7: Cosmetic Blepharoplasty

7 Cosmetic Blepharoplasty

Of all cosmetic facial surgery procedures, blepharoplasty can be the most simple yet the most complex. Its intricacies are significant but once mastered provide great satisfaction for both surgeon and patient. If the eyes are the windows to the soul, cosmetic surgery and facial rejuvenation should open the blinds. The upper face frequently ages earlier than the lower face, and the eyelids and brow are frequent areas of concern in patients from the age of 35 on up. Younger patients usually are concerned about droopy upper eyelids and fat bags. Older patients have additional concerns about wrinkled skin and brow repositioning. For most patients, it is a matter of cosmetics, but some have functional problems such as eyelid ptosis, lid laxity, and visual obstruction. This is a basic chapter on diagnosis and treatment, so our discussion will be limited primarily to cosmetic blepharoplasty.

Numerous specialties have adequate training and experience to understand and learn cosmetic blepharoplasty. Those specialties that deal with facial trauma have even a greater understanding of the eye and periorbita.

Learning blepharoplasty surgery (for non-core-trained surgeons) begins with reading texts and journal articles, attending cadaver and didactic CME courses, watching instructional videos, observing live surgery, and finally proctoring actual cases. In my experience, this learning curve requires 1 to 2 years of study to become proficient. A number of wisdom pearls will be discussed; some are critical to “staying out of trouble” with cosmetic blepharoplasty. Eye complications can be devastating for a patient and career ending for a cosmetic surgeon, but for the most part they are rare when conservative technique is used and some basic tenets are followed.

Orbital Anatomy

This is a surgical technique atlas, so space precludes an exhaustive review of orbital anatomy. The orbits and eyes have some of the most delicate and complex anatomy in the body, so a thorough understanding of eye anatomy is essential to understanding blepharoplasty. In considering the external anatomy, one must be familiar with certain structures and understand their form and function:

One must be particularly familiar with the structures of the upper eyelid (Figure 7-1):


FIGURE 7-1 Eyelid anatomy upper lid.

(Redrawn courtesy Steve Bosniak, MD.)

The key structures of the lower eyelid (Figure 7-2) are:


FIGURE 7-2 Eyelid anatomy lower lid.

(Redrawn courtesy Steve Bosniak, MD.)

The layers of lamellae of the eyelids are the outer lamella, which includes the skin and orbicularis muscle; the middle lamella, which includes the orbital septum and fat; and the inner lamella, which includes the tarsus and conjunctiva. (This classification is described differently in various texts and also varies by the specific level described.)

The eyelid skin is some of the thinnest in the body—sometimes as thin as 0.2 mm. The underlying concentric orbicularis oculi muscle is described in three portions: the pretarsal portion, which overlies the cartilaginous framework of the lids; the preseptal portion, which overlies the orbital septum; and the orbital portion, which overlies the bony orbit (Figure 7-3). Figure 7-4 shows the actual muscle intraoperatively. The orbital septum is a connective-tissue layer that is an extension of the periosteum and separates the muscle layer from the periorbital fat (Figure 7-5). Figures 7-6 and 7-7 show clinical views of the orbital septum.

Müller’s muscle is an autonomic muscle that lies deep to the levator palpebrae superioris muscle (Figure 7-8) and is responsible for approximately 2 mm of upper eyelid opening.

The tarsus represents the cartilaginous framework of the eyelids. The upper tarsus is approximately 10 mm in height, and the lower tarsus is about 4 to 5 mm in height.

The upper eyelid crease is determined by the insertion of the fibers of the levator aponeurosis into the eyelid skin. The normal Caucasian upper eyelid crease is 10 to 12 mm above the lashes in females and about 8 to 10 mm above the lashes in males (Figure 7-9, A). The Asian eyelid crease is 4 to 6 mm above the lash line and is inferiorly positioned because the levator aponeurosis fibers attach at a lower level (see Figure 7-9, B).

