sion and mood (Figure 2.3). Many texts include variations of
this “happy face” eyebrow model. If you look at your friends’
brows carefully, you see, and are impressed by, how the
slope, shape, and position of the eyebrows give you an
immediate impression of mood. Lifting a drooping tail of the
brow makes a melancholic-appearing patient look happier.
We see this later in Chapter 6.
The male and female brows differ in shape and position
(Figure 2.4). The normal male brow is flat and full in con-
trast to the thinner and more arched female brow. The
superior margin of brow hairs is “feathered” in men and
smooth in women. The male brow sits squarely at the super-
ior orbital rim. The female brow is typically arched, with the
highest point being above the lateral canthus or slightly
more medial to it. The position of the female brow is well
above the rim, especially temporally, where the superior
lateral part of the bony rim contour is visible and easily pal-
pable. The male rim is generally more prominent than the
female rim because of a larger frontal sinus. The male brow
tends to encroach upon the otherwise hairless glabella
between the brows.
The features of the brow are secondary sexual charac-
teristics that differ in men and women. Women manicure
the brows to make the female face more attractive.
Epilation of the brow hairs accents differences between
male and female brows in thickness, smooth margins,
arched contour, and position. Although the shape and
position of the brow change somewhat with the current
fashion, I suspect we all have the same image of male
 2 • Clinical Anatomy 33

Happy Angry Sad

Figure 2.3 “Happy face” diagram demonstrating how brow position reflects mood.

A B

Figure 2.4 Normal eyebrow contour. (A) Female. (B) Male.

(Diagram from Johnson CM, Alsarraf R. The aging face: a systematic approach. Philadelphia: Saunders, 2002.)

and female movie supermodel eyebrows. With age, the you to perform cosmetic or reconstructive surgery of
appearance of the brow changes also. The normally high the face.
arch of the young woman is lost as the brow tends to
droop temporally. A ptosis of the brow accentuates the CHECKPOINT
upper eyelid skin fold and fills in the deep superior sulcus
Identify in your mind or on a patient the following
of the upper eyelid seen in younger patients. Lifting a
features:
drooping eyebrow always improves the appearance of a
cosmetic blepharoplasty. With a severe brow ptosis, as in • Upper eyelid skin crease and skin fold
facial nerve palsy, the superior visual field is obstructed. • Lower eyelid skin crease
Lifting the brow helps to restore the visual field. Your • Thin and thick eyelid skin
appreciation of the eyebrow anatomy is important for • Nasojugal fold (tear trough)
34 2 • Clinical Anatomy

• Malar fold Margin Reflex Distance (MRD)

• Midface groove
• Melolabial fold (nasolabial fold)
• Marionette lines
Each eyebrow is divided into three parts. What are these
parts? Remind yourself of the differences between male
and female eyebrows. Normal
MRD1 = 4 mm
MRD2 = 5 mm
Palpebral fissure = 9

EYELIDS
The function of the eyelids is to protect the eyes and distrib-
ute the tears. It is important for you to understand the nor-
mal anatomy of the eyelids and to recognize conditions that
may prevent normal function.
The lateral canthus is usually slightly higher than the
medial canthus, although the slope of the eyelid fissures can
vary widely among individuals (see Figure 2.1). The upper
lid contour is more arched than that of the lower lid. The
peak of the upper lid is just nasal to the pupil. The lowest
point of the lower eyelid is below the lateral limbus. The nor-
mal contour of the eyelid must be re-created in a variety of
procedures, including ptosis repair and reconstruction of
the lateral canthal angle.
The horizontal length of the eyelids is 30 mm. The dis-
tance between the upper and lower eyelids, the palpebral
aperture or fissure, is about 10 mm. A useful way to measure
the position of the upper and lower eyelids is the margin
reflex distance. This distance is the number of millimeters
from the corneal light reflex to the lid margin. The upper
lid margin reflex distance (MRD1) usually measures 4 to
5 mm. That means that the upper lid margin rests slightly
below the limbus. The lower lid rests at the lower limbus,
making the lower lid margin reflex distance (MRD2) 5 mm
(Figure 2.5). These distances can be measured with a ruler
or estimated. When you estimate the distance, keep in mind
that midway between the corneal light reflex and the limbus
is 2.5 mm. The eyelid aperture measurements, especially
the MRDs, are an essential part of the eyelid examination
and one of the eyelid vital signs. A drooping upper eyelid is
known as ptosis or blepharoptosis. An upper eyelid resting
above the upper limbus or a lower eyelid resting below the
lower limbus is said to have lid retraction. The white between
the limbus and the lid is known as scleral show.
The eyelid skin is the thinnest in the body, allowing rapid
eyelid blinks (Figure 2.6). There is no subcutaneous fat in the
eyelid. Superiorly the eyelid skin thickens to become eyebrow
skin. As part of the eyelid examination you should measure
the amount of eyelid skin present. When performing a bleph-
aroplasty to remove excess eyelid skin, it is necessary to leave
enough of the thin eyelid skin to allow quick passive blinks.
Many (actually most) older patients have a sagging brow
contributing to the appearance of a droopy brow. In these
patients, an eyebrow lift (browplasty) is an important addi-
tion to the skin removal (blepharoplasty) (more on this in
later chapters). Worth noting now is that the complaint of
“droopy eyelids” can be the result of eyelid ptosis, redundant
eyelid skin, or a sagging eyebrow, or a combination of these.
There are three or four rows of eyelashes along the upper
lid margin and one or two rows of eyelashes along the lower
A
Upper lid ptosis
MRD1 = 2 mm
MRD2 = 5 mm
Palpebral fissure = 7
B
Upper lid retraction
MRD1 = 7 mm
MRD2 = 5 mm
Palpebral fissure = 12
C
Upper lid ptosis and
lower lid retraction
MRD1 = 1 mm
MRD2 = 8 mm
Palpebral fissure = 9 D
*Note palpebral aperture measurement is the same
for examples A and D.
Figure 2.5 The margin reflex distance.
lid margin. The eyelashes extend from just lateral to the
puncta to the lateral canthus. Misdirection of the eyelashes
against the eye, also known as trichiasis, causes a foreign
body sensation. In some cases, trichiasis can cause severe
corneal problems. Treatment is focused at redirecting or
eliminating the eyelashes.
The eyelids attach to the orbital bones via the medial
and lateral canthal tendons. The tendons attach to the tarsal
plates, which are the fibrous skeleton of the eyelids. A
favorite board examination question asks if the tarsal
plates are made of cartilage (which they are not; they are
made of fibrous tissue). The upper lid tarsal plate is about
10 mm high, corresponding with the skin crease height.
