The ideal upper eyelid and brow in women includes a relatively full brow positioned medially at the orbital rim, centrally just at or slightly above the orbital rim, and laterally above the orbital rim. The entire brow should form a gentle arch or should be slightly flat at the center. The lid crease is usually present less than 10 mm above the lid margin. The sulcus below the superior orbital rim should not actually define the bony margin. Laterally, the youthful appearing eye has no hooding of the skin at or beyond the orbital margin and the central lid is free of skin redundancy. The medial upper lid appears concave or flat never convex. The surgeon should have a general aesthetic sense of the ideal upper eyelid to discuss the subject intelligently with patients. Besides keeping abreast of the current medical literature, it may be valuable to follow the fashion media as well.
A baggy lower lid has always been considered unattractive. The fullness of the orbicularis just beneath the lid margin, a natural look in childhood and early youth, is different from the progressive hypertrophy of the pretarsal orbicularis that may accompany age. Fullness or bagginess beneath the preseptal orbicularis is always unattractive in the adult lower lid and gives the appearance of fatigue or even dissipation. This fullness can be secondary to fat pseudoherniation or preseptal orbicularis muscle swag. Any contribution secondary to fluid retention must be ruled out.
Evaluation of the blepharoplasty patient must include both motivational and medical history; examination of the upper lid-brow complex; examination of the lower lids; and a discussion of the surgical options, the preoperative preparation, the postoperative care and course, and possible problems and complications. Preoperative photographs are taken. Table 179.1 summarizes the diagnosis and evaluation.
As in all aesthetic surgery evaluation, determining the reason a patient is seeking surgery is important. The ideal patient for blepharoplasty has a family history of baggy lids and a relatively long-term desire for reversal of a progressively deteriorating lid appearance. The ideal patient is seeking surgery for self-improvement or would like to maintain or advance in a public-oriented career position and is realistic about the expected result. The patient who appears for aesthetic surgery consultation on a sudden decision is always asked to come for another consultation later to ensure that the decision is reliable. Patients with psychiatric history should have proper consultation and clearance before scheduling surgery. No patient should expect external-world changes as a result of the surgery. A change in the course of a relationship, career, or other goal should never be dependent on the outcome of the surgery.
There is a group of blepharoplasty patients who have had full and heavy upper lids all their lives, even as children. The surgeon will be creating an entirely new look to the patient’s face, not one that the patient remembers from the past. It is important that the new look is clearly explained and demonstrated before surgery in this case, especially to a spouse or significant other.
Any medical condition that would preclude elective surgery contraindicates blepharoplasty. Care must be taken to evaluate any condition that might be aggravated by the vasoconstrictors in local anesthesia. Many of the newer psychotropic medications can change a patient’s normal reactivity to sympathomimetic amines. Any medical problem that causes fluid retention should be controlled before surgery. A small group of patients have a combination of blepharochalasis and fluid retention of the lower lids. These patients will have persistent lower lid morning edema for several weeks postoperatively. As the scar tissue matures in the lower lids, the edema will resolve. An ophthalmic history is critical. Obvious ophthalmic problems must be dealt with by an ophthalmologist. A patient with full-blown dry-eye syndrome should not undergo blepharoplasty. The most important problem in this aspect is the occult dry-eye syndrome. Even conservative upper lid blepharoplasty can result in upper lid closure failure, exposing the cornea to drying and bringing an occult dry-eye syndrome into obvious dry-eye syndrome with severe consequences. In these patients, a minimal upper lid skin excision may be done in the patient with severe upper lid skin redundancy to relieve the pressure sensation of the skin weighing on the eyelashes. Any preoperative history of tearing, burning, use of artificial tears, or stinging pain at night requires a full dry-eye evaluation.
A near-field vision test can easily be incorporated into the patient’s history form as a reading test with each eye covered in turn. A previous blepharoplasty history is significant in that a secondary procedure must be quite conservative to avoid lagophthalmos or significant scleral show.
The orbicularis muscle is intimately attached to lid skin. It is divided by location into a muscular ring superficial to the tarsus (pretarsal orbicularis), a muscular ring superficial to the orbital septum (preseptal orbicularis), and an outer muscular ring that extends under the eyebrow and over the inferior orbital rim (orbicularis). The orbital septum is separated from the overlying orbicularis muscle by areolar tissue. The orbital septum is contiguous with the tarsal plates, both having a simular embryonic origin. The orbital septum attaches peripherally to the orbital rim and with the tarsal plates forms a diaphragm protecting the orbital contents. The orbital fat compartments, which pseudoherniate in some persons on a hereditary basis, occupy two spaces in the upper lid and three spaces in the lower lid. In the upper lid, the central and medial compartments are divided by the superior oblique muscle. In the lower lid, the central and medial compartments are separated by the inferior oblique muscle. The central and lateral compartments are separated by a fascial sling. The floor of the fat compartments in the upper lid is formed by the levator aponeurosis. The levator aponeurosis attaches to the superior tarsal plate and functions to elevate the lid. In the lower lid, the lower lid retractors attach to the inferior tarsal plate. The lateral canthal ligament inserts into the lateral orbital rim just behind the orbital tubercle. The inferior and superior preseptal orbicularis muscles blend together laterally over the orbital tubercle as the lateral palpebral raphe.