The globe is cushioned by periorbital fat positioned into distinct fat pads in the upper and lower eyelid. These fat pads are frequently reduced or repositioned in cosmetic blepharoplasty. There are two fat pads in the upper eyelid: the medial (sometimes called nasal) and the central (Figure 7-10). The superior oblique muscle separates the medial and central fat pads in the upper lid. Also sitting in the lateral upper orbit is the lacrimal gland. This gland is pinkish and similar in consistency to salivary glands; despite its appearance, it is sometimes mistaken for fat and removed, with disastrous consequences. It is imperative for the novice surgeon to remember that there are only two fat pads in the upper lid. The lower eyelid has three fat pads: the medial (sometimes called nasal), the central, and the lateral (sometimes called temporal). In the lower eyelid, the inferior oblique muscle separates the medial and central fat pads, and the arcuate expansion of the inferior oblique muscle separates the central and lateral fat pads (see Figure 7-10). Figure 7-11 shows the right upper lid lacrimal gland. Innervation of the periorbital area is complex; the main innervation of the eyelids and associated structures is given in Box 7-1.

Aging Conditions of the Eyelids and Periorbital Areas

As we age, various changes become evident in the eyelids (Figure 7-12). The most obvious is the presence of brow ptosis. Most young males have flat brows at or above the level of the upper orbital rim, and most young females have arched brows above the level of the upper orbital rim. As we age, the brows and forehead begin to droop, and this ptosis causes redundant tissue. This is especially obvious in the lateral orbital region of the upper eyelids, a condition known as hooding.

Many times patients will grab this excess skin and want it excised. It is important to point out to them that this is actually forehead skin and cannot be cut off. It needs to be repositioned with brow lift. One can easily excise excess skin of the upper eyelid proper, but failure to diagnose a ptotic brow and forehead is a common mistake, even by highly qualified surgeons. I have seen many patients who have had past blepharoplasties present to my office for endoscopic brow and forehead lift (EBFL). Unfortunately, a misdiagnosis on the part of the previous surgeon has not left enough skin to both elevate the brow and close the eyes. Because brow position is integral to proper blepharoplasty, many patients require both EBFL and blepharoplasty, especially women, so I perform simultaneous upper blepharoplasty on about 99% of my brow lift patients.

Aging changes in the upper and lower eyelid skin come from multiple sources. As mentioned, this skin is the thinnest in the body, sometimes only 0.2 mm thick, making it vulnerable. Actinic damage is a big contributor to elastosis and texture changes in the eyelids. Excess and wrinkled skin is referred to as dermatochalasis.

Fat pseudoherniation (steatoblepharon) is the next most common cosmetic problem occurring in the eyelids. Much discussion about whether this is a herniation or pseudoherniation exists; I think a more accurate word is prolapse. Most clinicians agree that the orbital septum becomes weakened with age, and the periorbital fat pads protrude though this weakened septum and cause the fat bags. To view the extent of prolapse, gentle pressure is placed on the globe while the patient closes the eye. This maneuver, called retropulsion, will cause the herniated fat pads to become evident. Additionally, asking a patient to look upward and open their mouth will accentuate the herniated fat. This condition is frequently familial and hereditary, with some patients developing protruding fat bags in their late teens. Eyelid fat collections are sensitive to fluid shifts and gravity, so they appear worse in the morning. Frequently, affected patients will present with the chief complaint of dark circles under their eyes. In reality, these “dark circles” may represent shadows cast by protruding fat bags; in a room with overhead lighting, the circles are much more apparent from shadowing. This can be illustrated by taking a photograph with the patient standing under an overhead light source and taking a photo with and without flash. The flashless picture will accentuate dark circles.

Dark circles or periorbital pigmentation can be multifactorial and sometimes represent true pigmentation. This may be from sun damage and if superficial will respond to skin resurfacing or excision. Some ethnic populations such as Indo-Pakistanis have extremely deep pigment that is difficult to improve. Venous congestion and hemosiderin pigment that has extravasated into the skin can also produce dark circles under the eyes.

Some patients will present with a chief complaint of “fat bags,” but in reality they have hypertrophic orbicularis oculi muscles in the lower lids. Patients with orbicularis hypertrophy show increased lower lid bulges when asked to smile and squint. Figure 7-13 shows a patient with lower eyelid orbicularis oculi hypertrophy.

