Blepharoplasty – Masters Book

BLEPHAROPLASTY

Norman Pastorek M.D. F.A.C.S.
Andres Bustillo, M.D.

The history of eyelid surgery dates back to approximately 25 A.D. when Aulus Cornelius Celsus, a first century Roman philosopher, described the excision of upper eyelid skin for the “relaxed eyelid” in his De re Medica. It is not known whether he was describing a true ptosis or an excess of skin. The first medical illustration of the aging eyelid was published in 1817 by Beer. A year later Von Graefe first used the term ‘blepharoplasty” to describe a case of eyelid reconstruction following a cancer resection. It was during this time period that many in Europe first began to advocate the removal of the upper eyelid skin to correct associated functional problems.

In 1844 Sichel described “ptosis adiposa” as a condition by which the excessive upper eyelid skin fold was filled with fat He theorized that the disproportionate adipose tissue caused the skin to hang down over the lid. However, it was Fuchs that later correctly recognized the role of the fascia) attachments between skin, orbicularis, tarsus, and the levator in the development of the supratarsal skin fold and the importance of its recreation in blepharoplasty.

In the early 1900’s, many surgeons began to popularize the removal of upper eyelid skin for aesthetic enhancement In 1907, an American surgeon named Conrad Miller wrote one of the first books on cosmetic surgery entitled Cosmetic Surgery in the Correction of Facial Imperfection. His diagrams of blepharoplasty incisions are still similar to those used today. Kolle, in 1911, detailed the value and safety of preoperative marking of blepharoplasty incisions to avoid excessive skin removal. Adabert Bettman made important contributions with respect to postoperative scaring. He advocated precise apposition of wound edges with elimination of tension as well as early suture removal to avoid unsightly incisions.

In the early 1920’s, Suzanne Noel, a Parisian surgeon wrote a book on cosmetic eyelid surgery. In it she stressed the importance of preoperative planning using photographs. Noel is also credited with being among the first to recognize the psychological implications of cosmetic surgery. In 1924 Julian Bourguet was the first to describe the transconjunctival approach for the removal of orbital fat Five years later, he described the removal of fat from the two separate compartments of the upper eyelid. He is also credited for being the first to publish ‘before and after” photographs of patients undergoing cosmetic eyelid surgery.

In the 1920’s Hunt described the coronal browlift and shortly after Joseph popularized the trichophitic and midforehead browlifts. In the 1950’s Castanares precisely detailed the anatomy of the eyelids and made an important contribution by identifying the role of orbicularis resection in blepharoplasty. Flowers in the 1970’s introduced the supratarsal fixation for the low eyelid crease.

In the last two decades the most notable advancements in blepharoplasty have been made in the avoidance of complications. The importance of pre-operative evaluation for dry eye and other ocular diseases was highlighted. Tenzel detailed the combination of horizontal lid shortening and lower lid blepharoplasty for lax lower lids. With this came the realization that such procedures should ultimately be performed at the lateral canthus to avoid lid margin incisions.

PERSONAL PHILOSOPHY

Blepharoplasty remains one of the most requested aesthetic facial procedures. Both heredity and aging can influence the appearance of the orbital area. The upper lid begins to show evidence of aging almost before any other facial feature. Familial fat psuedohemiation, while not a result of aging, can be seen to begin the early teen years. The eyes more than any other facial feature are a focus of attention to both the patient and observers. Changes, whether the result of heredity or the effects of aging, seem to take on a magnified importance in the orbital region. Because there is lithe room for error in blepharoplasty, both careful preoperative physical analysis and meticulous surgical execution are imperative for a successful outcome in blepharoplasty. In general, however, the benefits are much greater than the risks for these procedures. Both the surgeon and the patient universally find the results rewarding.

As in rhinoplasty or facelift surgery, each surgeon brings to the consultation and then to the operating room an artistic goal as to how the final result of blepharoplasty should appear. Though brow position is not part of blepharoplasty, brow position relative to the orbital rim is significant in the final appearance of the blepharoplasty procedure. Some surgeons prefer a very high brow others a low brow. Many patients also have a personal bias in this regard. Patients will come to a surgeon often based on his or her personal philosophy relative to a ” look ” he is known for. This certainly is true in rhinoplasty, but also is true in blepharoplasty. With most artistic vision there is no absolute best, just many individual sensitivities. There are certain goals, however, that every surgeon tries to achieve: 1) minimal scars in the upper and lower lids, 2) least possible redundant skin, 3) smoothest transition between bone and lid, 4) symmetry of the lid position 5) symmetry of fat position, 6) maintenance of lid to limbus relationship, 7) durability of the procedure, 8) an overall unoperated appearance, 9) a non-feminizing male upper lid, 10) rapid and uneventful post-operative course, 11) the absence of complications.

As is true for any surgical procedure, aesthetic or non-aesthetic, proper diagnosis and evaluation of the problem are of paramount importance. This indudes both physical and psychological assessment Other factors of success in blepharoplasty indude, a complete explanation of the pre-operative, intra­operative, and post operative facets of the procedure to the patient The surgeon must have a complete understanding of the technical aspects of upper and lower lid blepharoplasty and a complete grasp of how to manage minor and major complications that may occur. The information that follows is a compilation of a personal philosophy of upper lid and skin-muscle flap lower lid blepharoplasty.

ANATOMY Eyelid Anatomy

The lower lid margin has a tangential relationship to the lowest limit of the lower limbus. Seldom does the lower lid cover the corneal margin by more than a millimeter. The upper lid margin is positioned over the upper cornea at midpoint between the upper edge and the pupillary border. Occasionally in a normal eye there is visible sclera below the cornea. This variation may be aesthetically appealing in young woman, but more often its presence draws attention to the eyes and creates the illusion of prominence or exophthalmos. The lateral and medial angles of the palpebral aperture lie along a single horizontal plane.

The superior palpebral sulcus results from insertion of the levator aponeurosis into the lid skin. This insertion varies considerably in different persons. Measured from the lid margin, the fold or sulcus may be as high as 12 mm in eyes that have a high prominent, supraorbital rim and lithe fat in the superior compartment Conversely, the lid fold may be as low as 5 to 6 mm above the lid margin in an eyelid that usually appears to be heavy and full. The inferior palpebral sulcus marks the lower margin of the inferior lid tarsus. The variable palpebralmalar sulcus is formed by subcutaneous adherence of skin to deeper tissues.

Eyelid Skin

The average thickness of the eyelid skin is .13 inches, equal to that of a split thickness skin graft. In no other area does the integument approach this fragile quality. The thinness and smooth texture of the lid skin transforms into a thicker, coarser, more sebaceous-type skin lateral to the bony orbital margins. The dinical significance of this transition of skin types is in the manner each recovers from surgical incision.

Orbicularis Muscle

Three distinct yet conjoined bands of striated musde encircle the orbit just beneath the skin. These musde bands act to dose the eyes, protect the eyes, and through their pumping action medially aid expressing fluid into the lacrimal sacs.

The pretarsal musde lies directly over the tarsal plates. The preseptal musde covers the more peripheral orbital septum, and the orbital musde overlies the orbital bone margin, blending with the frontalis musde over the eyebrow and the deeper corrugator supercilii musde medially.

The medial canthal tendons are formed by the superficial heads of the pretarsal musde. The tendon attaches to the anterior lacrimal crest, and the superficial heads of the preseptal musde attach to the medial canthal tendon. The deep heads of both the pretarsal and preseptal musdes attach to the posterior lacrimal crest posterior to the lacrimal sac.

The upper and lower pretarsal musdes join laterally to form the lateral canthal tendon, which inserts on the lateral orbital tubercle. This tubercle is positioned just behind the orbital rim. The preseptal musdes join laterally to form the lateral palpebral raphe. The raphe is firmly attached to the skin in this area. There is a vascular space between the attachment of the lateral canthus and the more superficial raphe. Unlike the pretarsal and preseptal musdes, the orbital musde has no firm lateral attachment except to the skin lateral to the lateral canthus. When the eye is firmly dosed, the orbital musde draws the lids medially, producing the crow’s feet wrinkling at the lateral angle.

Orbital Septum

The orbital septum provides the skeletal framework of the eyelids. Thin at its periphery, it attaches circumferentially to the bony orbital margin and is anatomically continuous with the orbital periosteum. Condensation and thickening of this septal layer gives origin to the wide, crescent-shaped superior tarsus and the small, bar-shaped inferior tarsus. The entire structure provides an effective diaphragm for the orbital contents and is an efficient barrier to inflammatory and neoplastic diseases that arise on either side of it.

Normally, the orbital septum supports the orbital contents, especially the orbital fat The integrity of this membrane can be breached by trauma or weakened by hereditary predisposition. All of the important intraorbital structures of surgical concern during blepharoplasty lie posterior to the orbital septum.