Evaluation of the Upper Lid-Brow Complex
The brow position is all important in considering the aesthetic position of the upper lids. Brows tend to descend from their normal position (as indicated for the ideal position) as the patient ages; however, the brow may be very low at any age. If a substantial amount of upper lid skin redundancy is actually infrabrow skin, the surgeon must be aware that removing this apparent skin redundancy may depress the brow further. The best aesthetic result can be obtained by surgically repositioning the eyebrow into a normal relationship with the superior orbital rim. This can be done by a coronal, hairline, endoscopic, midforehead, or direct brow lift. For the patient with brow ptosis who does not want brow repositioning, the upper lid blepharoplasty must always be a compromise operation, and the patient must understand this. The surgeon must understand that ideal brow position relative to the superior orbital rim is relative. The position is influenced by individual tastes. While a difference of opinion may exist between the patient and surgeon, the patients desire is always paramount.
Significant unilateral brow ptosis, when present in repose, can be corrected by a midforehead brow lift if forehead rhytids are present. An upper lid blepharoplasty in the presence of an uncorrected unilateral ptosis will make the brow problem more obvious. The elements that can be altered in blepharoplasty include the skin, orbicularis oculi muscle, and fat pseudoherniation. Occasionally, a ptotic lacrimal gland must be repositioned; rarely, an infrabrow fat pad must be excised; and exceedingly rare, a lateral superior orbital rim bone segment must be removed to improve the overall appearance of the eye. In the evaluation, the surgeon anticipates the amount of skin that must be excised, with special attention to the presence of lateral hooding. The amount of medial and central fat is estimated. The presence of a ptotic lacrimal gland is noted. If, when the lateral upper lid skin is elevated, a bulge is noted in the superior lateral upper lid, then a ptotic gland is suspected. The position of the eyelid crease at the superior tarsal margin is measured as the distance from the lid margin. Orbicularis oculi muscle hypertrophy or redundancy is determined.
Skin type is especially important in upper lid blepharoplasty. The thin-skinned older patient usually requires a conservative resection of fat from the central compartment and a conservative resection of orbicularis oculi muscle as well to avoid a hollow look in the central upper lid sulcus just below the superior orbital rim. Conversely, the patient with heavy skin, especially the younger patient with thick skin who has never had a discernible upper eye crease, requires a more aggressive surgical approach. Surgical creation of a sculptured eyelid in thicker skinned patients requires excision of considerable skin, fat, orbicularis oculi muscle, and possibly a lateral extension of the skin excision. It is important to note the symmetry or asymmetry of the palpebral fissures and to make the patient aware of any unilateral lid ptosis that may be causing asymmetry. A 1- to 2-mm lid ptosis usually is not corrected in an aesthetic surgical procedure. The patient is usually unaware of the minimal palpebral inequality. Demonstrating this palpebral fissure inequality to the patient preoperatively is important. Recent onset of ptosis bears investigation: It may be due to opposite-side exophthalmos or same-side Horner syndrome. Finally, it is important to determine whether any degree of lagophthalmos (incomplete eye closure) exists in either eye. Some degree of lagophthalmos is usually present in patients who have undergone previous blepharoplasty, but it also may be present after even minor-lid injuries in youth. The presence of lagophthalmos dictates a conservative blepharoplasty. Although unilateral seventh-nerve weakness is uncommon, the strength of both lids should be tested against pressure to rule it out. It is also important to test for the presence of Bell ‘s phenomenon. In a patient with an absent Bell ‘s phenomenon, any postoperative lagophthalmos can be especially devastating because the central cornea would be exposed.
Evaluation of the Lower Lid
The lower lid is examined to determine the type of surgical approach to be used to achieve the optimal result. The simplest approach is the transconjunctival. However, the transconjuctival blepharoplasty is used only when there is fat psuedoherniation and either absent or very minimal redundant skin or lax orbicularis muscle. This procedure is used mostly in younger patients with early signs of baggy lid secondary to heritary fat psuedoherniation. The very minimal associated skin redundancy (1 to 2 mm) can be treated with the CO 2 or other laser technology or with a skin pinch’ approach in the subciliary line at the time of the transconjuctival blepharoplasty. When fat psuedoherniation is accompanied by skin redundancy and muscle swag, an external subciliary incision allows for either a skin flap alone or a skin-muscle flap to control the skin, muscle, and fat problems. The skin flap has a very limited usefulness aside from minimal skin redraping. Today, most isolated skin excess can be controlled with the CO 2 or other types laser modalities. Newer Intense Pulse Light technology may also be used to control minimal lower lid skin redundancy. The most useful approach to the aging lower eyelid is the skin-muscle flap. The incorporation of an orbicularis suspension suture with the skin-muscle flap allows for a powerful tightening of the entire lower lid. The relationship of the limbus to the lower lid margin should be noted. Any preoperative scleral show should be viewed by the patient. It is most important to measure the strength of the orbicularis oculi muscle and tension of the lid. Opening the lid with gentle force while the patient is holding the lids tightly closed gives an impression of the strength of the seventh nerve. Occasionally, unilateral seventh-nerve weakness is present in the orbicularis oculi muscle. Pulling the lower lid away from the globe and then quickly releasing it allows the surgeon to determine the lid strength or laxity (snap test) (Fig. 179.1). The lid should spring quickly to contact the globe without the influence of blinking. If the lid does not snap back to touch the globe but remains away from the globe until the patient blinks, a lid-shortening procedure is indicated. This procedure is beyond the scope of the chapter.
The lower bony orbital margin is palpated to determine to what extent, if any, the bony margin is contributing to the lower lid appearance. The presence and extent of malar or cheek bags are noted. These edematous skin conditions can result from fluid retention or the presence of a palpebromalar raphe. This condition is distinct from fat herniation and is present below the orbital rim away from the lid itself over the malar eminence. This malar bag is difficult to treat and may not be entitely eliminated even with placement of the suspension suture.