The lower lid tarsal plate is about 4 to 6 mm high. Within
the tarsal plates are the meibomian glands, modified seba-
ceous glands that secrete the majority of the oil layer of the
tear film. The eyelash follicles originate on the anterior
surface of the tarsal plate and exit the eyelid on the mar-
gin. The orbicularis muscle is tightly bound to the anterior
surface of the tarsus.
Another random document with
no related content on Scribd:
Hegel au contraire, ne me manque jamais. Toutefois je
reconnaissais l’accent du Maître, et sa pensée, à n’en pas douter. Il
fallait jurer, je jurai. Je décidai que ces pages seraient imprimées
telles quelles, et je fis bien. Maintenant je sais que le dernier mot y
est. Toutefois je n’aurais pas cherché si loin. Que me manque-t-il ?
Un genre de désespoir, et de n’avoir pas douté assez loin. De n’avoir
pas été assez Spinoziste pour perdre Descartes et le retrouver.
J’espère qu’une partie s’éclairera par l’autre. Pour ce qui est de cette
leçon, qui sera célèbre, et de ce Dernier Mot, voici ce que j’en
comprends.
Je n’ai jamais cédé au Fatalisme, et là-dessus j’ai bravé le
ridicule. On sait que tout penseur, ou presque, est sarcastique contre
la liberté, et Spinoza lui-même. Toutefois c’est en Spinoza que j’ai le
mieux compris que l’ordre des idées, quoiqu’il soit le même que celui
des choses, pourtant ne lui ressemble en rien, allant jusqu’à
apercevoir que l’idée du cercle ne ressemble nullement au cercle, ni
l’idée de la ligne à la ligne. Par là, il m’apparaissait impossible que
les idées fussent dites exister, en aucun sens ; mais plutôt elles
étaient faites et refaites, non pas arbitrairement, non pas
nécessairement non plus. Je compris alors en quel sens Lagneau,
dans une lettre sur Spinoza, dit qu’il y a deux nécessités. Mais
depuis, revenant à Descartes, je ne voulais point dire deux
nécessités, car c’est bien assez d’une. Et, quoique je ne sois que
trop sujet à prendre l’imagination pour l’entendement, je fus ramené
par la vertu des premières leçons de Lagneau sur la perception, et
aussi par l’avertissement Spinoziste, à comprendre de nouveau que
l’étendue en son idée n’est pas ce vêtement aux couleurs éclatantes
ou pâles, et que la ligne droite, en son idée, n’a point de longueur ni
de parties. D’où l’on est gardé contre ces erreurs brillantes et
grossières qui reviennent de temps en temps, et qui sont l’épreuve
de l’apprenti. Je regardais par là, content de tenir mon poste
d’homme, qui est à la surface de ce monde, et occupé à manier ce
monde le plus longtemps possible sans m’en laisser mordre.
Maintenant, en remontant vers mon propre être, j’apercevais
plusieurs choses qui étaient à considérer. La principale, la plus
étonnante, était que l’entendement lui-même était en quelque façon
mécanique, ou, si l’on veut, physique, comme Descartes l’avait dit.
Car il n’est point de démonstration sans objet, je dis sans existence ;
les figures et aussi bien les écritures d’algèbre sont des objets
existants ; ainsi mes conclusions sont toujours d’existence, comme
le Si de nos hypothèses nous en avertit assez. Ce monde
mécanique est bien l’image de l’autre ; et nous y glissons et nous y
tombons encore, sur un chemin seulement mieux tracé. Il y a de
l’irrévocable par une définition, dès que nous la faisons exister avec
d’autres. Mais que l’esprit soit jamais pris en ces jeux de nécessité,
c’est ce que je n’ai pu concevoir. Cette position intermédiaire
consiste seulement à supposer quelque chose fait et à chercher ce
qui en résultera, d’après cette convention que l’on se réduit à être
spectateur. Ainsi nos démonstrations et nos calculs imitent assez
bien les choses que l’on laisse courir, mais n’imitent point, et ne
peuvent, les actions véritables, où l’on modifie au lieu d’observer.
Cela est mal compris, parce que l’immédiat de l’action n’est pas
objet de réflexion ; la conscience, qui est toujours division, n’y peut
être, ni la mémoire en rien garder. Mais je ne vais pas maintenant
par là. Au contraire je dois remonter vers ce que nous appelons les
axiomes ou principes, dont nous faisons aisément un édifice abstrait
et comme décharné, un objet enfin qui n’est plus objet, mais qui
garde, et même qui rend plus sensible, le coupant et le résistant de
l’objet. C’est vouloir penser sans matière, et croire qu’on le peut, et
ne pouvoir. C’est garder du triangle ce qui est chose, ou existence,
et prendre cela pour l’essence. Or notre condition est telle que l’on
devine l’essence, mais que l’on ne peut la saisir comme un objet. Ce
que Descartes exprimait comme il pouvait, disant qu’il n’y a point de
nécessité en Dieu. En suivant ces difficiles idées, qui ne sont même
plus des idées, en les prolongeant jusqu’au foyer et à l’intersection
dernière, on trouvera quelque chose comme ce que trouva le
Stoïcien, qui n’apercevait plus d’autre raison de Vouloir que de
sauver le Vouloir même ; et cela parle assez clair à tout homme.
Mais dans l’ordre de la spéculation théorique, encore apercevoir la
Liberté suspendue à elle-même, sans rien d’autre, cela passe le
pouvoir des mots ; et pourtant c’est ainsi : car l’existence est
hypothétique par essence, et la course au premier moteur ou à la
dernière limite est peut-être ce qui le fait voir le mieux. Le monde
ainsi pris est cette fois absolument comme il s’offre, et insondable,
mais non point en fait. C’est le silence éternel de l’entendement qu’il
faut finalement reconnaître. Ce monde, infini à sa manière, serait
donc notre charte.
Je reviens toujours au monde, ou plutôt j’y suis toujours, et au
contact. Car ce que l’on trouvera de dialectique dans la célèbre
leçon dont je parle, cela peut éclairer d’autres hommes, mais cela ne
me touche point du tout. Il se peut que je tire Lagneau à moi, comme
l’autre à lui. Toujours est-il que je n’ai point connu Lagneau hors de
perception ; et c’est en cela que je le vis grand, et que je le vois
grand. L’idée que le monde ne serait qu’une apparence, dont il
faudrait se détourner, et que l’entendement ait des moyens d’aller
chercher l’autre monde au delà, ou aussi bien de le chercher en
deçà, par une réflexion sans yeux, c’est ce qui ne peut obtenir
audience de moi ; et il me semble même que j’en fus guéri à jamais
par le secours de ce génie terrestre. Kant, tant de fois lu, m’a
ramené là par dure discipline ; Spinoza aussi, parmi tant de preuves
qui glissent sur moi, par ces lumières des Scholies. Mais enfin c’est
Lagneau qui m’a mis à l’ouvrage. L’idée n’est point séparée, ni
séparable ; L’Esprit n’est ni loin, ni caché, ni derrière nous, ni
derrière la chose, mais dedans. Una eademque res. « Vint l’Esprit,
dit Anaxagore, qui mit tout en ordre. » Mais ce n’est que mythologie.
