Color Atlas of Cosmetic Oculofacial Surgery

It has been at least five to six years since the very popu-
lar First Edition of Cosmetic Oculofacial Surgery (Chen,
Khan, and McCord) was written. Further evolution in
lasers, BOTOX® applications, hyaluronic acid fillers as
well as less invasive aesthetic techniques have added to
the choices available for physicians and patients.
The Second Edition is a robust upgrade to this field
and includes additions in content covering concepts
of fat pad repositioning via lower blepharoplasty, use
of BOTOX® in the mandibular and platysmal region,
fractional CO2 laser in facial resurfacing, and the spe-
cific indications and various injection techniques for
hyaluronic acid fillers in the oculofacial areas. Colors
have been added to all diagrams, where appropriate.
All the desirable features from the original edition,
including arrangement of text, high resolution images
and drawings on the same page, Pearls and Pitfalls,
instructional tables, outlines and clinical pathways
have been continued to make this a valuable instruc-
tional manual. Most of all, the Second Edition comes
with a comprehensive new DVD that illustrates the
procedures, narrated by the two main authors. This
color atlas should be useful for beginning as well as
advanced audiences including ophthalmologists, plas-
tic surgeons, facial cosmetic surgeons, dermatologists,
as well as residents and house officers in these related
fields.
We are grateful for the added participation of
Dr Stuart Seiff, who shares with us the new chapter on
his use of dermal fillers including hydroxyappatite as
well as Botox applications; and Dr Michael McCracken
who has been a Co-Instructor with Dr Jemshed Khan
for their course on ‘Use of Hyaluronic Acid Filler’ at
the Annual Meeting of the American Academy of
Ophthalmology.
Preface
All of the standard techniques that have withstood
the test of time have been retained or upgraded in
details. This included forehead and eyebrow treat-
ment, upper and lower blepharoplasty, lower
blepharoplasty coupled with cheeklift, laser upper
blepharoplasty, transconjunctival laser lower blepha-
roplasty as well as ptosis repair. The fascinating topic
of Asian Blepharoplasty with concepts of eyelid crease
and its biodynamic are further elucidated in two new
chapters: one covering the concept of a glide zone and
its dynamics in healthy as well as scarred upper eye-
lid, and the other describing the advanced concept of
beveled approach in revisional Asian Blepharoplasty.
Dr Clinton McCord, who was one of the original
co-authors from the first edition of this text, currently
has a beautiful two volume book on Eyelid and
Periorbital Surgery; he is most gracious in allowing
us to continue use of his previous content from our
first edition, including the important topics of mid-
face cheeklift and endoscopic brow-lift.
It has been a pleasure for me to work with Russell
Gabbedy (Commissioning Editor) and Sven Pinczewski
(Senior Developmental Editor) at the Elsevier, London
office. I wish to thank Alan Nicholson (Project Manager)
of the Edinburgh office, Fraser Johnston and Colin
McEwan for guiding the video/DVD project; and
Annabel Milne (medical illustration) as well as Lee
Bowers (proofreading) for their assistance in the course
of this project. Without this sterling team, my life would
have been much more unruly. Lastly, I wish to express
my gratitude to Dr Jemshed Khan, my co-author, for
walking the publishing journey with me one more time.
William PD Chen MD, FACS

William PD Chen, MD, FACS
Clinical Professor of Ophthalmology
UCLA School of Medicine, Los Angeles, California;
and Senior Surgical Attending
Eye Plastic Surgery Service
Harbor-UCLA Medical Center
Torrance, CA
USA
Jemshed A Khan, MD
Khan Eyelid and Facial Plastic Surgery
Overland Park, KS
USA
Clinton J McCord, MD
Paces Plastic Surgery, Atlanta
Associate Clinical Professor of Plastic Surgery
Emory University School of Medicine
Atlanta, GA
USA
Michael S McCracken, MD
Clinical Instructor
Department of Ophthalmology
University of Colorado Health Sciences Center
Denver, CO
USA
Stuart R Seiff, MD, FACS
Chief, Emeritus Professor of Ophthalmology
Department of Ophthalmology
San Francisco General Hospital
San Francisco, CA
USA
List of Contributors

