Upper Eyelid Blepharoplasty

Key points

  • Upper eyelid blepharoplasty has become more conservative, where there is less excision and more emphasis on repositioning and restoring orbital anatomy and volume.

  • Thorough periorbital preoperative evaluation is necessary to determine the appropriate blepharoplasty procedure with or without the need for a brow lifting procedure.

  • Conservative approaches that reduce the risk of complications such as lagophthamous should always be considered.

  • Periorbital skin quality improvement and reduction of rhytids may require skin tightening or resurfacing procedures in addition to blepharoplasty as adjunctive therapy.

  • Ancillary procedures such as neurotoxin or dermal filler injections may be combined with blepharoplasty techniques to provide more complete rejuvenation and a higher degree of patient satisfaction.

Introduction

The periorbital region is one of the earliest and primary locations on the face where patients seek rejuvenation. When we interact and speak to one another, we tend to look at each other’s eyes for signs of approval, understanding, and any emotional responses elicited. Therefore, the patients who are considering facial rejuvenation typically begin their quest for a more youthful appearance by pursuing periorbital cosmetic procedures. Frequently, patients state during the consultation with their cosmetic surgeon that they do not like their aging face as a whole; however, they emphasize that they would like to start by rejuvenating their eyes. If the periorbital cosmetic procedures go well and result in a high degree of patient satisfaction, the patient gains confidence in cosmetic surgery and frequently goes on to rejuvenate other cosmetic regions of the face and body.

Introduction

The periorbital region is one of the earliest and primary locations on the face where patients seek rejuvenation. When we interact and speak to one another, we tend to look at each other’s eyes for signs of approval, understanding, and any emotional responses elicited. Therefore, the patients who are considering facial rejuvenation typically begin their quest for a more youthful appearance by pursuing periorbital cosmetic procedures. Frequently, patients state during the consultation with their cosmetic surgeon that they do not like their aging face as a whole; however, they emphasize that they would like to start by rejuvenating their eyes. If the periorbital cosmetic procedures go well and result in a high degree of patient satisfaction, the patient gains confidence in cosmetic surgery and frequently goes on to rejuvenate other cosmetic regions of the face and body.

Anatomy of the periorbital region

The eyebrow position, shape, and form must be considered along with the eyelids and periorbital skin when evaluating this region for age-related changes and surgical rejuvenation. Cosmetic surgery of the brow and forehead will be discussed in other articles (see Tirbod Fattahi’s article, “Open Brow Lift Surgery for Facial Rejuvenation” and Jon D. Perenack’s article, “The Endoscopic Brow Lift,” in this issue); however, the aging brow must be given equal attention when considering cosmetic surgery of the eyelids and surrounding skin.

The upper eyelid anatomy must be clearly understood, with each layer identified when traversing through the lid to address cosmetic concerns ( Fig. 1 ). The Caucasian eyelids should demonstrate a dominant lid crease 8 to 11 mm from the palpebral margin, and if absent with a deep upper lid sulcus, may indicate levator disinsertion and eyelid ptosis ( Figs. 2 and 3 ). This eyelid crease in the Caucasian patient is at 8 to 11 mm from the palpebral margin and represents a line of fusion of levator aponeurosis with the tarsal plate with its concomitant dermal attachments providing the crease ( Fig. 4 ). In the Asian eyelid, this line of fusion is below the cephalic margin of the tarsal plate, which allows some preaponeurotic fat to extend over the tarsal plate and diminish the appearance of a tarsal crease. The skin overlying the tarsal plate, which is about 8 to 10 mm in length, is considered the pretarsal skin that overlays the pretarsal orbicularis oculi muscle. The skin superior to the tarsal plate is the preseptal skin overlying the preseptal obicularis oculi muscle ( Fig. 5 ).

Fig. 1
Cross-sectional anatomy of the eyelids with subciliary (A) and transconjunctival incision outline (B and C).
( From Saadeh P. Conventional upper and lower blepharoplasty. In: Aston S, Steinbrech DS, Walden JL, editors. Aesthetic plastic surgery. St Louis (MO): Elsevier; 2012. p. 325; with permission).

Fig. 2
Bilateral eyelid ptosis.

Fig. 3
Periorbital frontal anatomy and landmarks.
( From Larrabee WF, Makielski KH. Surgical anatomy of the face. New York: Raven Press, 1993; with permission.)

Fig. 4
Non-Asian upper eyelid anatomy ( A ); Asian eyelid anatomy ( B ). m., muscle.
( From Larrabee WF, Makielski KH. Surgical anatomy of the face. New York: Raven Press, 1993; with permission.)

Fig. 5
Obicularis oculi muscle anatomy of the eyelids.
( From Larrabee WF, Makielski KH. Surgical anatomy of the face. New York: Raven Press, 1993; with permission.)

Superior to the tarsal plate and just below the obicularis oculi muscle lays the orbital septum, which originates from the periorbita and inserts into the undersurface of the tarsal plate and fuses with the levator aponeurosis. Just deep to the orbital septum lays the preaponeurotic fat that is contained in 2 compartments, the central and medial fat pads ( Fig. 6 ). The lateral space that would contain the lateral pad, if it existed, is occupied by the lacrimal gland. The medial fat fad is typically lighter in color than the central fat fad, and the lacrimal gland is more orange in color and more vascular on its surface. Fullness of the upper eyelid is frequently due to attenuation of the orbital septum, allowing the preaponeurotic fat to bulge forward (pseudofat herniation) (see Fig. 1 ).