Xanthelasma is an accumulation of yellowish plaques in the upper eyelid skin (Figure 7-14). This condition is related to increased blood levels of cholesterol or hyperlipidemia and sometimes with diabetes. These lesions are treated by surgical excision or laser ablation and frequently recur.

Periorbital festoons are swellings from skin damage and fat in the infraorbital or midface area (Figure 7-15). These are challenging areas to correct. They are frequently treated with skin resurfacing or direct excision.

Eyelid laxity is condition that can be critical to function and aesthetics and must be recognized preoperatively. This condition results from supporting-structure laxity and elastosis of the surrounding tissues. The eyelids lose their normal tight approximation to the globe and sag like an overloaded clothesline. This can be especially significant in the senescent population and is frequently seen in longtime contact lens wearers. Patients with significant laxity may show sclera below the inferior pupil, or in extreme cases, the lid margin is everted with visible conjunctiva. The lax lid can be permanently retracted by excessive skin excision or skin resurfacing and must be critically accessed in preoperative consultation. This will be discussed in the evaluation section of this chapter.

Diagnosis and Patient Selection

Some cosmetic facial surgery procedures can be done with minimal preoperative scrutiny and have limited complications, but eyelid surgery gone wrong can lead to serious consequences, including blindness. Some of the most important time spent with a patient is at the consultation, when the patient is shopping for a doctor, and the doctor is evaluating the patient surgically and psychologically. The primary considerations are the patient’s expectations and appreciation of the reality of the situation. An elderly patient who presents with a magazine picture of a young model may have unrealistic expectations. A patient who presents with an obsession over a minor flaw may have body dysmorphic disorder. It is the duty of the surgeon to give the patient an accurate presentation of what to expect in terms of diagnosis, treatment, recovery, and result. The more information presented up front the easier it is to deal with problems that occur postop. It is our job to present “typical scenario” as well as best and worse scenario options. As they say, a postop problem is a sequella if it was discussed preoperatively and a complication of it was not discussed preoperatively.

Adequate time must be scheduled for eyelid evaluation—on average 30 to 45 minutes. During that time, health history, procedures, complications, pre- and postoperative considerations, fees, and anesthesia evaluation must be discussed (Box 7-2). Pictures are everything in cosmetic surgery, and representative before-and-after images should be shown to give the patient an idea of what to expect. Having a list of patients who will serve as references to discuss their surgical experience with your prospective patients is a very useful adjunct. Additional information such as brochures, websites, before-and-after images, slide shows, and the like are very useful in supplementing patient information.

It is rare that a patient would only have one evaluation; all patients should return to the office for final preparation. In our office, this includes visual acuity, signing consents, making a down payment, obtaining forms for physician history and physical (if necessary), lab work, postoperative prescriptions, preoperative photographs, and finalizing surgery plans and questions. The more times you can see a patient before operating on them, the better your communication will be.

Several critical observations and instructions must be made by the doctor and staff, including the following:

Preoperative prescriptions, including antibiotics, antivirals (if resurfacing is planned), and analgesics are given at the final preoperative appointment.

Several tests assist the surgeon in assessing the risks of cosmetic blepharoplasty for specific patients and are a requirement prior to blepharoplasty:

Visual acuity is easily performed in the office by having the patient read an eye chart with and without eyeglasses. Some patients will claim their vision has changed after eyelid surgery, so for clinical as well as medicolegal reasons, this testing is paramount.

Dry eyes are very problematic, and if a patient cannot close his or her eyes after surgery, irreversible corneal damage may result. A Schirmer test may be performed, but an ophthalmology consult is recommended for patients who require eye drops on a regular basis before eyelid surgery.

Lower lid laxity can cause significant functional and cosmetic problems. The patient must be warned about this preoperatively, and the surgery must be modified to avoid postoperative lower lid malposition or ectropion.

Several simple exams can be performed to evaluate the function of integral functions of related anatomy. The snap test involves pulling the lower eyelid inferiorly away from the globe and letting it go. The lid should snap back into position within 1 second (Figure 7-16). Failure to snap back into position or an elapsed time over a second to return to position indicates a lax lower eyelid and merits caution (Figure 7-17).