Orbital Fat

Orbital fat provides a cushion and flotation to the intraorbital structures, both for stabilization and for frictionless movement Intraorbital fat fills the posterior orbit, loosely separating the musdes, vessels, and nerves.    The anterior compartmentalization of fat outlined by Castanares conceptualized the surgical anatomy, allowing for an orderly, thoughtful excision of pseudohemiated fat during blepharoplasty.

This anterior orbital fat is present just posterior to the orbital septum as three distinct compartments in the lower lid and two in the upper lid. In the lower lid the medial and central compartments are separated by the inferior oblique musde. This musde lies diagonally form the globe above, downward and medially toward the medial orbital wall. The lateral compartment is separated from the central space by facial extensions of the lateral and inferior rectus musdes. The medial fat compartment of the upper lid is isolated from the central part by the superior oblique musde. The quantity of fat in the upper compartment varies. It may stretch across the upper lid to the lacrimal gland or be present in a small pocket just lateral and adjacent to the medial compartment In its appearance and consistency, the lacrimal gland in the most lateral position of the upper lid is entirely different from fat A constant pattern of contrasts in texture and color is observed in the various pockets.

The fat of the medial lower compartment is always lighter yellow, or even white, when contrasted with the other compartments. It is also more firm and dense in comparison with the loose fluidity of the central and lateral divisions. The upper medial compartment may also share some of the pale and dense characteristics of the lower medial compartment but the differences are not so striking. These color and texture differences allow for positive identification of the sometimes elusive medial pseudohemia during blepharoplasty.

While it is generally true that these pockets of orbital fat are separate and distinct, surgical experience demonstrates that there may be interconnections rather than distinct boundaries, especially between the lower lateral and central compartments. Tension or traction in one area can often transmit reciprocal movement in an adjacent pocket that seems more than simple alteration in volume. During surgical excision, removal of one fat pseudohemia may cause an apparent lessening of the significance of the juxtaposed compartment Surgical application of this observation is discussed later in the text.

Tarsal Plates

The dense tarsal plates contribute rigidity and stability to the eyelids. The superior tarsal plate is 1 mm thick, with a horizontal width of 22 to 25 mm and a vertical dimension of 8 to 9 mm. The vertical dimension of the smaller inferior tarsus is 4 to 5 mm. Both tarsi merge with the lateral and medial lid ligaments at the canthi. The superior and inferior periphery of the tarsi are anatomically continuous with the orbital septum.

The levator palpebral superioris musde is the principle elevator of the upper lid. It spans 5.0 to 5.5 cm from its origin in the superior orbital apex to its insertion in the upper lid. As it passes over the superior rectus, it begins to thin and flatten. As the tendon emerges from beneath the bony superior orbital rim, it fans out into the levator aponeurosis. The aponeurosis extends across the full length of the superior tarsus. At the upper margin of the tarsus it fuses with the orbital septum. Together they pass downward to attach firmly to the anterior surface of the tarsus and to the orbicularis musde and the subcutaneous lid tissue. This attachment is responsible for the superior lid fold in the Caucasian eye. Above this fusion the orbital septum is separated from the aponeurosis by the preaponeurotic fat The aponeurosis extends laterally into the lacrimal gland, separating it into two lobes and blending with the lateral canthal tendon; medially, it attaches to the posterior lacrimal crest

Understanding and appreciation of the surgical relationship of the superficial orbital septum, the deeper orbital fat, and still deeper underlying levator aponeurosis are of extreme importance to the blepharoplasty surgeon.

In blepharoplasty, as in all aesthetic surgery, it is important to establish that a reasonable and rational motivation exists for the procedure before any physical evaluation is begun. Sound motivations indude (1) the patient who has considered blepharoplasty for some time, but because other more pressing social, family, or financial considerations has had to postpone the consultation and surgery; (2) the patient whose livelihood depends on youthful appearance; (3) the patient with a significant aesthetic problem who has not focused on that problem as the source or cause of his or her life difficulties,4) the patient who verbalizes that their reason for the surgery is improved self-image and self-esteem.

Questionable motivations indude (1) patients who present for blepharoplasty at the insistence of another person; (2) patients who have made a sudden decision about surgery; (3) patients who are hyper- focused on a barely perceptible eyelid irregularity; (4) patients whose demeanor, dress, or behavior, are extreme or at odds with what is customarily expected in a person seeking aesthetic surgery.

Generally, the patient should not have unrealistic expectations of the aesthetic surgery. Patients who request eyelid rejuvenation surgery and have as their goal a return to an appearance of a younger age are usually good candidates and, fortunately, are in the great majority. Rarely, patients wanting blepharoplasty may seek a completely different look, that is, palpebral fissures that are bigger than natural or lateral canthal positions that are markedly elevated. These patients are pursuing a personal fantasy and may not ever be pleased with the results of aesthetic surgery. The patient who has a lifetime fullness of the upper lid (dermatochalsis), with no or very minimal upper lid show is a special case. Upper lid blepharoplasty in these patients is not a rejuvenation procedure. The change that occurs with blepharoplasty is a completely different look. The newly defined look as demonstrated to the patient pre-op is usually most welcomed. But, a significant other may not welcome the new look. This is one of the few instances in aesthetic surgery where allowing some one other than the patient to be part of the decision making process ( FIG. 1 ).

Medical Evaluation

Medical conditions that would prelude any facial rejuvenation procedure should be elicited on the history form and taking and elaborated upon at the examination. Any systemic collagen disease, such as rheumatoid arthritis, systemic lupus erythematosis, and periarteri is nodosa, carries with it a good possibility of associated dry eye syndrome.

Any of the medications (allopathic or herbal) that can interfere with the blood-dotting cascade should be eliminated at an appropriate time before surgery so that they are no longer a negative factor.

Ophthalmologic History

The ophthalmologic history should include any vision problems, the need for corrective lens, and any sign of actual or impending dry eye syndrome. Any history of conjunctivitis, styes, chalazion, or ocular herpes is significant Recurrent chalazion is relatively common following blepharoplasty. It is also easily treated. It is considerably less alarming to the patient if they are advised about the possibility before surgery. Lower lid edema, noted daily on awakening may persist following blepharoplasty for several weeks. A history of previous blepharoplasty is significant, especially a history of multiple blepharoplasty. A history of upper lid injury in youth may be the cause of an unexpected lagophthalmos uncovered during an examination.

Ophthalmologic Examination

The ophthalmologic examination must indude a test of vision. Although a test of distance vision may not be suitable, a near vision test is easily performed using the text of the history form or a standard near vision test card. A vision test must be documented in the record. The upper lid protective mechanisms are evaluated by checking the following parameters: Bell’s phenomenon ( FIG. 2) , lagophthalmos ( FIG. 3 ), facial nerve function ( FIG. 4) , comeal sensitivity, and decreased blinking. The extra ocular musdes should be evaluated and documented. The Shirmer’s test for dry eye syndrome is probably not indicated for every patient undergoing blepharoplasty ( FIG. 5 ). It is absolutely indicated for any patient that has a positive history of tearing, burning, or eye sensitivity. In these patients, an ophthalmologic consultation will be necessary prior to surgery to establish the level of the dry eye problem and to determine if the surgery is indicated. Patients with moderate to severe dry eye syndrome are probably not candidates for blepharoplasty. Patients with mild functional dry eye syndrome may be candidates for surgery. The upper lid visor function is responsible for comeal coverage, and upper lid blepharoplasty can precipitate dry eye syndrome more readily than lower lid blepharoplasty in a patient with functional dry eye syndrome. The blepharoplasty procedure in a patient with mild functional dry eye syndrome must be done with deliberate conservatism. Both the patient and the surgeon must recognize that a result on the under corrected side of perfect is desirable. A visual field test is performed if there is a question of visual obstruction secondary to upper lid skin redundancy. A crude test can be performed with finger movement However, if the procedure is being done specifically for visual field improvement it is probably best to have an independent examiner determine the extent of the problem.

Evaluation of Eye Lid Aesthetic Problem

The eyelid skin type should be noted. Is it dry, oily, thin, or thick? The type and extent of pigmentation is determined. Are the palpebral fissures symmetric or asymmetric? Most patients with asymmetric palpebral fissures are unaware of the condition until it is pointed out to them. If it has always been present it is not seen as an abnormality. This condition is common. It is important that the condition be pointed out to the patient prior to surgery. It may likely become a focus of attention following blepharoplasty as observers closely scrutinize the result and bring the asymmetry to the patient’s attention. The relationship of the lid margin to the limbus should be recorded. Inequality of the upper lid relationship to the limbus may be secondary to a mild ptosis, may imply a unilateral exophthalmos, or can result form a unilateral lagophthalmos. Unilateral or bilateral mild exophthalmos is a common congenital variant Asymmetric positioning of the lower lid is less common, but can occur as a congenital condition. Any recent change needs evaluation. A static lifelong condition probably does not require further evaluation. However, an aggressive upper lid blepharoplasty can make an unnoticed palpebral fissure inequality very obvious.