Chapter 6: Direct Browlift, Internal Browpexy, Browplasty
x
To my parents, Fred and Katie.
William PD Chen
To my wife, Michelle, and my sons, Alex, Corey, and Christopher.
Jemshed A Khan

1
Chapter 1
Dr Chen’s viewpoint
Cosmetic blepharoplasty is one of the most popular
forms of aesthetic surgery of the face. The surgical
outcome is intimately related to the interaction of the
upper eyelids with the forehead and brows, as well as
the lower eyelids, lateral canthi, and the midface and
cheek’s topography. Therefore, in any discussion and
examination of a patient concerning this form of
surgery, an astute clinician should consider the entire
face, and not confine attention to only the superficial
upper and lower eyelid skin layers. This awareness
of surrounding as well as deeper structures will
ultimately yield much better surgical outcome and a
happier patient.
In my initial office consultation with a new patient,
I first listen to his or her complaints, and mentally
classify these into relative orders (or wish list) of
which include those that can be improved upon, ver-
sus transient improvement or no improvement at all.
I then assess from the patient’s personality and tem-
perament the degree of enthusiasm or tolerance he or
she possesses towards surgery. Ultimately, the surgeon
and the patient need to mutually agree on what
is comfortable, beneficial, and worthwhile for the
patient to undertake. This may include time commit-
ment as to postoperative healing course, financial
matters, as well as overall general medical conditions
that may have a bearing on the type of surgery and
anesthesia recommended.
I always try to encourage patients to speak their
mind, even if they may be embarrassed, and I try to
facilitate this in an environment free of stress. Very
often, patients may be overly self-conscious about
an issue that matters very little to anyone they inter-
act with, or the surgeon may need to point out an
extreme condition that requires correction before
the aesthetic outcome can be achieved, such as invo-
lutional ptosis in conjunction with upper eyelid
hooding. It is important to customize individual
aspects of your particular technique for that patient.
For example, I have not performed two exactly
identical procedures among any of my patients who
have come to me to have Asian blepharoplasty.
After an adequate prioritization of goals with
the patient, I then explain what the procedure
involves, before, during, and after the surgery, and
what is expected of the patient. This includes the
mandatory preoperative cessation of aspirin products,
non-steroidal anti-inflammatory drugs, as well as
anticoagulants like coumadin and heparin.
The patients need to be quizzed as to whether they
are taking any herbal formulas, ginseng compounds,
or herbal teas, which frequently may contain thera-
peutics with anticoagulative properties (‘circulatory-
promoting, blood-flow-promoting’ ingredients in
traditional Chinese medicine).
The patient is given a detailed written list of preop-
erative and postoperative instructions with regard to
bed rest during the first day, use of ice compresses as
well as antibiotic ointments, what to expect, and
instructions to call me should there be any unex-
pected outcome or medical emergency. The office
staff are trained to make a follow-up telephone call to
the patient the day after surgery, both to verify that
the patient is stable and to confirm a return date for
suture removal.
In the patient chart, I record particular aspects of
his or her facial structure (ptosis, ectropion, entro-
pion, lateral canthal dehiscence, thinning of levator
and aponeurosis, forehead brow overaction, promi-
nent sulcus) (Fig. 1.1), what was mentioned to the
patient (for example, one upper lid margin is half a
millimeter lower than the other, one eye is more
sunken and shows a more prominent sulcus), the
patient’s response and preferences (high crease, low
crease, shape of crease line selected), as well as skin
texture and pre-existent thinning of lower lid skin
and telangiectatic blood vessels observed, plus what I
tell patients as to whether their stated preferences
could be achieved (Fig. 1.2). If a patient has thick dry
skin, or oily complexion, superficial furuncles, or
rosacea, these are all noted on my plan of manage-
ment for this patient (Fig. 1.3).
Examination and Interactions with
Aesthetic Patients
William PD Chen and Jemshed A Khan