An additional test to evaluate eyelid laxity involves stretching the lower eyelid laterally and assessing the distance of travel of the punctum. When the normal lower eyelid is stretched laterally, the punctum does not move beyond the medial limbus (Figure 7-18, A). In the lax lower eyelid, the same maneuver will cause the punctum to move lateral to the medial limbus (see Figure 7-18, B).

The pull test also assesses lower eyelid laxity and is performed by pulling the lower eyelid anteriorly from the globe and measuring the distance (Figure 7-19). A gap of over 7 mm indicates lower lid laxity and again merits caution and conservative blepharoplasty if not an adjunctive tightening procedure such as canthopexy.

A mechanism exists to protect the cornea during sleep or unconsciousness. This phenomenon causes the globe to rotate superiorly and cover the cornea behind the upper eyelid to prevent desiccation and is known as Bell’s phenomenon. It can be witnessed in some patients who sleep with their eyes partially open, showing the white sclera. A patient with dry eyes or without a protective Bell’s phenomenon could have catastrophic corneal damage from corneal exposure and drying if a lagophthalmos (inability to close the lids) should occur post blepharoplasty. To check for the presence of Bell’s phenomenon, the patient is asked to close the eyes, and the examiner gently pries the lid open with their fingers; the eyeball should roll back and protect the cornea, and the examiner should see only the white sclera (Figure 7-20, A). A patient with an abnormal Bell’s phenomenon has their corneal surface exposed and visible with eyes closed and pried open (see Figure 7-20, B).

Needless to say, any patient with even a hint of an ophthalmologic problem should have an ophthalmology consult preoperatively.

The need for preoperative images cannot be overemphasized. Patients rarely pay attention to their eyes until you operate on them, then they become very critical. It is not unusual for a patient to complain about something that “was not there before the surgery.” They may focus on the tiniest skin excess or asymmetry and blame you, the surgeon, for this problem. Any asymmetry or other variable that may affect the outcome should be documented in writing preoperatively and signed by the patient. This practice has saved the author time and again. The fact is that soon after surgery, the surgeon and patient typically forget what the patient looked like preoperatively.

Besides being chart records and medicolegal documentation, consented before-and-after images are invaluable marketing tools. Cosmetic surgery is all about before-and-after pictures and they can be used (with consent) in the office, on the Internet, and for many other marketing purposes. The surgeon and staff must be meticulous about obtaining legal written permission from the patient. Significant lawsuits have been lost for improper use of patient images, which can be a Health Insurance Portability and Accountability Act (HIPAA) violation. Since this may vary from state to state, legal consultation should be obtained that clearly details the uncompensated use of images for educational and promotional purposes. Some patients are honored to allow their images to be used, but others are very private about this; consent should never be taken lightly.

As we addressed in depth in Chapter 3, photographic images should be standardized or they are useless. Common background, position, lighting, and pose are requirements.

A minimum preoperative series should include:

Figure 7-21 shows a typical preoperative series used by the author.

Treatment Planning

Blepharoplasty is not a simple procedure. Much of its success or failure lies in meticulous attention to planning the procedure. There are many loose ends to tie up before the scalpel touches the skin. Attention to previously mentioned details cannot be overstated and must be reinforced with staff so nothing falls between the cracks.

Although some patients will present for isolated upper or lower eyelid procedures, many patients will request four-quadrant blepharoplasty with browlift and possibly other cosmetic facial procedures. Upper eyelid blepharoplasty is pretty standard in technique, but lower lid approaches vary in internal and external approaches to the fat. For years, external skin-muscle approaches were used with a subciliary incision. This involves violating the middle lamella (orbital septum) and excising skin and/or muscle from the external surface. This approach is still utilized, but most contemporary oculoplastic surgeons maintain that violating the middle lamella can be a prime cause of lower lid malposition, which can result in lid retraction with scleral show, ectropion, and dry eyes (Figure 7-22). Transconjunctival approaches have become more popular because the orbital septum is spared, there is no external incision, and lower lid malposition is rare. The conventional transconjunctival approach is a retroseptal surgical approach and spares violation of the orbital septum. When dealing with transconjunctival approaches, alternate methods are used to address excess skin. In young patients, no ancillary skin removal may be required. In older patients, carbon dioxide (CO2) laser resurfacing of the eyelid skin is my treatment of choice. My second most common choice is 30% trichloroacetic acid (TCA), and skin-pinch techniques are my third choice and can address the skin excess without invading the lower septum. These techniques will be discussed in detail later in the chapter.