The amount of upper lid skin redundancy is first estimated with the patient’s eyes dosed. The skin is gentry grasped with a forceps from the medial to the lateral lid to give the surgeon an approximation of the amount of skin that can be safely removed at surgery. The extent of redundant skin lateral to the orbital rim is also evaluated. In this chapter the assumption is made that the brow position is adequate, that is, the brow is positioned above the orbital rim by observation and palpation. In this position, upper lid blepharoplasty can be done without brow lifting. If the procedure of upper lid skin excision ends at the orbital rim while redundant skin exists lateral to the rim the resulting post-op hooding will seriously mar the result The skin lateral to the orbital rim should be incorporated in the upper lid procedure. The skin lateral to the orbital rim is thicker (it is facial skin) than the very thin eyelid skin. The scar will take longer to heal, will stay erythematous for a longer time, and will require the use of cover make up. However, the end result is a much better looking upper lid. All this is explained to the patient Though the medial and central upper lid is important, in modem upper lid blepharoplasty, the focus is on the elegant lateral upper lid.

The amount of medial and central fat psuedohemiation in the upper lid is noted while gentle pressure is applied to the dosed eyelids. Occasionally, a lateral upper lid fat compartment may be present This almost always associated with massive fat psuedohemiation of fat in the medial and central compartments. An apparent lateral fat compartment without large amounts of medial and central fat should make the examiner suspicious of ptosis of the lacrimal gland. If the lid skin is pulled tightly upward, lacrimal gland ptosis will present as a small nodule showing beneath the lateral orbital rim. If the gland is ptotic, the surgeon should plan to suspend it behind the orbital rim at the time of surgery.

Asymmetric eyebrows must be evaluated in preparation for upper lid blepharoplasty. Asymmetry of the brows is common and hardly ever recognized by the patient until it is pointed out The eyelid skin beneath the elevated brow usually is viewed by the patient as less redundant, while the skin beneath the lower lid is viewed as more redundant If, in such patients, asymmetric skin excisions are performed in the upper lid, the more dependent lid will be pulled even further downward. Unilateral brow elevation is highly recommended in these patients. Again, if the brow asymmetry has been present through out the patient’s life they will not recognize this feature as abnormal. The patient must be educated about the consequences of doing the blepharoplasty without addressing the asymmetric eyebrows. The asymmetry will always more exaggerated following surgery. Some patients will elect not to address the brows despite the surgeon’s best efforts to explain the less than ideal results. Brow asymmetry that exists only in animation is entirely different This is a normal expressive variant No attempt should be made to correct this type of animated brow asymmetry surgically. The animated asymmetry may respond to botulinum toxin treatment

Occasionally, a prominent lateral bony rim may require reduction to complete an aesthetic effect Though beyond the scope of this chapter, the procedure is performed via the upper lid incision with a bone burr. Fat excess may also be found in some patients to cause a heavy appearance in the area beneath the lateral upper brow. This fat may be removed by elevating the upper outer quadrant of orbicularis musde and sculpting the fat over the upper outer orbital rim. The surgeon is cautioned to be sure homeostasis is complete as this fat is very vascular.

Testing the lower lid to determine tone will determine the vulnerability of the lower lid to postoperative sderal show, lateral ” hound dogging”, or ectropion. Simple observation of the lid can give the examiner an idea of the lid strength. If the patient has sderal show before surgery, the likelihood of this worsening with surgery must be considered and discussed with the patient especially if this has been progressive. Some patients have had a small degree sderal show for all of their life. It may be difficult to change this at a surgery, but it may also not be desirable to change it. Theses patients, with life long sderal show may feel that their eyes are ” smaller `Without some white showing beneath the limbus. These cases make up a small percentage of the cases that present for surgery, but are worth noting. The larger majority of cases are the ones that will be distressed if there is an inferior repositioning of the lower lid. These patients and other observers will see a ” rounded eye ” post operative result.

A simple snap test will reveal the lower eyelid tone ( FIG. 6 ). The lower eyelid is grasped gentry with the thumb and forefinger, pulled away from the globe and released. A normal lid will “snap” back to contact the globe with a spring like action. Any degree of delay in this repositioning is indicative of poor lid tone. The slower the return, the more likely that some problem may occur if the blepharoplasty is not adjusted to account for this laxity. The worse response is the lid that stays away from the globe until the patient blinks. The examiner must be careful to tell the patient to not blink during this test Blinking as the lid is released will allow even the poorest toned lid to reapply itself to the globe giving the examiner a false sense that the lid is normal. The surgeon must be alert to the patient with a negative vector. The negative vector is the anatomic observation, in a lateral position, of the globe being positioned more anteriorly than the orbital rim-malar bone complex. These patients are prone to lower lid malpostion following blepharoplasty. The most vulnerable case is the negative vector with an absent lid response to the snap test A standard blepharoplasty procedure, in these patients, without specific attention to lid tightening will always result in some degree of unacceptable lid positioning. They are candidates for surgery in only the most experienced hands.

The lower lid orbital margin is palpated to determine if any of the baggy appearance of the lower lid is secondary to bony protrusion. Once the problem the ascertained to be fat psudohemias, it is necessary to quantify the amount of fat By having the patient gaze upward and then to the right and left the fat psuedohemiation volume is amplified. This gives the observer an impression of the amounts and location of fat psuedohemiation, medial, central, and lateral, that will require treatment The amount of skin redundancy is estimated by gently grasping the skin with a smooth forceps while the patient gazes forward. Orbicularis musde hypertrophy is estimated by observing thickness just below the ciliary margin. Both skin and musde may be responsible for any swag or festooning at the orbital rim. By having the patient squint the examiner can observe the orbicularis tighten and the subseptal orbital fat pushed back into the orbit It also gives the examiner an opportunity to show the patient what the lower lid will look like in terms of the absence of redundant fat and the amount of fine skin rhytids, ( FIG. 7 ). Not all these fine skin wrinkles will be alleviated by surgery. This should be explained to the patient It is important to discuss other anatomic features that will or cannot be changed during blepharoplasty. In darkly pigmented lids, the fine pale lid scar that is ideal may be more obvious. In patients with thin skin or a familial predisposition to’ a bluish hue from underlying vascular patterns probably will not change. The fine skin crepe patterns of the upper lid are more difficult to control than those of the lower lids. Lateral crow’s feet will not be eradicated by upper or lower lid blepharoplasty. Patients frequently expect periorbital skin problems will be eased at the time of the surgery. The limits of blepharoplasty must be explained pre operatively. Any skin lesion such as keratosis, nevus, syringoma, trichoepithelioma, or xanthoma should be discussed as to the possibility of excision and the anticipated result.

As with for all aesthetic surgery, photographic documentation is required pre-operatively. Close-up 1:5 ratio photos with frontal eyes open, frontal gaze upward, frontal eyes dosed, oblique eyes open, and lateral eyes open should be obtained in addition to a 1:10 full-face view. Use of these photos with a digital imaging system is the choice of the surgeon. It is not essential. The use of pre-operative and post operative photos, at the condusion of the consultation, as examples of possible outcomes is also the surgeon’s choice.

THE OPERATION

Skin Marking in the Upper Lid

The upper lid skin is deaned with an alcohol pad to insure that the marking will not spread. A surgical marker of extreme thinness in selected to prevent a thick line. One millimeter of lid skin excision can make a difference in the surgical result. If the surgical mark on the lid skin is 2 mm thick on both the upper and lower limbs of the upper lid incision, it is possible to make a 4mm error in the lid skin excision.

Two notations should be made before marking the skin. The relationship of the brow to the bony rim must be determined while the patient is in an upright position. The weight of the scalp will pull the brow upward when the patient is supine. This movement will carry some of the upper lid skin with it giving an impression of less redundant skin than is actually present Also, the amount of medial upper lid fat should be established while the patient is upright The fat will fall back into the orbit in the supine position giving a false sense of the amount of fat considered for removal.