L’Esprit met tout en ordre, et voilà ce que signifie l’apparence. Ceux
qui ont suivi avec attention Descartes et Spinoza en ce réveil de
pensée, le seul sans doute depuis Platon, ont certainement
remarqué que ces penseurs ont cherché l’image sans la trouver,
voulant toujours dire, même devant un miroir ou un prisme, devant
un mirage même, que cela est d’entendement non moins que le
soleil quatre cents fois plus éloigné que la lune. Ainsi viennent-ils à
loger les images dans le corps humain, où elles ne sont plus images,
mais notions vraies de la liaison du corps à l’esprit. Celui qui n’a pas
médité, et j’ose dire à vide, sur les tableaux peints de Spinoza et ses
images rétiniennes, ne peut me suivre. Il faut apercevoir ici, pour
vaincre cette dernière apparence d’apparence, que ces deux auteurs
sont encore trop dialecticiens ; mais entendons bien aussi que, sans
cette préparation dialectique, nous n’aurions pu revenir du prétoire à
la nature. Ils cherchent donc cette première apparence, partant de
laquelle l’entendement pourrait s’élancer. Mais les images sont
images faute de réflexion, non point faute d’esprit. Lagneau ne
quittait point l’apparence ; d’où cette leçon sur la perception, qui ne
finissait point. Je le vois traçant au tableau les apparences du cube
et demandant si ces apparences étaient quelque chose avant qu’on
sût de quoi elles étaient apparences. Car, qu’elles fussent sur un
plan, et sans profondeur, cela se rapportait au tableau noir et à la
craie, non au cube ; c’était y chercher le vrai du tableau noir et de la
craie, non l’apparence du cube ; mais comme apparences du cube
elles étaient vraies, par le véritable cube. Et la signification d’un de
ces angles, qui me semble aigu ou obtus par la perspective, c’est
justement que je le pense droit ; non pas droit ailleurs, mais droit là
même où je le vois aigu ou obtus. Et à vrai dire je ne le vois pas aigu
ni obtus, ni non plus droit, mais tout cela ensemble, droit et obtus,
voir et penser cela, et l’un par l’autre, c’est voir qu’on voit, ce qui est
voir. La vue première ou immédiate n’est rien, parce qu’il n’y a que la
réflexion qui puisse faire tenir ensemble l’apparence et le vrai. Le
propre du rêve pur est qu’il n’est rien pour personne ; mais
l’apparence est le rêve retrouvé. Ainsi était analysée la réflexion
comme réveil, en même temps que la perception comme réveil.
Cette aurore de l’esprit émerveille. On ne s’en lasse point. Elle m’est
neuve encore à chaque fois. Mais on voudrait croire que c’est chose
faite, et courir aux conséquences ; journée de manœuvre. En cette
classe, comme sur ce visage architectural, c’était toujours matin.
 II
PLATON

De ses leçons sur Platon, qui furent nombreuses, amples, et

toujours quelque dialogue en main, le Théétète, le Philèbe, le Timée,
je n’ai retenu que Platon. Non point Platon athénien, non point
Platon accident, ni moment, mais Platon vrai. Je l’ai retenu et je l’ai
retrouvé. Je n’ai pas eu, une seule fois, le sentiment qu’il y eût
jamais, en ces œuvres illustres par-dessus toutes, la moindre chose
à reprendre, ni d’autres difficultés que celles qui s’offrent à nous tous
dans notre commune situation d’hommes percevants. Or, si je sais
ici expliquer ce que je sens, aucun auteur ne convient mieux pour
faire entendre que Lagneau pensait métaphysiquement.
Les idées de Platon sont communément un objet d’histoire, ou
bien une erreur admirable ; mais on les veut toujours séparer. Dans
Platon je ne les vis jamais séparées, mais à l’œuvre, et formant la
substance de ce monde. Car c’est en ce monde que l’un et l’être se
posent, s’opposent et se nient ; et le jeu célèbre du Parménide est le
jeu du monde. Deux est un en ces deux roses que je perçois,
comme quatre est un dans les osselets du Théétète ; et il est
pourtant vrai que cette unité qui les fait quatre n’est en aucun d’eux,
ni non plus l’unité de chacun, qui fait de chacun d’eux une partie de
quatre ; pas plus que Théétète n’est en lui-même grand ou petit.
C’est par de tels rapports pourtant que Théétète et les osselets sont
dits exister ; ces rapports sont substantiels, mais refusent d’être des
choses. Sous mes yeux, cette participation se fait et se défait. Sous
mes yeux, cette dialectique pose le courbe par le droit et le plusieurs
par l’un. Sous mes yeux le grand et le petit prennent leur course
alternée, et leur fuite fait en même temps deux abîmes pleins de
créations. Mais l’unité les ramène au repos. D’où nous allons faire le
compte de ces êtres, leur généalogie, leur filiation. Ici Platon sourit.
Voici le Timée, et tous les démiurges à l’œuvre, clouant le Même et
l’Autre sur l’écliptique. Et que faisions-nous tout à l’heure, nous-
mêmes, dieux inférieurs et préposés, et toujours faisant être les
choses par les idées ? Ainsi plaît-il à chaque Dieu, parce qu’il est
bon ; et, de vrai, rien ne l’y force. Ainsi Lagneau, tenant en main le
Timée, semblait lui-même une figure de Michel-Ange, séparant la
lumière et les ténèbres. Je ne pense pas que l’idée soit jamais
venue à aucun de nous de réfuter Platon.