In both the upper and lower lids, the presence of any skin lesions is noted (i.e., syringoma, trichoepithelioma, hyperplastic sebaceous glands, papilloma, or xanthoma). These may or may not be excised at the same time as blepharoplasty. The removal of these lesions is separate from the blepharoplasty procedure for the surgeon. The lesions are seen as part of the problem for the patient.
It is at this point, after a complete examination of the lower lids, that a decision is made to approach the lower lids via a suspension skin-muscle flap or via a transconjunctival incision. The older patient with large fat pseudoherniation, significant redundant skin, and prominent orbicularis muscle swags is an obvious case for skin-muscle flap because this approach will allow for adequate skin removal and tightening of the loose muscle and skin with a suspension suture. The younger patient with smooth skin, moderate fat pseudoherniation, and no muscle swag is an obvious candidate for transconjunctival blepharoplasty because there is no need to remove skin or tighten the muscle. Since the advent of the CO 2 resurfacing laser and other laser skin tightening technologies the indications for transconjunctival blepharoplasty have expanded. It is possible both to smooth fine wrinkles and to tighten the lower lid skin to some degree with the other modalities, lessening the need for the skin-muscle flap in patients who have 1 to 2 mm of estimated skin laxity. Beyond 3 mm of skin laxity, it is probably best to use the skin-muscle flap. By pushing the skin tightening features of the laser, the risk is increased that scleral show, ectropion, or scarring might occur because of tissue contraction. Also, over use of the CO2 laser can result in thinning of the skin which in the long term can produce fine rhytids. The subciliary scar of skin-muscle blepharoplasty has never been an aesthetic problem. Using the transconjunctival approach simply to avoid this scar would be a mistake. The skin-muscle procedure does take longer than the transconjunctival approach, but it remains a reliable method to tighten the loose lid skin and muscle. Expediency in lower lid blepharoplasty should be a minor factor in surgical judgment. The patient should be aware of the surgical plan and should understand the reason for a particular approach.
Malar bags (skin wrinkling or edema extending over the malar complex) may not be entirely removed with blepharoplasty and may keep the same appearance. Lateral orbital rhytids beyond the orbital rim probably will not be affected at all by blepharoplasty but can be helped to some extent by laser resurfacing and the use of Botulinum neurotoxin injections.
As with any aesthetic surgical procedure, preoperative photographic documentation is imperative. It may be done by a professional photographer or by the surgeon. Photographs must be standardized. The usual views include a full face at a ratio of 1:10 followed by close-up lid views at a ratio of 1:5 or 1:4. These close-up views are frontal eyes open, frontal gaze upward, frontal eyes closed, both obliques, and both laterals. For a detailed discussion of photodocumentation, see Chapter 171.
PREPARATION FOR SURGERY
The decision to perform blepharoplasty is based on favorable psychological, general medical, and lid examinations. The patient’s expectations should coincide with what is possible surgically. All patients are prepared for surgery with an in-depth preoperative discussion about what is expected of the patient before surgery, what the operation will be like, what the normal postoperative course will be, and what problems and complications can occur.
All medications that interfere with blood coagulation must be avoided for 2 weeks before surgery. This includes aspirin, nonsteroidal antiinflammatory drugs, vitamin E, and anticoagulant herbal preparations, especially Gingo, Gensing, Grape seed oil, and Garlic capsules. Alcohol should be avoided for approximately 4 days before surgery. Any post-op physical activity, especially sports and excersize programs that can interfere with the surgical result are discussed. Financial arrangements and the surgeon’s payment policies are discussed.
Most blepharoplasty surgery can be performed satisfactorily with the patient under local anesthesia as an outpatient or ambulatory procedure using preoperative and intraoperative sedation and analgesia. Lidocaine 2% with 1:100,000 epinephrine buffered with sodium bicarbonate 8.4% in a ratio of 10 mL lidocaine and 1 mL bicarbonate is used for local anesthesia. About 1 mL is infiltrated into the eyelid skin with a 1.5-inch 25- or 27-gauge needle. At least 10 minutes must elapse before the incision to allow for adequate vasoconstriction. If all four lids are being done under local anesthesia, it may be advisable to mix bupivacaine (Marcaine) 1/4% in equal amounts with the lidocaine solution to provide for a prolonged anesthesia of the lids. If a transconjunctival approach is planned for the lower lids, tetracaine 1/4% drops are used in the inferior conjunctival cul de sac before injection. The transconjunctival injection is best done with a 30 gauge needle. Of all the tissues of the face, the eyelids maintain anesthesia for the shortest period. If all four lids are anesthetized at the same time, sensation may return before the final lid is completed. It is advisable to first anesthetize the upper lids and the lower lids later as the upper lids are completed. Optimal anesthesia then will be present as each lid is operated. The needle is always held in a direction parallel to the eyelid. This eliminates the possibility of the patient ever moving upward into a needle directed vertically to the eyelid.
Surgical marking of the upper lids begins with a thorough removal of all skin oils with alcohol. A fine-line surgical pen is used to demarcate the upper lid crease. This is easily seen in a bright light and is the upper anatomic boundary of the tarsal plate. The line should be at least 8 mm above the upper lid margin. If it is less than 8 mm, then the skin mark is placed above the natural crease at a distance of 8 to 10 mm. The lid creases are usually symmetric; any asymmetry is adjusted so that the two planned lid creases are symmetric and 8 to 10 mm above the margin. The line is carried medially to include all the crêped skin into the sulcus into the nasal junction. Laterally, the line is carried to the sulcus between the lateral orbital rim and lid. If there is hooding of the skin lateral to this point, the drawn line angles slightly upward (Fig. 179.2).