Postoperative dietary recommendations are also
offered to facilitate uneventful and non-inflammatory
healing of the skin (this is an aspect of traditional
Chinese medicine that bewilders Western medical
practitioners somewhat).
In California, informed consent for surgery is
mandatory and we implement it in the office as well
as in the outpatient surgical facilities. All aesthetic
patients – for that matter, all patients in my offices –
must have adequate photographic documentation of
their current conditions. Typically, this includes a
frontal view, oblique side views, upgaze and down-
gaze, and, most importantly if the patient has had
previous surgeries, a close-up macro view of the
existent surgical lines or lid-crease scar. This last
item has been extremely useful for fully informing the
patients in many of the revision cases that I have
performed. In this very litigious climate, adequate
documentation is truly the best policy.
As regards photographic media, I have shifted to
digital photography since 1997. I still use a Sony
Mavica camera which take images in the 800×600
pixels range and stores them on flat 3.5-inch floppy
disks (cost less than 30 cents each). The disk is con-
veniently kept in each patient’s chart and can be used
for preparing simple Powerpoint presentations for
teaching purposes and community lectures (Fig. 1.4).
I use two other higher-resolution cameras for more
detailed images of selective conditions when I need
them for publication purposes. The cameras are a
Sony Cybershot with 8 megapixels and a third one
with video capturing capabilities.
If a patient appears extremely nervous, I usually
try to call them the night before the procedure, to
make sure all is well. On the day of surgery, in the
preoperative area, I greet patients again and reiterate
the goal(s) of the surgery. If there is any discrepancy
between what I told the patient and what they think
and expect of the surgery, I would always defer the
surgery until another day, although this is extremely
rare.
2
Chapter 1: Examination and Interactions with Aesthetic Patients
Figure 1.1 Elderly man with lower lid ectropion and cheek ptosis.
Figure 1.3 Asian female who developed postoperative upper lid cellulitis.
Figure 1.2 Actual drawing of patient’s clinical findings on medical records.
Prefers higher part of bifid
crease rather than lower
10mm
10mm
12mm
12mm
Thick eyeliner
(Has been using tape)
Patient prefers higher

Dr Khan’s viewpoint
Several critical issues should be resolved during the
preoperative consultation with a patient who desires
aesthetic periocular surgery. The present discussion
will focus narrowly on only those issues unique to
aesthetic patients. First and foremost, the surgeon
should elicit from the patient a designation of those
specific topographic facial features that the patient
would wish improved. Oftentimes, patients express
concern that their periocular facial features are com-
municating unintended signals such as disapproval
(glabellar frown lines), tiredness (lower eyelid fat pad
herniation or upper eyelid ptosis), worry or aging
(crow’s-feet). Otherwise stated, the face is malfunc-
tioning as an organ of communication.1
After ascertaining and documenting the patient’s
concerns as well as recording photographic appear-
ance, the surgeon should evaluate the facial features
for the anatomic basis of the patient’s concerns. Many
times, the patient’s concerns are related to familial,
gravitational, or age-related facial changes. The exam-
ination should also search for concurrent facial condi-
tions that may complicate management of the
patient’s concerns. For example, herniating lower eye-
lid fat pads may be accompanied by festoons, periocu-
lar skin pigmentation, tear-trough deformity, midface
descent, malar edema, skin wrinkling, and horizontal
eyelid laxity. In the upper eyelids, complicating factors
may include eyebrow ptosis, secondary eyebrow ele-
vation, eyelid ptosis, lagophthalmos, prolapse of the
lacrimal glands, asymmetrical eyelid creases or folds,
and prominent retro-orbicularis oculi fat (ROOF).
Documentation of the examination includes notation
of any complicating facial features or findings.
The next step is for the surgeon to educate the
patient regarding the anatomic basis for the patient’s
concerns as well as any relevant concurrent condi-
tions. From this discussion one can proceed to outline
the range of surgical options available that address the
underlying anatomic causes of the patient’s concerns.
One should actively solicit and receive the patient’s
feedback as to which options best meet the patient’s
needs. During this portion of the discussion it is criti-
cal that the surgeon clearly establishes, in the patient’s
mind, reasonable postoperative expectations as to
the degree of surgical improvement associated with the
various surgical options. Patients who cannot accept a
‘marked definite and noticeable improvement’ as
opposed to a ‘perfect result’ are sometimes poor can-
didates for aesthetic surgery. Informed consent regard-
ing the risks, consequences, benefits, and alternatives
of surgery consists of both a discussion with the
patient as well as a signed consent document.
Finally, it is important to keep in mind that
properly informed patients will not, and should
not, always choose the surgical option that most
effectively addresses their physical concerns. This is
because the patient must also factor in other con-
siderations, including cost, invasiveness, surgical risk,
the location and visibility of surgical incisions, recov-
ery times, postoperative morbidity, and procedure
length. Indeed, the goal is not to invariably create
the best aesthetic improvement, but rather to educate
the patients to the point that they can select those
pro cedures which best meet the patient’s aesthetic
goals while also respecting the patient’s financial
constraints, tolerance for surgical risk, and desires
regarding rapidity of recovery.
REFERENCE
1. Khan JA. Aesthetic surgery: diagnosing and
healing the miscues of human facial expression.
Ophthal Plast Reconstr Surg 2001;17:4–6.
3
Dr Khan’s viewpoint
Figure 1.4 Digital cameras. On the left is a Sony Mavica™ that uses floppy
disks for storage; on the right is a Sony Cybershot™ camera that uses
memory sticks.