The first skin marking is made just below the natural upper lid crease. The suture line will elevate slightly to settle at the natural lid level that is particular to each patient The natural lid crease is usually apparent If it is not, the patient is asked to open and dosed the eyes several times to make the crease appear. The average height of the crease is 8 to 10 mm above the palpebral margin at the center. This may vary between 6 to 12 mm. If the height at the lid center is lower than 8 mm then the lid crease marking is elevated to 8 mm to 10 mm. The marking parallels the natural curve of the lid. The medial mark terminates 1 to 2 mm medial to the puncta. The incision ends here. Incisions that continue into the concavity of the medial orbital rim may cause a webbed scar. If the incision is carried onto the nasal skin it is certain to cause an undesirable scar. Excess of creped skin in the medial portion of the eyelid present at the condusion of the upper lid blepharoplasty can be removed with small vertical triangular skin excisions. These excisions are base down at the incision and rarely even require suturing. The lateral end of the upper lid incision continues along the natural lid crease to about five-sixths of the lid. Here the incision should become more horizontal and then curves slightly upward. It is best to avoid the natural line that is seen as the lid crease extends into a lateral orbital skin rhytid. An incision in this area is often too low to cover with make-up. More importantly, however, a low incision may pull the tail of the brow downward to cause a persistent lateral hooding and thus countering the very purpose of the aesthetic procedure. Curving the incision upward to end between the lateral canthus and the lateral brow margin will reduce the lateral hooding by elevating the skin inferior to the incision upward. The incision ends in a position that is easily camouflaged by make up ( FIGS. 8a,8b ). Lateral extension beyond the orbital rim is not recommended in men.

The upper limb of the skin marking must be made to encompass all of the redundant eyelid skin. The gravity effect of the scalp pulling the brows up must be countered by gentry pushing the brow downward during the marking ( FIGS. 9a,9bJ. With the patient’s eyes dosed the redundant skin is grasped with a forceps to estimate the amount to be removed. One blade of the forceps in placed at the lower lid mark while the other blade is used to gather as much skin as possible without elevating the upper lid margin away from the lower lid margin, i.e., the eye does not open ( FIG. 10 ). The goal is to avoid opening the palpebral fissure and prevent lagophthalmos. Enough medial skin must remain to drape into the depression left by medial fat pocket excision. If the wound is dosed by tenting the skin over the depression a hypertrophic scar is almost certain to result. At both the medial and the lateral ends of the marks must end in a 30° angle to avoid a ” dog ear ” elevation ( FIG. 11 ).

Anesthesia of the Upper Lid

If upper blepharoplasty is being done alone it is easily performed as an ambulatory procedure under local anesthesia with a light premedication. A four lid blepharoplasty may require a heavier premedication simply because the procedure is longer. If the blepharoplasty is being done as part of total facial rejuvenation, the surgeon will choose an intravenous analgesia or general anesthesia. The common requirement for blepharoplasty is the need for local infiltrative anesthesia. The author uses Xylocaine 2% with epinephrine 1:100,000. Lesser concentrations seem to have a shorter effectiveness in the eyelid skin than in other areas of the face. Longer acting local anesthetics such as bupivacaine (Marcaine) may also be used. A mixture of these two anesthetics has been helpful in prolonging the pain free period following surgery. This benefit must be weighed against the prolonged absence of eyelid closure function in the post-operative period. The total volume of infiltrative Xylocaine 2% with Epinephrine 1:100,000 should not exceed 1 to 2 cc per eyelid. Greater amounts will distort the eyelid and will not provide improved anesthesia. This amount of anesthesia will provide and sustain maximum anesthesia for 30 minutes and some anesthesia for 1 hour. Maximum epinephrine vasoconstriction occurs 10 to 15 minutes following injection. The eyelids maintain anesthesia after infiltration for a shorter time than do other areas of facial skin. The addition of a small amount (1 cc to 10cc of local anesthetic) of sodium bicarbonate to the local anesthesia may decrease the burning sensation of the local infiltration. The anesthetic is infiltrated with a one and one-half inch 27 gauge or 30-gauge needle from lateral to medial. The needle addresses the lid in a horizontal fashion, never vertically. Sensory innervation of the upper lid comes from four branches of the ophthalmic nerve (VI) . The lacrimal nerve supplies the lateral upper lid. The supraorbital nerve emerges through a groove or canal at the superior medial rim to supply the central and medial lid. Two smaller contributions, the supratrochlear and infra trochlear nerves, pierce the orbital septum above and below the trochlea of the superior oblique musde. The maxillary nerve (V2) supplies the lower lid through a small zygomaticofacial twig and the superior branch of the infraorbital nerve. These nerves emerge via their respective lateral and medial foramen. There is lithe need for specific nerve blocks in blepharoplasty anesthesia. Nerve blocks for upper lid require penetration of the orbital septum toward the orbital roof. It is also not advisable to attempt injection of the orbital fat in the upper or lower lids during initial injections. Penetration of vessels behind the orbital septum, with secondary bleeding and possible hematoma formation, is avoided if the anesthetic infiltration remains subcutaneous. The initial sensation for the patient is that the lids feel heavy and it is difficult to open the eyes. Once the anesthetic becomes effective the patient may have trouble dosing the eyes because the orbicularis musde is affected. The levator of the lid remains unopposed, opening the eye slightly. Any application of topical anesthetic solution to the conjunctiva or cornea should be avoided in standard blepharoplasty (non-transconjunctival approach) since there is no indication for interference with the protective corneal reflexes. Some surgeons prefer to use corneal shields for all blepharoplasty. The incidence of corneal injury without shields is extremely rare.

The timing of the injections depends on the speed and experience of the surgeon. The length of time needed for a four-lid blepharoplasty can vary from less than one hour (experienced surgeon) to three hours. Do not expect a lid to maintain anesthesia for much more than an hour. The lids should be infiltrated accordingly. The surgeon with modest experience may find it useful to anesthetize both upper lids initially; then, just before beginning the skin incision on the second upper lid, both lower lids are infiltrated. If all lids are anesthetized at the outset, the final or fourth lid may become sensitive just as the incision is made. The secondary infiltration could make precise skin and fat removal unnecessarily difficult. The average required times for completion of lid surgery should be recorded to allow a realistic schedule for anesthesia.

General anesthesia is rarely necessary for blepharoplasty. If general anesthesia is used the surgeon and the anesthetist must be are and sensitive to the problem of postintubation coughing and post anesthesia retching. These factors can add greatly to the postoperative edema and ecchymosis associated with blepharoplasty.

Upper Lid Blepharoplasty

The procedure begins with placing tension on the inferior limb upper lid marking, pulling it laterally to straighten the mark as much as possible ( FIG. 12 ). The incision is made with a small blade (No. 15 Bard-Parker or No. 65 Beaver). The incision is made at a uniform depth through the skin beginning medially and continuing to the laterally in a single stroke. The incision is then made in the upper limb. The lateral angle must be very crisp at a 30°. This lateral angle can be made by turning the blade 180° and stroking medially from the point of convergence. The lid skin is then removed with a curved Steven’s scissors and a Brown-Adson forceps. Pushing the dosed scissors in a medial direction in the subcutaneous space between the upper and lower limbs of the incision and spreading facilitate the removal. A decision is then made to remove or not remove orbicularis musde ( FIG. 13 ). Removal of orbicularis musde allows for a greater definition of the upper lid deft and a sculptured appearance of the upper lid. This advantage must be weighed against the fact that orbicularis function doses the eye and that the musde is present in varying degrees in different individuals. Other considerations are that the deeply sculptured eyelid deft can have an aging look (think cadaveric) and the sculpted look in the male lid can appear feminine. Despite these considerations, some musde excision is probably desirable in most cases except in older and thin-skinned patients where the musde can be expected to be scant or thin. Point cautery is used to obtain absolute homeostasis.

Following removal of the redundant skin and any indicated orbicularis musde the medial fat pocket is exposed by gentry spreading the medial orbital septum with a Steven’s scissors or a fine hemostat This can be facilitated by having the surgical assistant elevate the brow. The color of the medial fat is whiter than the yellow fat of the central compartment The central fat can be dose to the medial fat The color difference can be helpful to avoid missing the medial fat pocket The medial fat pocket can be visualized by observing the slight bulging while applying soft digital pressure to the dosed eyelid. The medial fat is gently teased through the opening in the orbital septum ( FIG. 14 ). A small amount of local anesthesia is injected into the fat It is then damped and excised. Enough fat is left at the point of excision to allow it to be cauterized. The local anesthesia is necessary to prevent pain with manipulation of the fat when this procedure is done under local anesthesia. All the structures internal to the orbital septum maintain their sensitivity. The orbital septum is an effective barrier to the spread of local anesthesia. The upper medial fat pocket lies between the medial rectus musde and the superior oblique musde. The superior oblique musde is at small risk of injury if too much tension is applied drawing the fat up into the wound. The hemostat is applied only when it is dear that the musde will not be damped with the fat The superior oblique musde, however, is rarely seen. The fat is excised with a curved Steven’s scissors. Enough fat is left to allow cautery with a hot tip cautery. The hot tip cautery is used because it allows pinpoint precision hemostasis. The use of electocautery will almost always cause pain in the posterior orbit even when the fat is totally anesthetized. It is not suitable for use under local anesthesia. After the medial fat is removed the central fat is located by applying gentle pressure to the globe. A small incision is made at the point where the orbital septum bulges. The fat is then gently teased into the wound. Only the fat that lays external to the septum without retracting back into the wound is removed. This will produce a smooth non-retracted central lid. Over excision of fat in the central compartment is an error that often produces an A shaped retraction that defeats the intended rejuvenation. The fat is damped, cut and cauterized in the same fashion as the medial fat The levator aponeurosis is superficial and dearly visible beneath the central compartment fat Rarely, in extremely heavy lids there is a lateral fat compartment over the position of the lacrimal gland. If the lacrimal gland is seen to be ptotic preoperatively it is easily repositioned by using a 6-0 polypropylene suture to secure the gland capsule to the orbital roof just internal to the orbital rim. The gland color is pink and the consistency is lobular which differentiates it from orbital fat Occasionally, a broad heavy bony orbital rim will require reduction with a bone burr. Also, in particularly heavy lateral lids a separate fattiness can be found deep to the upper outer orbitalis musde (ROOF, or retro-obicularis orbital fat). Removal of this fat gives a refinement to the heavy outer orbital rim. This retro-orbicularis fat is extremely vascular, complete homeostasis is important