In terms of comprehensive treatment planning, brow position must be addressed preoperatively. If concomitant endoscopic or open brow lift and upper blepharoplasty is planned, the sum of both procedures can stretch the upper lid skin to a point where the eyelids cannot be closed, so both of these procedures must be tempered to account for adequate residual upper eyelid skin in order to close the eyes fully. I typically remove about 7 to 10 mm of skin in the upper eyelid, but this can vary significantly from patient to patient. When performing simultaneous upper lid blepharoplasty and brow lift, this amount is reduced by 50%. If skin resurfacing of the eyelids is planned with blepharoplasty and brow lift, even more caution is used. It should be kept in mind that the surgeon can always take more skin away later, but it is difficult to replace! For the novice surgeon contemplating both brow lift and simultaneous upper blepharoplasty, it may be best for safety reasons to perform the brow lift first and address the upper lids at a later procedure.

Preoperative Marking

Upper Eyelid

Blepharoplasty is a technique of finesse. Successful blepharoplasty surgery is more about what is left behind than what is removed. Removing too little skin may necessitate a revision surgery and be an inconvenience to the surgeon and patient, but over-resection can cause serious health and cosmetic problems and lead to lawsuits! My supreme word of advice to all blepharoplasty surgeons is to be conservative. You will never go wrong with this pearl. I tell all of my blepharoplasty patients in the preoperative period (and in the consent) that a small percentage will need some touch-up surgery. If they do, I told them, and they are not shocked. If they don’t, I am a hero.

The biggest challenge for novice blepharoplasty surgeons is learning how to properly mark the eyelids. Once you understand the marking procedure, the surgery is relatively straightforward, but there is no cookbook technique to marking the upper eyelid; each lid (even on the same patient) is different.

It is imperative to mark the eyelids with the patient relaxed in the upright position. When the patient is lying down, the brows and lids are not in a natural position, and the markings can be inaccurate. Also remember to take preop photographs before marking the patient.

The lids are wiped with alcohol before marking to degrease them for better adherence of the marking ink. These marks must remain visible through surgical scrub, local anesthesia, and manipulation, and some marking pens do not do the job. I have found the retractable ultrafine-point Sharpie markers to be the best for ink longevity on the skin. I have done several thousand eyelids without any problem of surgical tattoo with these markers.

The first step is to decide where to locate the upper lid crease. Most males (non-Asian) have an upper lid crease of about 8 mm above the lashes, and most females (non-Asian) have upper lid creases of 10 to 12 mm above the lashes. Generally the lid crease is marked using the patient’s existing lid crease. Females desire a high lid crease to have a significant lid shelf on which to apply eye shadow. A high crease in males can feminize the result; 8 mm is an average position in the Caucasian male. The position of the upper lid crease can be discussed preoperatively, but I prefer 10 to 12 mm for females and 8 mm for males. I elevate the brow to a normal position (at the orbital rim for males, above the orbital rim for females) and have the patient open and close their eyelid to visualize the crease. The crease is then marked from the lateral canthus to the lacrimal punctum (Figure 7-23). Generally the center of the crease is at the 8 to 10 mm mark, and the ends of the crease taper to 4 to 5 mm high, creating an arc. But in many patients, their natural crease is almost a straight line, so attempting to make too high an arch can cause an artificial look.

The next step is to mark the upper extent of the blepharoplasty incision. The upper portion of the upper eyelid marking is made approximately 10 mm inferior to the junction of the forehead and eyelid skin. If one closely examines the skin inferior to the eyebrow, an area (generally corresponding to the bony orbit) where the smooth, thicker forehead skin meets the thinner crinkly upper eyelid skin can be seen. This is usually just below the finest hairs of the eyebrow but can be lower in some patients. A mark is made 10 mm below this junction; this defines the upper extent of the skin excision (Figure 7-24). If the surgeon leaves 10 mm from the lash to the lid crease and leaves 10 mm from the forehead/eyelid skin junction, this will give a total of 20 mm of upper eyelid skin preserved and enable lid closure. Always leave at least 20 mm of upper eyelid skin intact for normal lid function (Figure 7-25). This is, in the author’s opinion, the most critical point of successful upper eyelid blepharoplasty. Failure to observe can result in overexcision of upper eyelid skin with permanent lagophthalmos.