Nous approchions plus près avec le Théétète ; et ce fameux
passage du cheval de bois, je ne l’ai jamais relu sans y apprendre
encore quelque chose. Si nous étions comme le cheval de bois, il y
aurait un objet pour notre main et même pour chacune de nos
mains, pour nos deux oreilles, pour nos deux yeux ; mais ce n’est
pas ainsi. Ce qui fait l’objet que nous percevons, cet encrier, ce
crayon ou cette fleur, c’est qu’il est objet à la fois pour nos mains et
nos yeux ; et ces milliers d’apparences d’un même objet ne le
multiplient point, mais l’affermissent en son unité, ou, pour mieux
dire (ainsi parlait le maître), ne sont elles-mêmes plusieurs que par
cette unité de la chose ; ainsi dans cet objet, encrier, crayon ou fleur,
il est pensé que toutes ces apparences sont vraies sous condition,
différentes les unes des autres, identiques les unes aux autres, et
variées selon les lieux du monde d’où on verrait l’objet ; ainsi la loi
universelle, dans tous les sens de ce beau mot, est la substance
même de l’objet ; non pas ce que le philosophe y suppose, mais ce
que chacun y pense dès qu’il le perçoit. Platon n’a rien ajouté au
monde. Il est dit justement le Métaphysicien, non pas parce que ses
Idées sont éternellement hors du monde, mais plutôt parce qu’elles
sont le tissu du monde. Lagneau n’ajoutait rien au monde ; c’était
Platon revivant. Un précieux ami me disait ce matin même, comme
nous parlions du Maître, qu’il a connu et admiré autant que moi :
« Poète lyrique que vous êtes, vous lui ferez dire tout ce qui vous
viendra à l’esprit ». Lagneau a laissé trop peu d’écrits pour que je
puisse me défendre là-dessus ; mais Platon existe en son œuvre ; il
est facile de savoir si j’ajoute maintenant quelque chose à Platon.
C’est toujours d’après l’image du Démiurge que je me représente
le philosophe véritable, ou si l’on veut le Métaphysicien. Non pas
isolant les idées et les produisant dans l’abstraction, comme s’il se
détournait du spectacle des choses, mais au contraire revenant de
ces abstractions faciles, allant toujours du clair à l’obscur,
épaississant le nuage jusqu’à lui donner la consistance des choses.
Ce qui est dit aussi dans la célèbre allégorie de la caverne ;
seulement il faut la lire jusqu’à la fin. Ces pages relues, on ne peut
rester dans les jeux logiques ; encore bien moins peut-on laisser ce
corps vivant se repaître d’ombres, ombre lui-même, mais il faut
donner substance à ces ombres, et les créer continuellement. « Être
ou ne pas être, soi et toutes choses, il faut choisir. » Je citerai sans
doute encore plus d’une fois cette parole étonnante ; je l’écris ici
pour que l’on comprenne qu’en suivant Platon je me tiens
étroitement attaché à la philosophie de Jules Lagneau. J’aperçois
bien les difficultés de mon sujet. Il ne manque pas de Platoniciens,
et la célèbre doctrine des Idées est comme un passage où tous les
philosophes finissent par se rencontrer. Lire, admirer, aimer Platon,
cela ne définit pas un homme. Mais de nouveau être Platon,
s’asseoir dans la caverne, et expliquer les ombres aux captifs, cela
je ne l’ai pas vu plus d’une fois. Seulement alors j’ai vu un Homme.
Si je ne sais pas faire toucher du doigt cette rare grandeur, à quoi
me sert cette plume ? Mais attention, je suis soumis à la commune
condition ; il faut que mon Philosophe existe de nouveau par l’idée ;
et, si je manque de courage, je n’évoquerai qu’une Ombre plaintive,
comme Ulysse. Quoi ? dit l’homme faible. Eh bien, il est mort et nous
le pleurons ; mais vous ne le ferez pas revivre ; et laissons cette
nécromancie. Il est vrai que si j’hésite à vouloir, aussitôt l’ombre
s’éloigne et se fond ; cela fait bien voir à la fois qu’il faut aimer et
qu’il ne suffit pas d’aimer. Mais quel est donc l’objet qui tient un seul
moment devant le regard paresseux ? Qu’est-ce qu’une maison ?
disait Lagneau. C’était là son centre ; il y revenait toujours. Aucun
objet n’est donné. C’est ici que l’exemple, encrier ou morceau de
craie, était mis à la question. Et il est rigoureusement vrai qu’il n’y a
de perception que par une vérité de la perception ; et il est vrai aussi
que la vérité de la perception ne peut être perçue ; il n’y a pas de lieu
d’où l’on voie toutes les parties d’une maison ; il n’y a point de lieu ni
de rapports de lieu qui représentent comment les parties ensemble
font une maison, et comment les perspectives ensemble font une
maison, et comment le toucher, la vue, l’ouïe explorent une maison,
et comment tout l’Univers autour jusqu’au plus loin fait cette maison-
là. Ainsi l’esprit dépasse la perception et à ce passage lui donne
existence et naît lui-même à l’être de conscience ; par quoi
l’apparence apparaît. Et je voudrais bien qu’un psychologue
m’expliquât ce qu’est l’apparence, et pour qui apparence, si
l’apparence n’est pas un moment dépassé. J’emploie ici le langage
de Hegel ; je ne crois pas que Lagneau le connût bien. Il n’en parlait
jamais, autant que je sais. Il n’était pas historien dans le sens où
l’autre l’est. Or j’ai tout trouvé dans Hegel, excepté une suffisante
théorie de la perception. C’est pourquoi ce spectacle de la nature, en
Hegel, se tient par soi et devient par l’esprit qui lui est intérieur ; les
moments de l’esprit sont ainsi représentés par des formes ; bref le
monde est créé, la nécessité se déroule, et l’esprit ne s’en échappe
pas sans peine, je veux dire que les lecteurs et disciples de Hegel
sont touchés toujours un peu par la Fatalité qui montre comme une
ruse de Dieu ; car il est vrai qu’il faut tout faire, mais il est vrai aussi
que tout est fait. Penseur politique et au fond religieux. Je voudrais
expliquer, et je n’y arriverai pas sans peine, que Lagneau n’était ni
politique, ni religieux ; bien plutôt cette dialectique divine à longues
périodes (mais qu’est-ce qui est long ou court ?) se ramassait toute
en un mouvement d’attention de Lagneau ; il surmontait en acte ; et
de la puissance comme telle il n’avait que le sentiment. C’est la
raison pourquoi hors de la pensée en acte il ne se promettait rien et
n’espérait rien. Personne ne pensait pour lui, et tout était toujours à
recommencer. Moins d’espérance donc, mais, il me semble, plus de
joie. C’est une des vertus de Platon de réduire le progrès. Jeu
d’imagination, qui revient toujours, par une mythologie qui
nécessairement jette l’esprit au delà. De façon que ce choix des
âmes, dans la Prairie du Jugement, il est clair que nous le faisons
sans cesse ; et, en disant mythologiquement que ce choix est
toujours fait d’avance, c’est cela même qu’il veut dire. L’Éternité n’est
pas un temps sans fin, mais plutôt c’est le miroir du temps ; ainsi le
salut est de toujours. Aussi les formes animales ne peuvent être
dans la mythologie Platonicienne l’état ancien de l’esprit en sommeil,
mais plutôt elles sont l’image de l’esprit déchu. C’est pourquoi il n’y
avait dans la pensée de Lagneau rien de pareil à ce que l’on trouve
dans Hegel sous le titre de Philosophie de l’Esprit. Une telle
philosophie signifie nécessairement que la nature se sauve ; ou,
pour autrement parler, c’est réaliser la pensée confuse. Mais disons
aussi que toute la dialectique de Hegel est suspendue à une
philosophie de la Nature, ce qui est évident pour la philosophie
sociale, où la Nature porte l’Esprit et en même temps le retient et
l’assure en fixant le progrès ; mais il en est de même pour la
Logique, portée au fond par l’histoire des Idées comme la
Philosophie de l’Esprit est portée par l’histoire politique. Sans quoi
tout recommence sans cesse, et la moindre réflexion physicienne se
porte de la Substance à la Cause et aussitôt à l’Action d’Échange
qui les fait être l’une et l’autre ; et le moindre réveil de l’attention
nous jette à l’être nu, qui reçoit tous les attributs aussi bien qu’il les
repousse tous ; car tel est le premier moment de l’apparition pour
Hamlet et pour chacun. Être Hégélien, c’est croire à un destin, ce qui
est Dieu Objet. Il ne faudrait donc point dire que Lagneau a ignoré
Hegel, et que c’est bien dommage, non plus que le temps lui a
manqué pour construire quelque Histoire Universelle de l’Esprit.