Repair of the wound can be accomplished with several varied sutures. However, the author finds polypropylene the most non-reactive, resulting in the finest scars. Nylon is somewhat more reactive and is more difficult to remove because its friction quotient grips the tissue when it is used as a continuous suture. Absorbable sutures are the most reactive in the skin producing redness that is not seen with polypropylene. Braided or multifilament sutures are the worst sutures to use for eyelid incision closure. They are notorious for leaving suture tunnels and skin suture marks.

The upper eyelid skin wound is dosed beginning with simple 6-0 ProleneTM sutures from lateral to medial to dose the lateral one-fourth of the wound. The orbital septal incisions are not repaired. The lateral or facial skin part of the wound is under the most tension and the most likely to separate if dosed with a running suture. The remaining wound is dosed with a running subcuticular beginning medially and continuing to the simple interrupted suture dosure ( FIG. 15 ). The ends of the sutures are left untied and long and taped to the skin above the eyebrows. The surgeon must handle the eyelid skin very gently. If a forceps is used, only the subcutaneous tissue is grasped. If any area of the dosure seems to need support, individual simple sutures are place using only a surgical twist instead of a knot Any skin redundancy noted at the medial end of the wound in handled by removing small triangles of skin (base down at the wound edge) both above and below the wound edge.

Skin glue alone has not been found satisfactory as a primary dosure following upper lid blepharoplasty. The authors find the suture dosure technique to produce consistently finer scars. Skin glue is used in selected cases as a supplemental dosure following suturing. It is also useful for dosing wounds that have separated because of trauma in the immediate post-op period. The use of 1/8-inch sterile surgical tape to cover the sutured wound gives additional support and security in the immediate post-op time period.

Case 1
FIGS. 16A, 16B, 16C, 16D
Case 2
FIGS. 17A, 17B, 17C, 17D, 17E, 17F, 17G
FIGS. 18A, 18B
FIGS. 19A, 19B, 19C, 19D FIGS. 20A, 20B, 20C, 20D

Skin Marking of the Lower Lid

The lower lid incision should be made parallel to a line 2-3 mm below the cilia of the lower palpebral margin . It extends medially along this line no further than the inferior lid puncta. Laterally, the incision curves upward as it maintains the 2-3 mm distance parallel to the ciliary margin. It then breaks at the lateral canthus into a more horizontal position and a lateral skin crease. Older methods required that this lateral portion of the incision angle downward and that the skin be advanced laterally to excise a triangle at the lateral lid. The resultant scars were obvious, uncorrectable, and a permanent reminder of the blepharoplasty surgery. The method described here involves a superior elevation. It is usually necessary to mark only the lateral limb of the incision since the infra ciliary incision is alwaysthe same position. It is actually easier to observe the infraciliary crease without the marking. Again, it is important to use the finest point marker on the skin.

Lower Lid Skin Muscle Flap Blepharoplasty

Lower lid blepharoplasty can be performed through a skin flap, skin-muscle flap, a transconjunctival approach or a combination of these approaches. Each has its advantages and enthusiasts. The author has used all of these approaches to the lower lid in various patients with varying lid problems. This chapter will discuss the skin-muscle flap, as it is the most commonly used type of lower lid blepharoplasty used by the author. The advantage of the skin-muscle flap lies in versatility of being able to alter skin excess, skin tightness, musde excess, musde tension, fat volume and fat repositioning. The use of suspension suturing, developed many years ago, allowed all of the anatomical aberrations to be accomplished safely, without problems in lid margin positioning.

The marked skin is incised with a No. 15 Bard Parker blade or a NO. 67 Beaver blade down to the orbicularis musde while the upper lid is opened slightly to observe and assure that the incision in no lower than 2 – 3 mm from the lash line ( FIG. 21A, 21B ). The remainder of the incision is made with a small sharp straight scissors. The lower blade of the scissors is used as a pushing dissector subcutaneously as the upper blade cuts through the skin in a straight line in the natural crease 2-3 mm below the lash line ( FIG. 22) . No cilia are cut. The incision ends laterally at the lower lid puncta, never beyond. Any medial extension of the incision invites post-op problems with tear drainage. A small skin flap is the developed for approximately 3 mm to expose and preserve the pretarsal fibers of the orbicularis oculi musde ( FIG. 23). By preserving this pretarsal musde sling, the lower lid can be expected to have a more immediate tension response after surgery, reducing the possibility of sderal show or ectropion. A curved Stevens scissors is the used to separate the pretarsal and preseptal musde to the puncta ( FIG. 24) ( FIG. 25 ). Blunt dissection with a cotton-tipped applicator sweeps and separates the orbicularis musde from the orbital septum down to the bony inferior orbital rim exposing the lateral, central, medial orbital rims. A decision is made at this point to excise, preserve, or reposition the orbital fat When abundant fat is present in all compartments, some fat must be removed. The author has found fat preservation and repositioning of value in the medial lid when a deep tear trough deformity exists. In the lateral lower lid the suspension suture (described below) effaces the orbital rim – lateral orbital septum junction. In the central lid precise fat excision will create a smoothness at the bony rim-central orbital septum junction. In the lateral and central compartments the fat is removed to a level 1 mm below the bony rim. The fat is removed by first incising the orbital septum and then teasing the fat into the wound. If this done under local anesthesia it must be done with gentleness. Aggressive traction will cause pain. The fat redundancy is then infiltrated with local anesthesia, damped, excised and cauterized. (The same procedure is followed as in the upper lid described above). The central compartment fat is always the most obvious. The lateral compartment orbital septum is the thickest The medial fat compartment is usually the most elusive. Identification and notation of this compartment preoperatively is important At times, it may by necessary to apply gentle pressure to the dosed eye and watch for the location of orbital septum bulging to locate the medial fat compartment Once identified, the orbital septum is incised with the scissors and the fat is teased into the wound. Before infiltrating and damping the fat, the inferior oblique musde should be observed. In contrast to the upper lid, this muscular structure is almost always visible and should be found before damping to avoid injury to the musde. The fat in this medial location is also more dense and vascular than the other compartments of the lower lid ( FIG. 26,27,28) . Homeostasis must be absolute to avoid a bleeding medial fat stump that could retract back into the orbit When a pre-op tear trough problem is in need of correction, the medial fat is handled differently. There have been many papers and presentations on this subject Most authors have recommended that the fat or the orbital septum be sutured into the tear trough depression. At times, especially when this technique is first used by the surgeon, the lid margin can be pulled downward or worse, everted when the orbital septum is sutured to the periosteum. The tarsal plate and the orbital septum are a single continuous structure. The author has found the following technique useful. In those individuals who require filling of the tear trough, the medial orbitalis musde (the portion of the orbicularis musde extending over the orbital rim) is elevated with a small short dissector for a distance of approximately 1 cm. This area must be thoroughly infiltrated with local anesthesia if the procedure is done under local. Once the musde is elevated, the surgeon should observe if the elevation is completely under the tear though. Incising the orbital septum along the orbital rim opens the fat compartment The fat is then allowed to spill into the wound. It is pushed gently into the space beneath the elevated musde. It has not seemed necessary to secure the fat in the new position. Whether secured with sutures or not the results have effaced the depth of the tear trough. Once the medial fat has been dealt with the surgeon should go back to the lateral compartment to be sure the proper amount of fat has been removed. One of the most common complaints following lower lid blepharoplasty is the presence of persistent bulging in the area of the lateral fat compartment If more fat can be teased into the wound it should be removed.