When the patient is in a supine position, the weight of the forehead and scalp displaces the eyebrows superiorly. To estimate upper lid skin removal correctly, the brow is pushed gently downward with the thumb and forefinger. The redundant skin is grasped gently with forceps. The lower blade is at the already marked lid crease and the upper blade is in the region of the maximum estimated excision (Fig. 179.3A). With forceps blade closure, the upper lid margin should not elevate. This amount of skin excision will allow for cosmetic enhancement but not for lagophthalmos. The skin is marked at several points, and the points are connected into a line. The lateral extent of the skin excision is determined by the amount of lateral hooded skin. The skin excision must incorporate all lateral hooding (Fig. 179.3B). If necessary, the incision may be carried 1 cm or more past the orbital margin. The direction of the final scar should be planned to lie between the lateral brow and the lateral canthus. In this position, the scar can be camouflaged by eye shadow make-up in the immediate postoperative period.
The medial skin redundancy should always be underestimated slightly if the patient has a large medial fat compartment. The defect caused by the excision of a large fat compartment is likely to create a subcutaneous dead space. If slightly less skin is removed, the skin can drape into the defect rather than tenting over the defect at the time of closure. Medial tenting of skin is a cause for hypertrophic scarring postoperatively. Both medially and laterally, the skin excision lines should meet at 30-degree angles.
If a skin-muscle flap is planned, the lower lid is marked at the lateral lid at a point 2.5 mm below the lid margin and just at the lateral canthus. The entire incision medial to the point continues along at 2.5 mm below the lid margin in the subciliary crease to the lacrimal puncta. Lateral to this point, the incision breaks to become horizontal just as it crosses the orbital rim. The incision should not angle downward laterally.
It is customary to complete both upper lid procedures before beginning surgery on the lower lids. The initial incision is made across the lower limb of the planned skin excision in a single sweep while holding the lid skin taut, followed by a skin incision of the upper limb. The skin excision is completed by separating the skin from the orbicularis muscle with a curved Stevens scissors. Next, the orbicularis muscle is excised in all but the most thin-skinned patients. The muscle excision removes a central trough of orbicularis muscle along the path of the skin excision (Fig. 179.4A). The depth of the excision is to the orbital septum. In the upper lid, the central fat compartment is the easiest to remove initially. A large amount of central fat may completely obscure the medial fat compartment. The orbital septum is opened sharply and the fat is teased into the wound. Only fat that easily flows into the wound is removed. The fat is infiltrated with local anesthetic, clamped, and excised. The stump is cauterized with hot tip or electrocautery to eliminate bleeding once the clamp is released. The use of an electocautery under local anesthesisa may cause pain even if the fat is injected with xylocaine.
The medial compartment usually requires some gentle exploration, especially when the amount of fat is small. If the medial fat compartment is identified as an aesthetic problem preoperatively, it must be sought at the time of surgery. Gentle pressure on the globe usually makes its location obvious. The central and medial fat compartments are separated by the superior oblique oculi muscle. This muscle is rarely observed, but it is wise to look for it before clamping the medial fat.
Theoretically, a lateral fat compartment should not be present in the upper lid, but sometimes in a patient with larger amounts of fat a lateral compartment is found overlying the lacrimal gland (Fig. 179.4B and C). If a ptotic lacrimal gland is identified a 6-0 Prolene suture needle is used the carefully pick up the gland capsule. The needle is the used to pick up the periosteum of the orbital roof just behind the orbital rim. As the knot is pulled tight the gland advances upward into its normal position. Prolene 6-0 is recommended for wound closure. It is a reliable suture that will not leave suture marks, even if left in place for more than the usual 3 to 4 days. The most tension in the upper lid closure occurs laterally. This portion of the wound is closed with interrupted simple sutures (Fig. 179.5). The rest of the wound is closed with a subcuticular suture, beginning medially and continuing laterally. It is unnecessary to knot the ends of the subcuticular suture. To alleviate any tension in the lateral portion of the wound, this area may be taped at the conclusion of the procedure. If any redundancy still exists medially, small triangles of skin can be excised above and below the closure line. The triangle’s base is at the initial incision. Usually, these excisions do not require closure, but paper tape can be used if necessary.
The lower lid incision is made with a small sharp blade at the lateral canthal mark 2.5 mm below the lid margin in the subciliary crease. The initial incision is through the skin and measures about 6 to 7 mm. A small, straight, sharp scissors then is used to carry the subcutaneous incision medially to the puncta (Fig. 179.6). A small skin flap then is developed for about 3 mm to expose and preserve the pretarsal fibers of the orbicularis oculi muscle (Fig. 179.7). By preserving this pretarsal sling, the lid will have more immediate tension response after surgery, reducing the possibility of scleral show or ectropion. A curved Stevens scissors then is used to separate the preseptal and pretarsal muscle to the puncta. This incision stays above the orbital septum. Blunt dissection with a cotton-tipped applicator sweeps the preseptal orbicularis muscle away from the orbital septum to the orbital rim exposing the lateral, central, and medial fat compartments (Fig. 179.8A).
Fat removal is begun laterally. The orbital septum over the lateral fat compartment is quite dense and is separated from the central fat compartment by a fascial barrier (Fig. 179.8B). Local anesthetic infiltration into this fat, clamping, excision, and cautery are the same as for the upper lid. The central compartment fat pad is usually the most obvious and the easiest to remove in the lower lid (Fig. 179.8C). The medial fat compartment is more elusive and usually contains more fat than is obvious from the patient’s supine position. In this compartment, it is usually necessary to tease the fat from the orbit somewhat more aggressively than the central or lateral compartments (Fig. 179.9).