Fig. 6
Anterior view of deep dissection of right lower eyelid orbital fat pads. The inferior oblique muscle divides the medial from the central fat, and the arcuate expansion fascia ( asterisks ) of the inferior oblique muscle divides the central from the lateral fat pads. CFP, central fat pad; LFP, lateral fat pad; MFP, medial fat pad.
( From Burkat CN, Lemke BN. Anatomy of the orbit and its related structures. Otolaryngol Clin North Am 2005;38(5):828; with permission.)

Fullness of the eyelids can be related to endocrine disease and other systemic disorders that must be ruled out before performing blepharoplasty. Deep to the preaponeurotic fat lays the levator aponeurosis and the levator palpebrae superioris muscle. These structures must be preserved and respected during cosmetic eyelid surgery to prevent levator disinsertion and subsequent ptosis. This layer is addressed for ptosis repair surgery through levator suspension. The only layer remaining before encountering the globe, once deep to the levator, is the palpebral conjunctiva. Therefore, levator suspension procedures require the use of globe protection in the way of a shield to prevent injury to the bulbar conjunctiva.

Eyelid esthetics

The palpebral margin should demonstrate a superior lateral inclination or slant in the nonsyndromic patient. The medial portion of the palpebral margin is more vertical than the lateral forming the almond shape of the open eyelid margin. The superior eyelid margin should end at the superior limbus of the iris and not extent more than 2 mm into the iris. The upper eyelid crease does not extent medial to the fornix, except in Asian eyelids, where epicanthal folds exist. The lateral fornix should be the lateral extent of the upper eyelid crease; otherwise, lateral hooding and redundant eyelid or brow skin are present (see Fig. 2 ).

Age-related changes of the periorbital region

Age-related changes of this regional cosmetic subunit must be understood in 3 dimensions and cannot be isolated to only the upper eyelids. Therefore, the age-related changes and preoperative assessment of the entire peri-orbital region to include the brows and upper and lower eyelids are discussed. Gravity and subdermal atrophy result in a decreased projection of the eyebrows and a tendency toward a lower brow position with loss of the brow arch in women, resulting in redundant eyelid and brow skin encroaching on the palpebral margin. Attenuation of the orbital septum allows pseudoherniation of fat of the fat pads and contributes to an appearance of bulging or fullness of the eyelids. Dermal thinning allows discoloration of the eyelids as previously mentioned and the appearance of underlying anatomic structures, such as the orbital rim, vessels, and fat pockets. The effects of gravity and dermal and subdermal atrophy contribute to brow ptosis, dermatochalasis, periorbital rhytids, and the appearance of nasojugal folds (tear troughs) and prominent infraorbital rims. Excessive ultraviolet light and extreme environmental exposure contribute to collagen degradation and loss of elastin fibers that also result in periorbital rhytids and redundant skin. Constant squinting during extended exposure to sunny environments can lead to orbicularis hypertrophy of the lower lid pretarsal obicularis oculi muscle that may masquerade as baggy lower eyelids that may elicit cosmetic concerns from affected patients.

Attenuation of the medial and lateral canthal ligaments associated with aging will result in decreased lid tone and predispose the patient to lateral canthal rounding, scleral show, ectropion, and lagophthalmos following cosmetic surgical procedures of the eyelids. A thorough understanding of these age-related changes of the periorbital region is necessary to assess and plan 3-dimensional periorbital rejuvenation using resective techniques as well as volumizing procedures where necessary.

Preoperative assessment

A thorough history and physical examination are necessary to identify any systemic condition that may adversely affect the surgical outcome. A detailed ocular history is imperative, and if any significant ocular history is identified such as glaucoma, Graves disease, myasthenia gravis, visual acuity changes, or prior orbital surgery or trauma, a preoperative ophthalmology consultation is prudent. Current medications that may interfere with coagulation or platelet function should be identified and discontinued before surgical intervention if approved by the patient’s primary care provider. The ocular physical examination should, at a minimum, document visual acuity, extraocular muscle function, lid tone (snap test) and function, the degree of eye lubrication, and the presence of orbital or ocular abnormality. Preoperative photographs in the frontal, oblique, and profile views in repose and smile are an absolute requirement to document the patient’s baseline periorbital appearance.

Assess and document the following:

  • The eyelid position relative to the globe and iris

  • Skin for abnormality, rhytids, thickness, redundancy, laxity, and color

  • Visual presence of the infraorbital rim, nasojugal folds, malar fat pad, or cheek festoons

  • Presence and position of the supratarsal fold (lid crease)

  • Position and presence of the fat pads (gentle globe pressure to accentuate pseudo fat herniation)

  • Eyelid excursion with opening and closing of the eyelids (check for ptosis)

  • Presence of ectropion, scleral show, proptosis, enophthalmos

  • Tear film management (epiphora or dry eye symptoms)

  • Lid tone/tension with the lower lid distraction snap test when contemplating lower eyelid surgery

  • Prominence of lacrimal gland

  • Brow position identified relative to the orbital rim (brow ptosis will contribute to redundant upper lid skin). Average vertical distance from palpebral margin to the mid brow position is 27 mm

  • Patient’s motivating factors and expectations as well as their impression of body image

  • Thorough discussion of the risks, benefits, and alternatives as well as the limitations and expected outcomes if no complications are encountered. Delineate the most common complications and answer all questions to establish consent.

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Jan 23, 2017 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Upper Eyelid Blepharoplasty
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