5
Chapter 2
Upper Eyelid of Asians Without
Crease
Approximately half of all Asians have some form of
an upper eyelid crease; thus, there are about 50% of
Asians who do not have a crease. This seems to affect
Asians of Han origin, including the Chinese,
Koreans, Japanese, and China’s minority tribes. The
incidence within any given family appears to parallel
the above statistic in that I often elicit the history that
one of the parents has an upper lid crease whereas
the other parent does not, and this also seems to hold
true among the siblings.
In the past, the stereotypic conclusion that all Asians
are without an upper eyelid crease may stem from the
fact that Western plastic surgeons often may get to
examine only those Asians who have no crease and
therefore seek their services, although many do not.
We will describe some of the commonly observed
features in Asians who do not have a crease (Figs 2.1
& 2.2), and also, among the Asians who do have a
crease, what crease shape and size these tend to be.
Eyelid Anatomy
William PD Chen and Jemshed A Khan
Figure 2.2 Asian upper eyelid with no crease.
Figure 2.1 Cross-section of Asian upper eyelid without crease.
(Reproduced with permission from Chen WP. Asian blepharoplasty. In:
Oculoplastic surgery: the essentials. New York: Thieme; 2001:211–24.)
Sub-brow fat
(ROOF)
Orbital septum
Submuscular fat
Pretarsal fat

Asians, as compared with Americans and Euro-
peans, tend to be more petite. This is simply an obser-
vation that their body height, weight, and facial
features all tend to be lesser in dimension. The upper
tarsal plate (tarsus) of Asians usually measures only
in the 6.5 to 8mm range, with the tarsal height in the
majority, when measured over the central portion of
the upper lid, being within 6.5 to 7.5mm. The upper
border of the superior tarsus normally corresponds to
where a natural upper lid crease would sit, assuming
that this is measured in a young adult and that there
has not been any involutional change in the lid skin or
levator aponeurosis. Compared with a non-Asian’s
upper tarsus, which is often in the 9–10.5mm range,
this is a substantial difference. The critical importance
of this clinical observation has to do with the place-
ment of the height (or width as measured from the
upper eyelash margin) of the desired crease. If one were
to assume that 10 or 11mm is a standard crease and
apply it to an Asian face, the resultant look will not
be aesthetically acceptable, due to its high placement
and proximity to the mid segment of the upper eyelid
skin. Other complications, including injury to under-
lying tissues such as the septum and levator, as well
as inadvertent creation of multiple creases and
segmentation, may occur.
It has been postulated that Asians without an
upper lid crease have a lower point of fusion of the
orbital septum onto the anterior surface of the upper
tarsus, or that the lower positioning of the pre-
aponeurotic fat pad is the culprit that disrupted or
prevented crease formation. It is uncertain as to
which came first – whether the inferior point of fusion
of septum to aponeurosis is the reason for absent
crease or the lower migration of the fat. Rather,
the true reason may be multifactorial and these are
just findings by association.
There are at least four types of fat seen in the upper
eyelids:
■ pretarsal fat;
■ preseptal or suborbicularis oculi fat;
■ postseptal (preaponeurotic) or orbital fat; and
■ submuscular or sub-brow fat.
The preseptal fat of the upper lid and the sub-brow
fat seem to occupy contiguous space within the same
general tissue plane over the periorbital and supra-
brow regions. All four types of fat pads have been
observed among Asians with or without an upper lid
crease, as well as in Caucasians with crease, thus
these four types of fat are not unique to Asians. It is
just that among Asians without a crease, the inter-
mingling of these four types of fat seem to be of
a greater extent and the boundaries are much less
distinct (Fig. 2.3).
6
Chapter 2: Eyelid Anatomy
Figure 2.3 Upright view of left upper eyelid incision
showing three zones of fat pads in this Asian patient:
lowest of the three is the pure yellowish pretarsal fat
pads located in the anterior surface of the upper tarsus
and anterior to the opened orbital septum above it;
above it is the orange-pinkish vascularized
preaponeurotic (postseptal) fat pads with capillaries
running horizontally through; and the sub-brow fat pads
above the preaponeurotic fat. On top, the sub-brow fat
appears pale yellowish, and is located anterior to the
opened orbital septum. It may extend inferiorly to
become the preseptal fat.