Before clamping the medial fat pocket, the inferior oblique muscle should be observed. In contrast to the situation in the upper lid, this muscular structure is almost always visible and should be found before clamping to avoid injury to the muscle. The fat in this location is also more dense and vascular than in the other compartments of the lower lid. Hemostasis here must be absolute to avoid a bleeding medial fat stump that could retract back into the orbit. The fat excision in the lower lid should leave the orbital rim exposed 1 mm. This depth of fat excision provides a good aesthetic result with no depression along the inferior orbital rim. If the preoperative examination revealed a tear trough deformity ( a deep sulcus along the medial eyelid-bony orbital rim junction), the surgeon should consider a fat repostioning procedure. A fat repostioning will either partially or less frequently, entirely efface the depth of the tear trough. The neccessity of repostioning is made before surgery. The orbital septum in incised at the inferior orbital rim (arcus marginalis). The fat is teased into the wound. The medial orbicularis muscle is then elevated away from the medial one-third of the infraorbital bone. Care is taken not to injure the infraorbital nerve. If the periosteum is left intact, it is possible to suture the fat down into the depths of the tear trough. The author has found that simply moving the fat down onto the anterior face of the maxilla beneath the elevated orbicularis muscle is enough to efface the tear trough. Some surgeons have advocated placing a trancutaneous suture through the repositioned orbital fat. If central compartment fat is removed so that it lies just 1 mm below the rim, the transitional area between lid and bony rim should be smooth.
The suspension suture in the lateral orbicularis will prevent a depression in the lateral eyelid-lateral orbital rim junction. Before beginning closure, the lateral fat compartment is inspected again to determine whether additional fat should be removed. Also, the area beneath the fascial barrier separating the lateral and medial compartments will occasionally sequester a small amount of the central compartment fat. This area should be inspected if additional fat present needs to be removed.
Once fat removal, and/or repostioning, and hemostasis are complete, the skin-muscle flap is draped superiorly. Skin excision is done with a straight Stevens scissors while the patient is looking upward with the mouth open (Fig. 179.10). This maneuver places maximum tension on the lower lid, providing a guide for the safe excision of skin and muscle. To ensure that no downward pull occurs on the lower lid, there should be no wound gap after excision with the patient looking upward with the mouth open. This may be achieved under general anesthesia by making sure the limbus is covered by the lower lid margin by at least 1mm. This minimal safe excision, however, may in some cases leave the patient with some skin redundancy. To allow further excision of skin, to prevent scleral show, and to draw the lateral skin upward, a lid suspension suture is used after excision of skin (Fig. 179.11A). The lid suspension suture is placed between the lateral orbicularis oculi muscle in the skin-muscle flap and the lateral orbital periosteum (Fig. 179.11B). The most appropriate suture is a clear 5-0 Prolene. The suture is placed in a vertical direction so that the lid is pulled neither laterally nor medially. It is a buried suture placed so that when tied, the knot will be directed downward. The suture is placed so that there is no purchase on the subcutaneous tissue and hence no indentation of the lid skin at the point of suture.
Once these suspension sutures are placed, the wound is closed with a simple running 6-0 Prolene suture (Fig. 179.12). Multiple surgical tapes are used to suspend the lid laterally and resist the downward pull on the postoperative lid. Figure 179.13 shows preoperative and postoperative views of one patient after upper lid blepharoplasty and lower lid skin-muscle blepharoplasty. Table 179.2 summarizes the procedures.
After the application of tetracaine drops to the lower lid and scleral conjunctiva,
lidocaine 2% with epinephrine 1:100,000 is injected into the subconjunctival space along the inferior margin of the tarsal plate from the puncta medially to the lateral canthus (Fig. 179.14). The lower lid is also injected subcutaneously as if a skin-muscle flap is to be done. The subcutaneous injection provides increased relaxation of the orbicularis muscle for improved visualization of the orbital fat. It also provides anesthesia if the lower lid skin is to be laser resurfaced or if a pinch of skin is to be removed.
The procedure begins with an incision through the conjunctiva along the inferior tarsal border and through the attached inferior lid retractors (Fig. 179.15). Because of the vascularity of the arcuate vessels in this area, it is essential the incision is made with a fine electrodissection needle, such as the Colorado pediatric microdissection. The fine needle does minimal damage to the tear glands in the conjuctiva. Two sutures of silk or Mersilene are placed through the proximal conjunctiva at the incision line approximately at the location of the medial and lateral limbus margin. These sutures are draped over the patient’s forehead and frontal area (Fig. 179.16).
Hemostats applied to the suture ends act as a gentle weight pulling the proximal conjunctiva over the cornea. The dissection is now immediately over the orbital septum and under the orbicularis muscle. Firm blunt dissection separates the orbicularis away from the orbital septum down to the orbital rim. At this point, the exposure is identical to the presentation afforded by the skin-muscle flap after separating the flap from the orbital septum. Each of the three fat pseudohernias is opened as with the skin-muscle flap and resected sharply after clamping (Fig. 179.17). Fat is removed to 1 mm below the orbital margin. A hot tip or electrocautery is used on the fat stumps. The orbital septum is not repaired. The lid is grasped and elevated superiorly and released. Gentle compression of the globe will reveal any pulsation of orbital fat irregularity and provide a guide to any additional subtle fat removal (Fig. 179.18). As in the skin-muscle flap procedure descibed above the medial fat can be repositioned beneath the medial orbitalis muscle to efface any tear trough deformity. The retraction sutures then are cut, and the lid is again draped superiorly to ensure that the transconjunctival incision lies in approximation (Fig. 179.19). Sutures are not required to close the transconjunctival incision. If any laser resurfacing is planned, it can be done just before removing the retraction sutures so that the benefit of corneal protection is continued during laser use. Skin removal with the pinch technique is done after releasing the traction sutures.