Once fat has been dealt with and homeostasis is complete, the skin musde flap is redraped superiorly. Under local anesthesia, the redundant skin is removed, while the patient is looking upward, with a straight Stevens’s scissors ( FIG. 29 ). The amount removed should leave a small gap between the upper and lower limbs of the lower lid incision. The suspension suture will dose this gap. If the patient is being done under a general anesthesia, the lower lid is positioned so that the lid margin is crossing the limbus at an appropriate position. As the decision is being made about how much lower lid skin is to be removed during blepharoplasty, if the lower lid will falls inferiorly and redundant skin and musde are removed to accommodate this inferiorly positioned lid, a rounded palpebral fissure, sderal show, or ectropion becomes a definite possibility. After the redundant lid is excised, the surgeon observes to see if any thickness of musde is present along the inferior limb of the wound. As the skin musde flap is draped superiorly it is not uncommon to see the preseptal musde overlie the pretarsal musde causing an elevation or ridge below the subciliary incision. The adult female always wants this subciliary area smooth. Any redundant musde is removed. Homeostasis is again established. At this point the suspension suture is then placed. The suspension is always a vertical vector elevation. The suture found to be most effective is the 5-0 dear ProleneTM. The suture placement is between the deep preseptal orbicularis musde and the lateral orbital rim periosteum at the region of the lateral orbital tubercle. The knot should be buried. If any tethering is noted in the skin of the lower lid, the suture should be placed at a deeper level. It is also important not to place the suture so tightly that the lower lid skin gathers at the lateral rim. The skin at the lateral extreme of the wound should be smooth. The suture must be cut on the knot ( FIGS. 30,31,32,33,34,35,36,37,38,39,40,41)

Once the suspension suture has been placed, the wound is dosed with a running 6-0 ProleneTM suture from lateral to medial. The medal ends of the suture are left long and taped to the cheek skin. Short suture ends can turn back toward the globe to irritate the cornea. Three 1 /4 in. sterile surgical tape strips are place laterally to provide an upward pull on the cheek skin to decease any downward pressure on the wound. ( FIGS. 42,43,44,45,46,47,48,49,50,51 )

Postoperative Care

No bandages are used on the lids, but the eyes are covered by cold compresses as continuously as possible until bedtime the day of the surgery. The wounds are lubricated with a steroid-antibiotic ophthalmic ointment If the upper lid wounds have been covered with 1/8-inch sterile surgical tapes (as recommended above) then the ointment is not used. Some bloody spotting will be noted and should not cause alarm. Pain is not a major problem. A burning sensation for 1-1.5 hours following surgery is not unusual. This discomfort can almost always be relieved with minor analgesics such as acetaminophen with or without codeine. Anything that would produce vasodilatation should be avoided. The patient is instructed not to consume coffee, alcohol, or highly spiced foods and to keep exertion limited to activities of daily living. On the second post operative day, compresses are used 20 minutes per hour. Maximum post operative edema is usually seen on the morning of the second postoperative day. Sutures are removed on the fourth postoperative day. Make-up can be applied on the fourth postoperative day to the lid skin and to the wound itself on the sixth postoperative day. Contact lens use may begin on the fourth postoperative day. Most patients feel comfortable returning to work or normal activities on the seventh postoperative day. Partial exercise can begin at 2 weeks and full exercise at 4 weeks. One or two weeks before the operation, the patient is given pre-operative and post-operative instructions and an accounting of the expected events following surgery. This material is best prepared from the surgeon’s own experience.

Serious complications of blepharoplasty are, fortunately, uncommon. There are many frequent minor or lesser complications and sequelae that occur following blepharoplasty. These lesser sequelae are complex and related to subjective aesthetic judgments as well as to specific objective observations. Many of these sequelae are temporary and are related to variations in the healing process.

Most texts on blepharoplasty list the complications of blepharoplasty and the management of these problems. While a complete understanding of these more specific complications is imperative, each surgeon must develop a much broader perception of the post operative blepharoplasty course to indude all gradations of normal post operative healing, postoperative problems, and true complications that deviate from the ideal result. When this more graduated approach is related to the postoperative course chronologically in days and weeks, it becomes a valuable informational source to the patient

Problems seen shortly after surgery that can be expected to resolve quickly (one or two weeks)

• Chemosis, especially of the lower lateral lid (one week)
• Subconjunctival hemorrhage (three weeks)
• Separation of the lateral lower lid from the bulbar conjunctiva (may be helped by surgical tape support in the immediate post operative period)
• Tearing
• Burning sensation
• Visual blurring secondary to ointment
• Edema of the lids
• Pain (unusual beyond the first few post op hours, may be felt with coughing or sneezing if a suspension suture has been used)
• Asymmetry secondary to swelling
• Insensitivity of the upper lids noted when applying make up

Slowly resolving problems after the second postoperative week Eyelid ecchymosis

The usual progression of ecchymosis is from blue-black through magenta to yellow and on to normal skin color within one to two weeks. An occasional patient may retain a uniform or patchy subcutaneous hemosiderin deposit for a considerable time. This most commonly occurs along the palpebralmalar sulcus following a particularly dense ecchymosis in the darkly pigmented patient It is totally unpredictable in patients with no previous history of bruising. Permanent pigmentation is very rare. Particularly stubborn problems may take up to 18 months of continuous reassurance. No particular treatment seems to hurry the resolution process. However, some patients seem to benefit from the application of Arnica Montana. Camouflage make up is an appropriate recommendation.

Tearing

Tearing and burning may persist as a mild annoyance beyond the immediate postoperative period without any visual disturbance. This is secondary to the minimal palpebral margin separation, which allows some drying of the conjunctiva. These symptoms are almost always self-limiting, but the use of artificial tears before retiring may be advisable. Continued follow-up is necessary until the symptoms abate.

Contact Lens

Some difficulty with the insertion of contact lens may be anticipated. The alteration of the lid tension may change the darity of vision. A change in lens prescription should wait several months of healing. Some patients who maintain the use of hard contact lens may discover that there is difficulty removing the lens. The lens issuer can provide a small suction cup devise especially designed to assist removal. The problem should be anticipated prior to the surgery.

Recurrence of dormant inflammatory lesions of the upper lid

Long-dormant chalazions can be reactivated in the first few weeks following surgery. A preoperative questionnaire is helpful to anticipate this problem. This relatively painless swelling of the upper lid results from the obstruction of the opening of a meibomian gland. The swelling is localized between the upper lid margin and the incision. The problem is not an infection, but an inflammation related to the inspissated accumulation of glandular secretion. Surgery is not indicated. The problem responds to warm compresses and possibly prophylactic antibiotics.

Hyposensitivity of the lids

The hyposensivity of the upper lids may persist beyond the immediate postoperative period. It is most likely secondary to persistent mild lid edema. It always resolves.

Wound problems at the time of suture removal

The lateral extension of the upper lid incision may be subject to overlapping during the post; op edema phase of healing. If this is found the wound should be teased open and the wound resutured. If healing is allowed without addressing the overlap, an unattractive scar will result.

Texture and appearance of lower lid skin

Noticeable laxity, fine creping, and slight shine can be expected to persist in the lower lid skin for ten days or more when postoperative edema is pronounced. This appearance can be most upsetting to the unprepared patient Calm reassurance is helpful.

Persistent sensation of tightness

A sensation of tightness or resistance to opening or dosing the eyes without any evidence of a functional problem may persist for several weeks. Explaining that this is a self-limiting condition will relieve anxiety.

Contact dermatitis

Antibiotic ointments, especially those containing neomycin, are a common source of contact dermatitis. In patients, not previously sensitized, a recurrence of lid edema associated with itching may develop after several days of ointment usage. It is common for patients to continue to use the ointment on the lids beyond the immediate post op time period for which it was intended. Discontinuing the ointment and the use of cold compresses usually will reverse the problem. Oral corticosteroids are used for the most severe cases.

Other problems usually discovered postoperatively

It is important that patients fully understand all of the problems that will or will not be resolved with blepharoplasty. Non-resolvable problems in the periorbital area are the most frequent source of alienation between the patient and surgeon. While these are not complications from the surgeon’s viewpoint, they may be considered a complication by the patient

Malar Bags

The persistence of malar bags probably evokes the most persistent postoperative complaints. The uninformed patient always expects their removal as part of blepharoplasty or finds their relatively increased prominence following removal of lid fat intolerable. The malar bag is always seen as a stigma of aging and the patient is not easily swayed from this condusion. Preoperative discussion of the problem is obviously imperative.

Animated lateral wrinklinq

Lateral temporal and upper malar wrinkling occurring when the patient smiles is not changed by blepharoplasty. It may become relatively more conspicuous. The patient may have not had a preoperative awareness of the problem or may be disappointed that the blepharoplasty did not eradicate them. The patient will hold a mock smiling appearance to demonstrate to the surgeon how unhappy they are with the results of the procedure. This condition must be evaluated and carefully discussed with the patient before surgery. BotoXTM treatment following the surgery will definitely help the appearance.

Other preoperative sources of postoperative dissatisfaction are persistent fine wrinkling, asymmetric palpebral fissures, asymmetric brow position, persistent sderal show and persistent lid pigmentation.