Disons plutôt que le penseur rigoureux s’est détourné d’une
nécessité extérieure qui serait esprit. Monstre divin ; dieux
d’autrefois, dieux de boue et de sang, comme parle Hegel, un de
ceux qui ont mesuré le mythe immense de l’Homme-Dieu, mais il ne
l’a point tiré tout à fait hors de l’idolâtrie. Adorer l’État sauveur, c’est
comme adorer la Vache ou le Crocodile. Platon était déjà à sa tâche
d’homme. A mes yeux tout cet effort de pensée de Lagneau, et
presque tout perdu, représenterait, si l’on voulait des âges, le dernier
âge, auquel Renouvier n’a pas été tout à fait étranger, la liberté ne
pouvant se conquérir, soit dans la réflexion, soit dans l’action, qu’en
repoussant à elle-même la nécessité purement mécanique ; et c’est
cette pensée en acte qui efface tout à fait le Destin. Mais toute
religion enferme un destin, comme les Jansénistes eux-mêmes l’ont
éprouvé. C’est pourquoi, en cette leçon que je n’ai pas entendue,
Lagneau voulait prouver que Dieu ne peut être dit exister. Le lecteur
voudra bien croire, au moins par provision, que je suis ici au centre
de la difficulté. Si j’avais pour fin de coordonner les documents qui
nous restent, j’arriverais trop aisément à résumer une philosophie
idéaliste qui ressemblerait à beaucoup d’autres. Ce genre d’erreur
serait le pire ; et c’est pour n’y point tomber que j’ai pris cette
méthode libre et tâtonnante, sans autre prétention que d’avertir. Si
l’on me suit dans ce long détour, je suis assuré que les textes et les
témoignages s’éclaireront alors autrement. Quand j’étais jeune, un
bon ami, et fidèle disciple lui aussi, me disait quelquefois : « Ne te
crois pas obligé d’être obscur. » Dans une note que je fis passer aux
journaux après la mort de Lagneau, j’avais employé le mot Génie
sans aucune épithète ; mais les philosophes d’institut écrivirent à la
place de ce mot ambitieux une périphrase assez plate : « Un
véritable génie philosophique » ; ainsi dirent-ils. Je veux gagner ce
procès-là.
Puisque j’étais sur le sujet de la religion ou de l’irréligion, il est
maintenant à propos que je me risque à comparer deux hommes
que je place très haut, mais qui, à mon sens, ne se ressemblent
point du tout. D’après le conseil de Lagneau, nous lûmes alors la
plume à la main le Fondement de l’Induction et surtout Psychologie
et Métaphysique. Ce genre de pensée, mieux lié, était certainement
plus facile à suivre que la pensée de Lagneau. Je me souviens que,
dans une conversation particulière sur ce sujet-là, je fus ramené par
une remarque du Maître bien inattendue, et que je ne compris pas
tout de suite : « Oh ! derrière M. Lachelier il y a l’Évangile. »
Comment interpréter l’oracle ? Non pas certes en ce sens que
l’Évangile serait de peu et dépassé ; mais pourtant c’était bien le
signe de l’irréligion en un sens. Et d’un autre côté quel rapport entre
l’Évangile et une dialectique abstraite, rigoureuse, subtile, et, surtout
dans le célèbre article qui était alors nouveau, purement rationnelle ?
Dans la suite, et assez longtemps après la mort de Lagneau, j’eus
plus d’une fois l’occasion d’entendre le Penseur Catholique, en des
remarques sur tous sujets et toujours de grande portée et d’une
pénétration merveilleuse. Mais, pour moi qui avais connu le Penseur
Incrédule, je voyais bien clairement que cet esprit catholique était, si
j’ose dire, absent de ses pensées les plus hardies. Si je puis me
permettre une autre comparaison, sans manquer du tout au respect
que je dois à la mémoire de cet homme vénérable, je le comparerais
à ces gymnastes qui voltigent au-dessus d’un filet : ils ne tombent
jamais ; mais enfin il y a un filet. Il est impossible de croire que la
doctrine catholique, si explicitement métaphysique et même
dialectique, ne donne pas à un penseur cette sécurité de la chose
jugée, ou si l’on veut en soi pensée, en soi achevée, à laquelle
l’esprit doit finalement et toujours se conformer. En toutes les
aventures de pensée on se trouve soutenu alors par un invincible
préjugé ; l’esprit est adoré comme par serment ; mais c’est encore
trop peu dire, car le serment, selon la doctrine, serait encore
suspect ; ce serait un parti pris une fois contre le doute toujours
menaçant ; cela même est hérésie. Je soupçonne, faute
d’expérience, car je n’ai connu que la foi de l’enfant de chœur, qui dit
son chapelet et qui a peur de l’enfer, je soupçonne, dis-je, une
certitude de fait, et un accord de l’esprit avec la Providence, aussi
intime et aussi familier que le rapport de notre corps avec l’Univers
nourricier. Tout étant réglé pour le fond, la pensée s’exerce alors
professionnellement dans le détail des choses ; le professeur,
l’ingénieur, le général, l’homme d’état pensent alors chacun selon
son métier, ce qui fait voir tantôt des pensées médiocres et à la
suite, tantôt des vues de génie, politiques, ou mécaniciennes, ou
métaphysiques ; mais la liberté de ces esprits, qui passe souvent
toute audace, a ceci de remarquable qu’elle est soutenue de toutes
parts et toujours sans risques. Dont Descartes a offert sans doute le
plus illustre exemple. Et ce qu’il dit du libre arbitre, qui va fort loin,
est premièrement une opinion de gentilhomme bien pensant. Si l’on
veut considérer la chose au point de vue de l’histoire, peut-être faut-
il dire que l’obligation de croire fut, à ce moment décisif, un précieux
secours et peut-être indispensable contre le prestige de la nécessité
mécanique. Enfin le catholique n’a jamais la charge de penser tout.