Several quarter-inch surgical tape strips are used laterally to help support the lid during the stage of continued anesthesia effect and later while the lid is heavy with postsurgical edema. Figures 179.20 and 179.21 demonstrate preoperative and postoperative views of patients who have undergone transconjunctival lower lid blepharoplasty. Both patients had remarkable orbital pseudoherniation of fat without any fine-skin wrinkling or skin laxity preoperatively. At the conclusion of the transconjunctival blepharoplasty in a patient with fine wrinkling or minimal skin laxity, a CO 2 skin resurfacing procedure can be done immediately to smooth and tighten the skin. The skin resurfacing also can be done at a later date if fine wrinkling becomes apparent in the proximal postoperative period.
No bandages are used on the lower lids, but the eyes are covered by cold compresses. The wounds are lubricated with an antibiotic ointment. The patient should remain quiet for remainder of the day of surgery. The cold compresses are used continuously. Pain is usually minimal; acetaminophen with codeine is usually adequate for pain relief. Looking downward for the next 24 hours is forbidden because the downward gaze could allow the skin-muscle flap to slide inferiorly over the underlying orbicularis septum. Occasionally, after transconjunctival lower lid blepharoplasty, the patient will notice a temporary lower lid elevation, due to the transection of the lower lid retractors away from their attachment to the inferior tarsal plate. It is common to note slight bleeding from the transconjunctival incision seen as a drop of blood on the lower lid margin. The bleeding is entirely self-limited.
Only sedentary activities are allowed until the sutures are removed on the third or fourth postoperative day. It is usually advisable to retape the lateral upper wound for 2 to 3 days more to prevent even minimal wound separation. Eye makeup may be used on the sixth postoperative day. Mild physical activities may resume on the tenth postoperative day. Contact lenses may be safely used at 9 to 10 days postoperatively.
Complications and emergencies are listed in Tables 179.3 and 179.4.
Hematoma is rare after upper lid blepharoplasty but is more common after lower lid blepharoplasty. Unilateral swelling and discoloration immediately postoperatively should raise the question of hematoma that should be differentiated from ecchymosis, which would appear dark but soft; hematoma has a palpable firmness. The wound is reopened, the bleeding vessel cauterized, and the wound closed. The best prevention of hematoma is meticulous hemostasis during surgery. Because the transconjunctival incisions are not closed, any bleeding has an immediate escape path. Hematoma risk in the procedure is greatly diminished.
This problem is unusual, and its cause in seemingly routine cases remains unexplained. It is far more frightening to the patient than to the surgeon. It always resolves completely in 3 weeks or more, and reassuring the patient is important. Medical therapy to speed the resolution is usually unsuccessful.
Chemosis is usually related to lower lid blepharoplasty. It can occur with or without the use of suspension sutures. Either it resolves quickly (several days) or it will remain for up to 6 weeks. When it is present, the gelatinous conjunctiva holds the lid away from the orbit, making the eye look almost proptotic or as though the palpebral fissure on the affected side is wider. The patient must be reassured that this condition is temporary and always resolves satisfactorily. If it is present beyond 2 weeks, a steriod ophthalmic drop is recommended.
Lagophthalmos can be present for a short time after upper lid blepharoplasty. It is usually mild and may cause minor tearing and burning. The use of artificial tears or ointments usually alleviates the symptoms until full healing occurs. Severe lagophthalmos usually occurs after secondary upper lid blepharoplasty when an inexperienced surgeon overestimates the amount of skin excision or when a forehead lift and upper blepharoplasty are performed simultaneously. Conservatism in upper lid blepharoplasty is important.
Scleral show is possible after lower lid blepharoplasty, even with conservative or no skin excision. Postoperative squint exercises and upward massage usually reverse this problem. Ectropion occurs when an obvious shortening of the lid accompanies a too-generous skin excision. It also can occur when a horizontal lid laxity exists preoperatively but is not identified. In the latter condition, a horizontal lid-shortening procedure is required. Occasionally, ectropion will occur from a downward displacement of the skin-muscle flap. In this condition, the lid appears to be stuck when the patient attempts an upward gaze. In this condition, a simple releasing incision, which elevates the skin-muscle flap and redrapes it, may resolve the problem.
Obvious scars in the lateral upper lid wound may occur when wound separation occurs at the time of suture removal and is not recognized or when sun exposure occurs in the immediate postoperative period to pigment the wound. In either case, a small secondary excision and repair may be necessary. Poor medial upper lid scars are always due to excessive skin excision in the face of a large medial fat compartment. Scars result when the wound is repaired over a large dead space. These scars can be treated by injecting very small amounts of triamcinolone (Kenalog 10 mg/mL).