Aesthetic Problems following Blepharoplasty Persistence of Fat Pseuedohemias

Persistent fat pseudohemias most commonly occur in the lateral compartment The compartment should be evaluated preoperatively with the patient in extreme superior-lateral gaze to determine the extent of the fat problem. This fat compartment can be illusive. The author always deals with this compartment first and goes back at the condusion of the procedure to check that more fat is not present Additional fat can be removed after a minimum of three months of post op healing. It can be removed via a transconjunctival approach or via a subciliary approach. The thickness of scar tissue in the area and the thickness of orbicularis musde make the dissection deceptively deep to remove the redundant fat

Persistent fat in the lower lid medial and the central compartments can usually be removed via a transconjunctival approach.

Persistence of fat in the medial upper lid is also common when there is an extraordinary amount of fat preoperatively. The fat is removed via an incision in the upper medial lid incorporating the original scar. Again, subcutaneous scar tissue may make the excision more difficult than the surgeon anticipates from the appearance of the problem. Additional skin is excised only if there is overlap of the skin edges following removal of the fat

Persistence of Redundant Skin in the Lower Lid

The surgeon with limited experience should view this problem not as a complication but as acceptable conservative consequence and an easily corrected alternative to a complication. It is difficult for even the most experienced surgeon to attain consistent perfection in the amount of skin removal. The surgeon should acknowledge the problem when the patient inquires. Denying or minimizing the significance of the redundancy could be particularly upsetting to the patient in the short-term post op time period. Once the patient hears that the redundancy is a minimal problem to ” fine tune” once healing has occurred all anxiety abates. The skin excess can be dealt with by skin flap or minimal skin musde flap.

Persistent Redundant Skin of the Upper Lid

Most cases of minimal upper lid skin persistency are secondary to a miscalculation of the brow position while the patient was supine. The upward displacement of the brow gives an erroneous measure of the amount of upper lid that will require removal. This is especially true of the lateral brow and skin. Persistent medial skin is more common in the aged eye. The apparent skin excess seen in the patient following secondary upper lid blepharoplasty is noted only with eyes open. The patient and surgeon may estimate the excess at 2-3 mm. However, with eyes dosed there is no excess and no skin can be grasped with a forceps. These patients should not have additional skin removed. It will lead to a lagophthalmos and may cause the brows to descend.

Prominent Orbicularis Ridge Beneath the Lower Lid Incision

This problem results when the preseptal orbicularis musde in the skin musde flap is elevated and overlaps the pretarsal musde. At the time of wound closure this musde overlap and consequent ridging should be obvious and its presence anticipated. This problem can be addressed following complete healing of the wound. A small skin flap is elevated, the musde is excised, homeostasis is established, and the wound dosed.

Scar Problems

Asymmetric scars of the upper lid can be avoided if the lid skin is marked under magnification with a very fine pen. A wide pen mark can lead to a difference of 2mm between eyes in the final scar. It is important to remember that the lower limb of the upper lid incision will always elevate as the wound is dosed. Also, if the natural lid crease is at different positions when comparing the two lids an adjustment must be made to bring the two upper lid scars into symmetry.

Webbed Scars

A webbed scar can result from carrying the medial upper lid incision beyond the medial canthal sulcus and onto the nasal skin. Healing of this scar will elevate into a web. By using the web as the central limb of a Z-plasty, the problem can be eliminated.

Vertical Scars in the Lateral Lower Lid

Early texts on blepharoplasty advocated a subciliary incision ending with an incision angled downward at the canthus that allowed for the lid skin to be pulled laterally. The skin laterally was excised as a Burrow’s triangle. This always resulted in an obvious scar, which is almost impossible to camouflage. This technique is not advised. The lower lid incision should always be horizontal. The direction of lid pull should always be vertical.

Scars in Mid Upper and Lower Lid

Scars in this area usually result from overlapping the skin edges or wound separation during the initial healing stage. The wound edges should be adjusted at the time of suture removal and resutured.

Suture Marks

Suture marks occur when undo tension is placed on the wound edges or when the sutures are allowed to remain long enough to produce inflammation at the suture placement sites. Monofilament sutures always cause less inflammation than braided or absorbable sutures. Removal of sutures by the third or fourth day is essential in preventing suture marks.

Suture tunnels and incisional milia

The use of any braided suture material encourages epithelial growth along the path of the suture. The resultant tunnel will trap epithelial debris. The solution is to connect the two openings with a tiny blade incision. Milia or small sebaceous cysts may result from blockage of many eyelid sebaceous gland ducts along the suture line or trapping of epithelial debris in the wound. Milia appear as extremely superficial white skin indusions, sebaceous cysts are deeper. Either is easily resolved by a minute pointed blade incision and expression of the sebaceous material.

Problems of Lower Lid Position Sderal Show

Ideally, the lower lid margin contacts the comeal limbus. Post-operatively the lid margin may be displaced 1 mm inferiorly following conservative skin-muscle excision. It can be seen following a skin-muscle blepharoplasty in which no skin was removed, even when the preoperative musde tone was normal. This minimal sderal show or almost sderal show is an equivocal complication, especially since it is frequently seen as a normal variant Usually, this minute sderal show is considered as complimentary to the guide -eyed” or ‘bright eyed” youthful appearance following blepharoplasty. The surgeon may notice the minimal displacement of the lid, but is wise to allow the patient to initiate and reference to it

Moderate Sderal Show, Inferior Rotation of the Lid Margin, and Ectropion

These complications may result from unrecognized lid laxity preoperatively, excessive removal of lid skin, or both. Indication for surgical intervention to reverse a minimal sderal show is determined by the patient’s perception of the problem. An optimistic approach to some resolution of the problem overtime is warranted. Upward massage and dosed-eye squints (to strengthen the orbicularis) will produce some reversal of minor lower lid displacement If the visible sdera remains a focus of dissatisfaction over a period of months, an additional procedure, such as lateral Orbicularis musde suspension following minimal elevation of skin and musde, usually produces a satisfactory elevation of the lid margin.

Moderate to severe sderal show, lateral lower lid rotation (hound dogging) or ectropion following blepharoplasty will require either horizontal lid shortening alone when the complication is related solely to poor lid tension or a horizontal lid shortening in combination with skin grafting (and possible mucosal grafting) when the skin deficit has caused a vertical shortening and tethering of the lid. Certainly, prevention by careful preoperative assessment and conservative surgery is preferable to producing these complications.

Problems of Upper Lid Position Blepharoptosis

Postoperative lid ptosis either existed preoperatively and was not recognized or is secondary to some interference with the levator mechanism. The levator can be injured if the fat dissection is carried deep in the central compartment or laterally where it becomes more superficial and divides the lacrimal gland. Mild ptosis can persist for several months following a blepharoplasty procedure that indudes fixing the lid skin to the levator just above the tarsal border (supratarsal fixation). This procedure has been fostered as way to obtain a deep upper lid sulcus, but is not recommended by the authors.

Correction of a persistent ptosis should await resolution of the healing process following blepharoplasty.

Lagophthalmos

The inability to completely dose the palpebral fissure following blepharoplasty is usually temporary. With normal lacrimal function and a normal Bell’s phenomenon, it is usually noticed when the patient sleeps and causes no discomfort It also may be seen as a slight tethering when the patients head is back and looking downward. This minimal lagophthalmos is most commonly seen following secondary or tertiary blepharoplasty or when a primary blepharoplasty is done in conjunction with a brow-lift or forehead lift. The constant tendency for the upper lid skin to stretch as an accommodation to tension usually prevents functional problems following generous excisions of upper lid skin. However, there are limits to the ability of the upper lid to accommodate. The cases most prone to functional lagophthalmos problems are: aggressive secondary or tertiary blepharoplasty, aggressive forehead-brow elevation in conjunction with upper lid blepharoplasty, and cases where an earlier eye lid trauma had produced a lagophthalmos but went undetected before surgery.

At the completion of the upper lid wound dosure in primary blepharoplasty it is common to see a palpebral fissure separation of up to 4 mm. Much of this observation is due to activity of the levator while the orbicularis is anesthetized. If the palpebral fissure separation is 5-6 mm the possibility of lagophthalmos is real. Overestimation of skin excision can occur when the thin lid marking is spread widely during four-point skin fixation at the time of the skin incision. It is not difficult to replace a strip of upper lid skin if over resection is suspected at the condusion of the procedure. A strip of replaced skin will be totally viable without the need for a pressure bandage. The replaced skin will be totally unnoticeable in several weeks.