Quelqu’un pense pour lui. Il est sauvé par là de ce « désespoir
absolu » que Lagneau a nommé une fois, au moins une fois. Cet
autre Atlas portait toute la pensée. Par la fatigue, ou seulement par
l’inattention, tout était par terre. De cela je suis bien sûr. Après des
peines infinies et une lutte inégale, on dirait ingrate, contre des
doctrines faibles, dont la force est qu’elles traduisent très bien nos
faibles pensées, il arrivait toujours quelque éclair ; mais on ne voyait
point de progrès, ni d’une semaine à l’autre, ni d’une année à l’autre.
Tout était toujours à recommencer ; et pour avoir dit une fois ce que
c’était qu’espace et ce que c’était que temps, on n’était point assuré
du tout par là contre des apparences trop connues, toujours
également redoutables. Preuve que le mécanisme pensant était
surmonté ; mais un tel régime peut user l’homme.
Il est difficile de croire, mais agréable, il est plus beau de savoir.
On peut penser, comme Comte pensait de Hegel : « Que veut-il dire
avec son Esprit ? » Cette position est difficile, et au fond impossible
par un continuel balancement de la conscience à l’objet, et de l’objet
à la conscience, la connaissance étant reléguée dans le corps
vivant, qui pourtant, ensemble avec les autres corps, est l’objet de la
connaissance, et se trouve en elle plutôt qu’elle en lui. Et comme il
faut croire au monde, et que toute raison s’appuie là, comme toute
folie à ce qui n’est qu’en la conscience, la réflexion se trouve
aussitôt suspecte et contre l’ordre, comme il apparaît en la forte
maxime de Comte : « Régler le dedans sur le dehors. » Cette
division et cet exil en quelque sorte est propre à l’incrédulité ; elle en
est comme la punition à chaque instant.
Tous ceux qui perdent communication avec l’esprit, par une sorte
de crainte à l’égard de l’attention véritable, se retrouvent aussitôt
étrangers au monde et soumis au monde par une sorte de religion
renversée, comme on voit au tragique dans Lucrèce, et plus
secrètement en tous ceux qui se font une idole de l’expérience brute.
Le génie, en ses moindres éclairs, est alors une sorte de maladie,
comme ils finissent par dire tous. On n’ose conjecturer ce qu’ils
pensent de Platon, et eux-mêmes n’osent pas le dire. Tel est l’état
du matérialisme conséquent ; la fatalité y revient toujours, qu’on
l’atténue ou non, que l’on ruse ou non, et une misanthropie irritée,
par une peur bien naturelle de tous ces fous en liberté, qui se croient
eux-mêmes.
De ceux qui sont religieux dans le sens strict du mot, ce qui
revient, je pense, à trouver des signes de l’esprit en des apparences
étrangères à l’esprit, je ne sais que dire. Je suppose seulement que
leur pensée se retourne contre elle-même, par une critique sans fin,
mais qui est aussi sans inconséquence et sans peur puisque l’on
sait qu’il y a promesse de salut, et extrême objectivité dans l’extrême
subjectivité. L’Esprit Absolu est une garantie en quelque sorte contre
la témérité de penser ; car quoi que l’on pense, ce n’est jamais vrai
que par la négation. Toutes nos représentations restent à l’état
d’énigme. Et c’est ce qui m’a toujours arrêté en ce célèbre ouvrage
de Jules Lachelier sur le Fondement de l’Induction, dont la
conclusion est bien qu’il faut croire contre les preuves. Toute la force
de cette analyse est en ceci que la représentation et cet ordre qu’elle
montre ne se justifie nullement et ne s’explique nullement par elle-
même ; l’esprit de Hume, proprement diabolique, s’y étale, par ceci
qu’on ne voit pas pourquoi ce monde est réel ; mais comme le
penseur sait bien que Dieu ne trompe point, il faut donc croire que le
désordre à chaque instant menaçant pourtant n’est pas possible ; et
c’est faire l’inventaire de ce que nous devons croire si nous voulons
vivre, j’entends nous sauver de cet insupportable ennui de penser,
que Hume a pour finir si bien décrit. Cela m’apparut un jour que
Jules Lachelier lui-même, contre de téméraires affirmations
empruntées à son ouvrage, du moins je le croyais, voulut bien se
faire l’avocat du diable, et le fit avec cette puissance de critique et de
négation que devineront tous ceux qui ont entendu ce croyant, le
plus incrédule peut-être des hommes, hors sa foi. Mais je dis
maintenant incrédule par sa foi même. Plus près de Hume que de
Kant. Au reste, ce que j’ai lu dans les fameux disciples de Kant et
surtout en Fichte, à savoir que Kant ne suffit pas et qu’on n’y peut
rester, je l’ai compris par la pensée même de Lagneau, qui
connaissait fort bien Kant, mais était bien loin de s’y jeter comme en
Platon. Toutefois par où Kant ne suffit pas, c’est ce que je vis dans le
tissu même de l’analyse. Et l’induction ne sera pas un mauvais
exemple pour l’expliquer, quoique, comme on va voir, Lagneau ne
traitât jamais, à proprement parler, de l’induction.
Je considérerai un objet perçu, soit cet encrier ou cette boîte à
craie qui fait un cube. Exemples sacrés pour moi. Qu’on m’excuse si
je parle tant de moi ; je suis le témoin, j’oserais dire le seul témoin, le
seul bon témoin, et voici pourquoi. Quand je fus assis à mon banc
d’écolier devant cet homme vénéré et évidemment vénérable, je
l’écoutai d’abord avec une extrême défiance, m’attendant à de belles
phrases et à quelque doctrine vertueuse. Les discours publics de
Lagneau offrent bien cette apparence, et je suis capable maintenant
de les préférer à beaucoup d’autres, et seulement d’après le son.
Mais il reste vrai pourtant que préférer n’est pas la même chose que
penser. Or, en ce temps-là, assez et trop nourri de discours
vraisemblables, et n’ayant encore trouvé de pensée à me satisfaire
que dans la géométrie d’Euclide, je me trouvais placé dans un état
d’indifférence qui n’est point en général celui des jeunes, avides
d’admirer et d’imiter. J’ai souvent pensé à ce Polémon couronné de
fleurs, et qui entre par hasard aux leçons d’un sage. Couronné moi
aussi de jeunesse, et nullement inquiet des grands problèmes,
encore moins des solutions d’aventure que l’on m’avait proposées,
je me trouvais ici comme au spectacle, sensible au plaisir de
combiner, mais bien résolu à n’être pas dupe. Aussi ne le fus-je
point.