Loss of Vision
Most reported cases of visual loss follow hematoma formation after lower lid or lower and upper lid blepharoplasty. Hypertension, old age, anticoagulant medication, and metabolic diseases are often present as cofactors. In the case of a hematoma, rapid decompression of a progressing retrobulbar hematoma is essential to preserve vision.
n Successful blepharoplasty depends on the surgeon’s understanding of the interplay of the aesthetic components contributing to the appearance of the eye region and to the face as a whole.
n Preoperative medical screening of the patient desiring blepharoplasty should include evaluation of medical problems that might be aggravated by medications required in the perioperative period and an ophthalmic history, including dry-eye symptoms and a near-field vision test.
n Evaluation of the brow area includes consideration of brow position with respect to the bony superior orbital rim, bilateral brow symmetry, brow shape, and hair distribution.
n Evaluation of the upper eyelid includes skin condition (thin or thick), palpebral fissure position, presence of orbicularis muscle hypertrophy, fat pseudoherniation, superior orbital rim bone position, lacrimal gland position, existing lagophthalmos, and presence of Bell’s phenomenon.
n Evaluation of the lower eyelid includes skin condition, presence of skin crêpiness, pigmentation, festooning, fat pseudoherniation, inferior orbital rim position, and lid laxity.
n Preblepharoplasty photography ideally includes a full face view at 1:10 ratio and closeup eyelid views at a 1:4 or 1:5 ratio in frontal, eyes open, frontal gaze upward, frontal eyes closed, both obliques, and both lateral views.
n Preoperative surgical marking of the eyelids is performed with a surgical pen with the patient in a supine position. Depressing the brow mimics the upright position.
n In the lower lid, the transconjunctival approach is selected for those with a predominance of fat with minimal skin redundancy and muscle swag. The subciliary incision and skin-muscle flap is chosen for patients in whom remarkable skin redundancy and muscle hypertrophy are of as much concern as the amount of fat. After transconjunctival blepharoplasty, laser resurfacing can both smooth the crêped skin and diminish a small amount of skin redundancy.
n During fat removal from the eyelid compartments, only fat that flows easily into the wound is removed; fat is never pulled forcefully from deeper within the orbit. Before removal, the fat is infiltrated with local anesthetic and clamped. After removal, the stump is cauterized to eliminate bleeding before the clamp is released. During fat removal from the lower lid’s medial compartment, slightly more aggressive fat removal is needed. The inferior oblique muscle should be located before clamping fat to avoid injury to the muscle. Fat repostioning is considered when a tear trough deformity exists.
n Complications of blepharoplasty include hematoma (rare on the upper lid, more common on the lower lid), subconjunctival ecchymosis, chemosis, lagophthalmos, ectropion, poor scars, and loss of vision (thought to be secondary to retrobulbar hematoma formation).
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FIGURE 179.1. The lower lid is tested for tension strength by grasping the lower lid skin, pulling the lid slightly away from the globe, and releasing it. The normal lid should snap back quickly against the globe. Having the patient look down while performing this maneuver tests the ultimate lid tension. A slow return indicates caution with skin excision and the possible need for a horizontal lid-shortening procedure. No return or a very slow return may contraindicate aesthetic blepharoplasty.
FIGURE 179.2. A: The classic extension of the upper lid skin excision is in a horizontal line carried laterally at the orbital rim. This line classically was placed in a lateral rhytid (crow’s foot). This extension, however, often made a fine lateral rhytid permanent and more obvious and also had the effect of pulling the lateral brow downward. B: By curving the lateral skin excision upward into the space between the lateral canthus and the lateral eyebrow, the wound can be camouflaged by cosmetics. The other major advantage is that natural tethering, which is present close to the lateral brow, prevents the downward pull of the brow.
FIGURE 179.3. A: Estimating the amount of upper lid skin excision. As the redundant skin is drawn together with a forceps, the upper lid margin should not elevate. B: The redundant skin is completely marked. The amount of excision that extends beyond the orbital rim is indicated with the patient’s eyes closed.
FIGURE 179.4. A: A strip of orbicularis oculi muscle has been excised down to the orbital septum. This muscle excision is variable. In the thin-skinned older eyelid, sometimes no muscle is removed, whereas in the heavy lid with thick skin, the muscle is often hypertrophic, requiring considerable excision. The purpose of the muscle excision is to define better the lid crease by allowing scarring at the wound closure to the region of the superior border of the tarsal plate. B: A large amount of hypertrophic orbicularis oculi muscle requires excision down to the orbital septum. C: Large amounts of pseudoherniated fat have been excised. In this patient, a lateral fat compartment was present over the area of the lacrimal gland. The gland is displaced by the retractor. If the gland is ptotic, it must be reattached to the orbital roof periosteum by a Prolene suture. If it is not resuspended, it will be palpable as a subcutaneous nodule.
FIGURE 179.5. The surgical wound is closed laterally with individual Prolene sutures because this is the area of maximum tension in eyelid wound closure. The remainder of the wound, centrally and medially, is closed with a subcuticular Prolene suture.
FIGURE 179.6. The lower lid is marked for a distance of less than 1 cm at the lateral canthus. This line parallels the orbital margin and is 2.5 mm below the margin. The skin incision is made over the skin marking. The remainder of the lower lid incision is made with a small, straight, sharp scissors. The incision is carried to the lacrimal puncta.
FIGURE 179.7. A skin flap is developed for 3 to 4 mm. This skin flap allows the pretarsal orbicularis oculi muscle to remain intact along the entire lid margin, providing an active muscle sling for lid support immediately and lessening the possibility of scleral show and ectropion.