The final step is to connect the incision at the lateral canthal area. If a brow lift is not planned, then a “Bird beak” incision is used with a lateral extension of extra lid skin excised to correct hooding (see Figure 7-26, A). If simultaneous brow lift is planned, lateral hooding of the upper lid is corrected, and a “Napoleon’s hat” incision is used for the lid skin (Figure 7-26, B). Since the brow lift elevates the lateral lid skin, excision of lateral lid skin is unnecessary. (These nicknames are used by the author for teaching purposes and are not official nomenclature in the ophthalmologic literature.) It can be of value to extend the lateral excision into a natural crow’s-foot wrinkle; this may better blend the scar. Although some authors recommend extending the lateral incision up to 15 mm lateral to the orbit, this can leave a scar that looks unnatural and takes much longer to heal. I personally do not extend the lateral portion of the incision past the bony lateral orbital in most patients. When I do, it is generally not more than 5 mm or so. Another important pearl is that this lateral incision extension should always taper up (like a smile) and never inferiorly (like a frown). The latter can look unnatural.

When addressing the medial junction of the upper and lower marks, it is important to avoid the multicontoured depression lateral to the nose. Generally, the medial corner of this incision ends at the punctum. If the excision is carried out laterally onto the nose, an obvious scar will be apparent, and scar webbing of this multicontoured area can occur (Figure 7-27).

After the lid markings are made, a “pinch test” is made to check that the lids can still be closed with the prospective skin excised. With the brow elevated to a normal position, the skin is pinched with a forceps; the lashes should just evert, but the eyes should still be able to remain closed (Figure 7-28). This test reinforces that excessive skin is not removed and is especially critical when simultaneous brow lift is planned. If simultaneous brow lift is planned, much less skin should be removed relative to the amount of anticipated lift.

An additional means of marking the upper eyelid is to mark the upper lid fold. This not only provides an alternative means of determining the superior extent of the upper lid incision but can serve to verify other marking methods for accuracy. This is done by having the patient stand in front of the surgeon and stare at a fixed point. I generally place my index finger on the tip of my nose and ask the patient to focus on that point. The patient must be able to stare straight ahead at my fingertip without looking up or down, so I adjust my position to accommodate patient height. The point is to have the patient look straight ahead with a focused gaze, brows relaxed. I then use the surgical marker to make dots on the bottom of the overhanging skin fold of the upper lid (Figure 7-29). These dots are amazingly accurate in relation to what will become the superior extent of the upper blepharoplasty incision and will usually correspond to the line marked in Figure 7-24.

I generally use both of these methods to mark my superior extent of the upper blepharoplasty incision. First I use the “stare at my finger” technique and make a series of dots across the bottom of the upper lid fold, as shown in Figure 7-29. Then with the patient seated and the brow elevated, I reconfirm these marks by measuring 10 mm below the junction of the forehead/eyelid skin, as shown in Figure 7-24. These dots and lines usually correspond very closely and serve as affirmation of the proper excision of the superior margin.

A third means of determining the upper extent of the incision is usually reserved for the experienced blepharoplasty surgeon. With the patient lying down (or the brow manually elevated to its normal position), the center of the upper lid is pinched with a forceps until the upper lashes just begin to evert (Figure 7-30). A mark is made at the pinch point. This is repeated on the lateral and medial portions of the upper lid, and these marks are then connected. This ensures adequate skin preservation to close the lids. Again, this technique is best reserved for the experienced blepharoplasty surgeon.

All of the aforementioned techniques can be accurately used, but will not work on every single patient due to anatomic variation and experience may be necessary to accurately mark some patients. When in doubt, error on the conservative side.

Jan 12, 2015 | Posted by in Oral and Maxillofacial Surgery | Comments Off on 7: Cosmetic Blepharoplasty
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