Nulle piperie ; nul étalage de doctrines louables. Mais cet encrier
et cette boîte à craie ; mais une exacte analyse de ce que c’est que
voir, toucher, entendre ; une lenteur et une confusion héroïques. Tout
le bagage des naturalistes, d’abord, étalé là ; toutefois bientôt lacéré,
exactement en morceaux. Car qu’est-ce que voir si ce n’est que
voir ? Qu’est-ce que toucher si ce n’est que toucher ? D’abord cette
folle idée des images renversées sur la rétine et qu’il faudrait donc
redresser. Mais toutes les images renversées, que signifie ? Ici le
rire du Maître ; et je me prends au jeu. Cette raison qui vient de
paraître en éclair n’est pas timide ; elle ne conjecture pas. C’est le
faux qui m’est découvert, non pas le douteux. Le naturaliste croit
qu’il perçoit d’abord de l’objet l’image qui se peint sur sa rétine ; mais
cette image est au vrai la perception d’une rétine, par exemple de
bœuf et grattée, et de l’image qui se peint dessus. Ainsi
m’apparaissait une immense méprise. Autre étonnement. La double
image visuelle et le stéréoscope étaient décrits selon la rigueur.
Comment arrivons-nous à voir l’objet simple ? Mais nous ne le
voyons pas simple ; les deux images ne coïncident pas ; elles ne
peuvent. Mais les différents aspects, innombrables, de ce cube, ne
coïncident pas ; ils ne peuvent. Je me souviens de cette formule :
« Les deux images sont justement une occasion de remarquer l’unité
de l’objet. » Or cet objet unique, quel œil le verra ? Quelle main le
touchera ? J’abrège encore maintenant, comme autrefois je me jetai
sur l’idée du cube, raison de toutes les apparences du cube, mais
qui ne ressemble à aucune de ces apparences. Dès que l’on en est
là, on n’a plus à craindre que les diverses images tactiles, visuelles
et autres, ne se rassemblent pas bien en une image composite ; car
il est vrai que le toucher que je reçois d’un cube ne ressemble
nullement à la forme diversement colorée que j’en vois ; mais il est
vrai aussi qu’une des images visuelles du cube ne ressemble
nullement à une autre et qu’elles ne coïncident jamais en un cube ;
et c’est l’idée du cube qui les explique toutes et les rassemble, sans
du tout les mêler ni les confondre. Mais que dis-je ? En les
distinguant au contraire. Seulement n’allons pas si vite ; rendons-
nous ces vérités présentes. J’en étais déjà à y croire. Par chance la
sévère méthode, l’incroyable scrupule du Maître me ramenaient à
les former de nouveau d’après d’autres exemples, et toujours l’idée
dans la chose, l’idée réelle, nullement l’idée séparée.
L’analyse infatigable défaisait enfin cette fantasmagorie, ce
charlatanisme des images flottantes qui seraient d’abord subjectives,
et qui prendraient réalité par la supposition d’une idée. L’Homme ne
jouait point ce jeu. Non qu’il montrât quelque préjugé contre les
analyses du genre anglais ni contre les arrogantes méthodes de la
Revue Philosophique. Au contraire il prenait leurs descriptions de
bonne foi ; mais il fallait enfin sourire devant cette naïveté sans
mesure. Car qu’est-ce enfin qu’une image visuelle qui ne serait que
visuelle ? Qu’est-ce que cette surface sans la profondeur et cet
espace mutilé ? Au vrai n’importe quelle image n’a de sens que
parce qu’elle représente un objet. Par exemple que peut signifier
une forme visuelle sinon une règle de mouvement ? Et comment
parler d’espace visuel quand l’espace est cette loi même qui d’un
sens à l’autre nous représente l’effet de nos mouvements ? Par
exemple la profondeur visuellement connue n’est telle que pour le
toucher. L’image qui n’est qu’image tombe donc au néant. Faisons
bien attention ici. Quand on demande d’où nous savons que les
objets réels se conforment à des lois, cette question même suppose
des objets d’abord donnés, mais comme des images subjectives et
dont on demanderait comment ils sont liés et s’ils sont liés. Et en
bref on se propose de passer des apparences subjectives à un
monde ordonné, d’un monde interne à un monde externe. Or déjà
Kant avait, par une sorte de force dialectique, écarté tout à fait cette
question, ce qui est sans loi n’étant point du tout objet. Par exemple
le permanent soutenait le changeant, la causalité soutenait la
succession, et l’action d’échange donnait seule un sens à la
simultanéité. D’où un théorème célèbre, et beau de force abstraite :
« La seule conscience de soi pourvu qu’on n’oublie pas qu’elle est
empiriquement déterminée, etc. » Mais l’objet sans loi avait encore
une ombre d’existence ; et l’espace se montrait encore à
l’imagination comme un cadre, ou comme un contenant dont on a dit
sans précaution tant de fois qu’il est quelque chose d’abstrait et de
rigide ; sur quoi s’est greffée cette étourdie manière de dire, qu’un
espace peut être courbe. C’est ainsi que l’imagination se repaît de
géométrie. Lagneau ne suivait pas ce chemin ; trouvant non point un
chimérique espace visuel, ni un inconcevable espace tactile, mais
trouvant l’espace en même temps que l’objet, il n’y pouvait voir
jamais que la représentation d’une loi qui lie d’un sens à l’autre nos
impressions à nos mouvements. Ce n’est aussi autre chose
qu’apercevoir la loi substantielle, intime à l’objet, inséparable, l’objet
étant liaison. On voit en quel sens le problème de l’induction était
dépassé. Aussi bien apparaît-il à chacun que c’est par induction que
nous lions le vert des feuilles à leur consistance, et l’odeur de la rose
à sa couleur. Mais la paresse d’esprit, qui, à mes yeux, fait scandale,
consiste en ceci qu’on ne se demande jamais ce que serait la
couleur d’une rose sans ce lien au tissu soyeux, à la tige, aux
épines, à la terre et à toutes choses. Et c’est par là que cherchait le
Philosophe. D’exemple en exemple et comme en tâtonnant il
poursuivait la sensation pure, attentif, et longtemps, et revenant
toujours, à vouloir dire ce que serait le solide senti comme tel, sans
aucune représentation ni anticipation ; aussi ce que serait la couleur
sans distance aucune, sans anticipation d’aucune sorte ; enfin le pur
évènement, sans aucun rapport ; poursuivant, après Platon, la vérité
Héraclitéenne. Et l’antérieure et première expérience toujours
s’enfonçait dans le sommeil. Nul autre rêve que le monde. Nul genre
de conscience hors de la perception des objets réels. Nul temps
séparable ; car, encore plus profondément que l’espace, le temps
exprime la liaison de toutes choses, un chemin réel parmi tous les
possibles. Tout au dehors ; et ce seul réel soutenu et comme tissé
de rapports. Comme le monde ne se retire point de l’esprit, l’esprit
ne se retire point du monde. C’est pourquoi j’ai mis en avant ces
deux formules que la sensation est un abstrait et qu’il n’y a point de
connaissance subjective. C’est toujours le vrai qui éclaire le faux ;
l’esprit est partout présent, et entier partout. Car ce n’est pourtant
pas la chose qui est loin ou près, grande ou petite ; et c’est tout le
carré qui est carré. Que chercher de plus ? Que chercher au delà ?