Hematoma of the Lids

Careful homeostasis at every point of the blepharoplasty procedure has been persistently emphasized in this chapter. Development of a hematoma in the immediate post operative time period requires reopening the wound and establishing homeostasis. In the first few hours following surgery, hematoma must be differentiated from edema and ecchymosis. These problems usually involve the lower lid. Progressive enlargement, elevation of the lower lid margin, a deep purple discoloration, and firmness to touch are indications of the need for prompt exploration. When the bleeding involves a vessel associated with fat resection the vessel can be hard to find because of extravasation and the fat stump retracting back into the orbit The time to control these vessels is at the moment any bleeding is detected following release of the fat stump. Slow development of ecchymosis and a pitting edema, just above the orbital rim is more compressible than tense is a hematoma. The ecchymosis/ edema can be treated expectantly.

Lid hematoma discovered after the immediate postoperative period should be allowed to liquefy (7-9 days) and be removed by needle aspiration and gentle pressure expression. This may require several daily visits for repeated treatments. Failure to remove the dot will result in a firm nodular scar that may persist for many months.

Overcorrection of Fat Pockets

Excessive removal of fat from the lower lid can give a cadaveric appearance as the concave effect of the lower lid brings the boney rim into relief. In this chapter, the authors have addressed repositioning of the medial fat in those patients where a tear trough deformity exists medially. Certainly, in these cases, fat removal will worsen the appearance. In the central and lateral lid the fat removal is carefully executed so that the level is no more than 1 mm below the boney margin. In the upright position this will translate to a smooth transition between the bony rim and the remaining central and lateral orbital fat

If over resection of fat is recognized intraoperatively, orbital fat can be replaced in small amounts as needed. These grafts of orbital fat have a high success rate. If the over resection is noted in the postoperative period, injected fat from donor submental or abdominal regions may be used in small amounts to elevate the depressed area. Some experience is needed to produce a perfect result Fat injected in this area can move to an adjacent area of the lid.

Functional Problems associated with Blepharoplasty Dry-eye Syndrome

Dry eye syndrome is the most common functional problem following blepharoplasty. In most cases this is related to exposure of the cornea in patients with a subdinical dry-eye syndrome. In patients with minimal dry eye problems that have only a functional and no anatomic component preoperatively, a perfectly performed blepharoplasty should have lithe negative effect on increasing the problem. But, the surgeon can never know if the dry-eye syndrome might progress coincidentally with the blepharoplasty. In patients with an anatomic cause for the dry-eye syndrome, if the anatomic component can be corrected with the blepharoplasty they may experience an improved quality of life. If the anatomic cause of the dry-eye syndrome were worsened, then the dry-eye syndrome would become more severe. In these patients, the easiest solution is not to operate. If the patient is accepted as a surgical candidate the most conservative approach and procedure is indicated. Patients with certain systemic diseases are known to be prone to postoperative blepharoplasty dry-eye syndrome, i.e., systemic lupus erythematosis, sderoderma, Wegener’s granulomatosis, ocular pemphigoid, Steven’s Johnson syndrome, ocular rosacea associated with acne rosacea, and paresis or paralysis of the seventh cranial nerve.

A history of any ocular symptom of itching, foreign body sensation, burning, or mucoid secretion should alert the examiner to a potential problem. Surgery in these patients is performed only after ophthalmologic consultation.

Once a patient presents with dry-eye syndrome following blepharoplasty the use of artificial tears, nocturnal lubricants, and lid taping to ensure corneal protection and the participation of an interested ophthalmologic colleague are all necessary over an extended period.

Epiphora

Tearing following blepharoplasty is common in the immediate postoperative course. Persistence of tearing may indicate interference with the lacrimal canaliculi by mechanical obstruction, distortion secondary to lateral tension, or external rotation of the puncta out of the normal tear collection pathway.

Examination of the outflow tract by an ophthalmologist experienced in this testing may be necessary to evaluate obstruction and to assure an anxious patient that there has been no injury to the duct system.

Surgery on the lacrimal system for epiphora should follow only after six months of hopeful spontaneous resolution.

Orbital Hematoma

In addition to the cessation of medication known to cause operative bleeding, preoperative laboratory evaluation is indicated with any history of easy bruising, previous surgical bleeding, or a suspicious family history.

Intraoperative orbital bleeding is rare during blepharoplasty. The method of lid anesthesia advised in this chapter specifically avoids penetration of the orbital septum with a needle to prevent intraorbital vessel injury. Cautious intraoperative attention to homeostasis, especially when fat is being excised, has been stressed. Any recurrence of bleeding following cautery homeostasis requires immediate attention before visualization of the bleeding vessel is obscured by extravasation.

Orbital hematoma in the immediate postoperative period is also a rare complication. The sudden intense pain associated with lid swelling and proptosis is a surgical emergency. Bleeding is usually arterial and associated with lower lid blepharoplasty. Increasing pressure within the orbit can damage the optic nerve and lead to blindness. Any sudden increase in pain in the immediate post operative period must call attention to the possibility of orbital hematoma. The wound should be opened, dots expressed, and the vessel controlled. If the orbital pressure causes any decrease in vision or if the IOP approaches 80 mmHg, a lateral canthotomy and inferior cantholysis should be performed. These release the diaphragmatic confining effect of the orbital septum and inferior lateral canthal tendon and thus decompresses the orbit, relieving pressure on the central retinal artery and optic nerve. The wound should be left open and small drains should remain in place for 24 to 48 hr.

The extra ocular musdes are always at risk in blepharoplasty. The superior oblique, inferior oblique, and the medial rectus musdes can be damaged if medial compartment fat is damped without first specifically observing that the fat is free of any musde. Extraocular musdes may be traumatized by cautery, blind damping for homeostasis or during direct cautery dissection of fat Fortunately, most visual disturbances from musde imbalances secondary to surgical trauma show progressive improvement with eventual return to normal. Secondary surgery to restore continuity of transected musde or balance by musde resection may be required when the injury is severe, but usually recommended after several months of observation.

Blindness

Blindness following blepharoplasty is an extremely rare occurrence. In most cases other than orbital hematoma, there has been no specific causal relationship between the blepharoplasty and the loss of vision. The suspected cause of the blindness- toxic amblyopia, idiopathic optic nerve atrophy, retrobulbar optic neuritis, or optic nerve changes secondary to systemic disease-seems beyond preventability. Still the possibility of blindness following blepharoplasty does exist To the author’s knowledge, all reported cases thus far have followed surgery on the lower lids, and all have been unilateral. The moral issue of performing blepharoplasty on a patient with one seeing eye must be resolved by the individual surgeon and the patient’s informed consent

FUTURE

Though the current surgical treatment of eye lid to reverse the effects of aging and correct the effects of heredity will continue to be important in the future, newer procedures may be expected to either augment or replace what we now see as state of the art There are many modalities that may augment or even replace surgical treatment of the aging eyelid. Many light therapies of various wavelengths have been available in the recent past and the progress in this area of medical skin rejuvenation has been most remarkable. A steady progression of lasers has proved effective in the treatment of the eyelids. Intensive pulsed light, intensive fluorescent pulsed light, LED therapy, and photodynamic therapies all have had some recent profound effect on eyelid skin. Newer variations and advances are inevitable. Treatment for collagen induction by surgical needling, radiofrequency treatment, and fine point laser penetration for collagen stimulation all have had some positive effect on the eyelid skin. The future for this type of treatment looks very positive. The rapid development of dermatologic treatment by topical application will undoubtedly continue to be of great value in the treatment of the aging eye. There is no limit to the possibilities. There exists the possible breakthrough in gene therapy or hormonal therapy that may applicable in this area of interest The progressive surgeon must be acutely aware of all that is new in this area of expertise, but also must be aware of which new modalities and products are of proven use and which are being popularized by medical suppliers and manufactures creating public interest in the media before the modalities are clinically validated.

SUGGESTED READINGS

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Castanares S. Blepharoplasty for herniated infraorbital fat anatomical basis for a new approach. Plast Reconstr Surg 1951;8:46.

Castanares S. Anatomy for a blepharoplasty. Plast Reconstr Surg 1974;_53:_587.

Fagien S. Reducing the incidence of dry eye symptoms after blepharoplasty. Aesthetic Surg J 2004;24:464-468.

Honrado CP, Pastorek N. Longterm results of lower-lid suspension blepharoplasty: a 30 year experience. Arch Facial Plast Surg 2004;6(3):150-154.

Kaizen, L.B. The history of cosmetic blepharoplasty. Adv Ophthal & Reconstruct Surg 1986;5:89-96.

Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient bypassing the pitfalls. Clin Plastic Surg 1993;20:213-223.

McCord CD, et al. Lateral canthal tightening. Plast Reconstr Surg 2003;112(1) :222-237.

Pastorek N. Upper lid blepharoplasty. Facial Plast Surg 1996;12:157-169.

Patipa M. the evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg 2000;1 06(2):438-453.

Zide BM, Jelks GW. Surgical Anatomy of the Orbit New York: Raven Press,