FIGURE 179.8. A: The skin-muscle flap is elevated down to the inferior orbital rim. Festooning of the muscle or extreme skin redundancy dictates that the skin-muscle flap is extended further inferiorly. In such situations, the surgeon should note that a blood vessel accompanies the eyelid nerve branch from the infraorbital nerve. This vessel, when cut, bleeds vigorously. Cautery of the vessel invariably affects the sensory nerve, producing hypesthesia in the lower lid that can be prolonged. B: The lateral fat pocket lies high against the junction of the lower orbital rim and the lateral rim. It is divided from the middle compartment by a fascial barrier. The orbital septum is heaviest in the lateral region. The fat pocket, once encountered and drawn into the wound, can cause deep pain, which must be alleviated by a local anesthesia injection. The thickness of the orbital septum can camouflage the lateral fat pocket. If the lateral fat pocket was identified as a problem during the preoperative evaluation, it must be sought at surgery. C: The central fat compartment is the most obvious and must be removed to a level at least 2 mm below the orbital margin to produce an aesthetic effect. Removal of fat is accomplished by first injecting a small amount of local anesthesia to prevent pain when the hemostat is applied. A small cuff of fat must be left on the clamp to allow application of the hot-tipped cautery.
FIGURE 179.9. The medial fat pocket is teased into the wound after the orbital septum is opened. The inferior oblique muscle must be observed while the medial fat pocket is being clamped to ensure that no injury occurs to the muscle. If the patient has a tear trough deformity ( a deep depression at the maxillary – medial lid junction) the fat is repositioned rather than excised. A pocket is developed by firmly elevating the medial orbicularis muscle from its firm attachment to the medal maxilla. The fat is released by an arcus marginalis incision and positioned beneath the muscle. It may be secured with a 6-0 PDS suture, but this has not been found to be absolutely necessary for the fat to remain in the new postion.
FIGURE 179.10. The amount of redundant lower lid skin to be removed is gauged while having the patient look upward with the mouth open. If the amount of skin to be removed leaves the two skin edges in complete opposition, there will be little possibility of scleral show or ectropion. The patient and surgeon may believe that not enough skin was removed. If slightly more skin is excised, the lid can be supported by a suspension suture to ensure an appropriate lid level while obtaining maximum skin tightness.
FIGURE 179.11. A: This view shows the orbicularis muscle reflected off the orbital rim and the two areas that are encompassed by the needle and suture for the suspension suture ( arrow ). 1 , the periosteum over the orbital tubercle; 2 , the preseptal orbicularis muscle. B: The direction of the suspension suture must be vertical.
FIGURE 179.12. The immediate postoperative appearance of the upper and lower lid skin-muscle flap blepharoplasty.
FIGURE 179.13. A: Preoperative frontal view of upper and lower lid skin-muscle blepharoplasty in a 29-year-old woman. B: Postoperative view.
FIGURE 179.14. After application of tetracaine drops to the conjunctiva, the subconjunctival space is infiltrated with Xylocaine 2% with epinephrine along the inferior tarsal border from the puncta medially to the area of the lateral canthus.
FIGURE 179.15. The initial incision in the conjunctiva is made with a fine guarded electrocautery needle. The arcuate vessels immediately beneath the conjunctiva will bleed profusely if this incision is made without the use of electrocautery. The incision is made quickly to avoid dissipating heat into the adjacent conjunctiva. The tear glands in this conjunctiva are valuable and necessary for the protective tear film. Destruction of these glands has led to dry eye by using the wider destructive swath that can be caused by a CO 2 laser used for this incision.
FIGURE 179.16. A pair of sutures placed through the proximal side of the conjunctival incision are used to drape the conjunctiva over the cornea. The sutures are clamped with a hemostat to give weight to the suture retraction. A corneal shell also may be used.
FIGURE 179.17. After the incision through the inferior lid retractors, blunt dissection is used to separate the orbicularis muscle away from the orbital septum, down to the orbital rim. The orbicularis muscle is retracted with a blunt double-pronged hook. Exposure at this point is exactly the same as that with a skin-muscle flap. The fat pseudohernias are removed from the lateral, central, and medial compartments in the same fashion as with the skin-muscle flap.
FIGURE 179.18. After fat removal, the lower lid skin is redraped in its normal position. With gentle pressure on the globe, nuances of additional fat can be detected as they pulse outward beneath the lid skin and muscle. Any additional fat then is carefully removed.
FIGURE 179.19. At completion of the procedure, the lid is elevated as far superiorly as possible and released, ensuring that the edges of the conjunctival incision are in close apposition. No sutures are required in the incision. Sutures may be contraindicated because they will irritate the sclera or cornea or cause granulation.
FIGURE 179.20. A: A 48-year-old man with massive familial lower lid pseudoherniation of fat. B: Postoperative view of the patient after transconjunctival lower lid blepharoplasty.
FIGURE 179.21. A: A 35-year-old woman with marked lower lid familial blepharochalasis. B: Postoperative view after lower lid transconjunctival blepharoplasty.
TABLE 179.1. DIAGNOSIS BLEPHAROPLASTY
Complaint of baggy eyelids (progressive)
Positive family history
No allergic, fluid retention, or metabolic etiology
Strong motivation for cosmetic change
Absent or progressive loss of upper lid crease secondary to skin redundancy
Upper medial fat pocket herniation
Hooding of lateral upper skin
Herniation of fat into lower lid
Lower lid skin redundancy
Check for lagophthalmos, lower lid laxity, vision loss, dry-eye syndrome, ptosis of lacrimal gland, ptosis of eyebrows
TABLE 179.2. TREATMENT BLEPHAROPLASTY
Excision of redundant skin
Excision of skin redundancy
Orbicularis muscle (if required)
Postoperative cold compresses
Limitation of physical activity
Preoperative and postoperative avoidance of anticoagulants
Suture removal 34 days postoperative
TABLE 179.3. COMPLICATIONS BLEPHAROPLASTY
Severe cutaneous ecchymosis
Pigmented, wide, too low scars
Loss of vision
TABLE 179.4. EMERGENCIES BLEPHAROPLASTY
Severe dry-eye syndrome