L’essence porte l’existence. Il ne s’agit plus de croire ou de ne pas
croire. Savoir va plus loin que croire. « Il n’y a, disait-il, qu’un fait de
pensée, qui est la Pensée. » Ainsi trouvait-il plus qu’aucune religion
ne veut. Mais aussi tout est vrai de ce que disent les religions, et
plus vrai qu’elles n’osent dire. Mais aussi l’on ne peut plus croire ; on
ne peut que savoir en acte, et la preuve ne peut être gardée. Tout
est signe, et sans nul mystère ; mais le mystère est bien plutôt en
ceci que les petites raisons reprennent force aussitôt. En sorte qu’il
est vrai que nous avons tout secours de ce monde merveilleux et
ami, mais qu’il est vrai aussi que nous n’avons d’autre secours
chacun que nous-même, étant abandonnés de tout dès que nous
nous abandonnons. On en voudrait jurer, on n’en peut jurer. Il n’y a
rien de plus simple, de plus facile, ni de plus agréable que d’oublier
que l’on est esprit. Les religions nous le rappellent, mais en vérité
nous dispensent aussi de le savoir. Et, sous le nom de matérialisme
pur, c’est encore la même facilité qui nous guette. Comme me le
disait un jeune homme fort instruit : « Si vous preniez le parti d’être
matérialiste, toutes ces difficultés seraient effacées. » Je le crois
bien ; une sensation associée à une autre, quelle formule plus
maniable et plus riche ? Et qui ne retombe pas là ? Lui jamais. Sa
voix se faisait rude pour nous redresser. Et telle est, à ce que je sais,
la seule leçon de morale qu’il nous donna jamais. Mais c’est celle
aussi qui effraie le plus ; car certainement la charge d’un esprit est
lourde. Pourtant la force de l’attention doit surmonter ici même
l’impossible ; car ou il n’y a rien ou c’est ainsi. C’est ainsi. Et cette
solution nous ouvre des difficultés sans fin, un travail qui est toujours
à refaire, des devoirs sans mesure, des scrupules sans fin et sans
aucun secours extérieur. Ainsi pensait-il, avec joie, sans aucune
crainte et sans aucune espérance. L’esprit imaginaire promet tout et
est lui-même promesse. L’esprit réel ne promet rien ; il ne
commande même pas, mais plutôt il demande, comme l’exprime le
beau mythe du dieu faible et trois fois renié.
Il est bon que l’on sache que ces développements n’étaient
nullement dialectiques, comme on voit dans les philosophes qu’une
idée conduit à une autre. La philosophie de Lagneau était
premièrement et je dirais peut-être uniquement une théorie de la
perception. Il semble que la nature même l’avait averti au sujet de
cette connaissance qui semble immédiate. Un jour, comme je lui
faisais visite, en cette chambre où la fatigue le retenait souvent, il me
fit voir par la fenêtre un treuil qui servait à des maçons. « Ce n’est
pas, me dit-il, un petit avantage d’avoir une mauvaise vue ; les
moindres objets sont alors des énigmes ; ainsi ce n’est qu’après des
heures d’attention que j’ai bien saisi ce que c’est qu’un treuil. »
J’avais la vue bonne et j’ai toujours deviné très vite le secret des
mécaniques. Le treuil est une des plus simples, et c’est l’élément de
toutes ; je l’aurais toujours supposé assez connu, et je me serais
amusé aux composés sans cet oracle. Depuis je n’ai jamais vu un
treuil sans y faire grande attention, et à chaque fois j’ai découvert
quelque chose. D’où je dis souvent que, si j’avais écrit quelque thèse
doctorale, c’eût été sur les nœuds de corde, qui sont des treuils
combinés, à bien regarder, en vue de prouver que tous les exemples
sont bons pour penser, et que les plus simples et les plus vulgaires
sont les meilleurs. Mais sans cet oracle, j’étais perdu, je crois bien,
par la diabolique facilité ; je vois qu’elle en a perdu d’autres. C’est
peu de chose que comprendre le treuil ; toutefois cette méditation,
extérieure encore, mais du moins délivrée des signes, avait
certainement contribué à éveiller cette réflexion percevante, dont j’ai
voulu retracer ici quelque chose.
Cette méditation n’avait d’autre objet que les choses mêmes, et
c’est pourquoi elle était naturellement si éloignée de la forme écrite ;
c’est pourquoi aussi, je ne puis que la raconter. La célèbre illusion
d’Aristote, par les doigts croisés, était interrogée sans fin. Quiconque
a ainsi perçu deux billes au lieu d’une doit sentir que le secret de la
représentation est ramassé ici sous ses doigts. Ces pièges aussi
tendus à notre vue, ces reliefs ambigus, ces lignes parallèles qui
semblent divergentes, cette réaction des grandeurs sur les
grandeurs, c’était l’espace vivant en quelque sorte, l’espace pensé,
et le jugement sans paroles. Et cela revient à montrer que l’idée de
l’objet change les apparences et déplace si l’on peut dire les
sensations. Mais Lagneau ne pouvait pas dire, et ne disait jamais,
que ce sont là des jeux d’imagination. Les reliefs, les grandeurs, les
distances, les formes représentent un objet réel ou ne sont rien.
Encore une fois qu’est-ce qu’une apparence qui n’est
qu’apparence ? Ces grandes idées paraissaient en ces figures
tracées au tableau. Et c’est tout à fait autre chose que de montrer
que toutes choses sont en vue d’une fin. « L’esprit vint, qui mit tout
en ordre » ; mais, comme Socrate l’avait remarqué, il ne suffit pas de
le dire ; et non plus, dirai-je, d’en jurer. La religion soutient la
philosophie comme la nourrice soutient l’enfant ; ce n’est pas
marcher. Lagneau ne pensait point théologiquement, ni
politiquement, ni pour le bonheur, ni pour la vertu ; mais sans soutien
aucun que ce monde, et toujours tenant la preuve entre ses doigts ;
assuré et confirmé en sa place d’homme ; toujours creusant,
toujours trouvant ; assez riche du monde autour et de soi. Souvent il
m’apparut comme le Génie de la Terre.