Most Asians have some form of medial canthal
folds, even among those who have a crease. The medial
canthal fold may be present with the nasally tapered
crease (which is a shape prevalent in two-thirds to
three-quarters of those who have a crease) or with the
parallel crease shape. Both are compatible, natural,
and not pathologic at all. The majority of requests for
medial canthoplasty or epicanthoplasty or epicanthal
fold excision are based on preconceived perception or
on patients who have pathologic epicanthus associ-
ated with congenital blepharophimosis syndrome as
reported in the Western medical literature.
Lash ptosis, a secondary downward angulation of
the upper eyelashes as a result of the presence of a fold
of redundant skin over the ciliary margin, is a feature
often seen in Asians without a crease (Fig. 2.4). It
seldom causes any direct corneal touch or symp toms,
and is not to be equated with true trichi asis. Rarely,
one does see patients who have corneal touch as a result of
prominent eye position, and, even more rare, one may
see some Asians who may have very coarse, kinky or
straight upper eyelashes, as is sometimes seen in older
individuals with the floppy eyelid syndrome.
Epiblepharon is another curious finding sometimes
seen in younger Asian patients near the medial por-
tion of their lower eyelids. It may result in secondary
trichiasis and can be relieved by simple infraciliary
excision of this redundant skin–muscle fold.
Distichiasis, especially medially over the upper as
well as the lower lids, may occur and is treated by
Asian blepharoplasty of the upper eyelid without any
need for tarsal rotation; and in the lower lid by
a combination of excision of epiblepharon and/or
segmental tarsal rotation.
7
Upper Eyelid of Asians Without Crease
Figure 2.4 Lash ptosis with straight lashes pointing down.

Asians often manifest a subtle head-back position,
with the forehead-to-chin plane about 5–10 degrees
tilted backwards. Perhaps this is an adaptive head
posture to allow greater pupillary clearance with the
presence of a single eyelid’s redundant fold. We will
come back to discuss this point in the section on
postoperative management of Asian blepharoplasty
patients in Chapter 7.
Curiously, some Asians may manifest a relatively
poor upgaze in the absence of clinically noticeable
ptosis or known neuromuscular disorders. Some
other patients may have only fair or borderline levator
function; these patients may have true ptosis and this
will present a challenge when the time comes to per-
form ptosis repair as well as attempting to crease a
dynamic upper lid crease.
The above two conditions are often associated
with an overactive forehead or brow action, as a
compensatory move.
The aesthetic purposes of creating an upper lid
crease are several fold:
■ to enhance and create a visually apparent
eyelid opening, in terms of both the vertical as
well as the perceived horizontal dimensions of the
palpebral fissure size;
■ to create a more consistent platform
for the application of cosmetics, eye-shadow, and
eyeliners;
■ to correct and reverse the downward angulation
of the upper eyelashes in patients with absent
crease;
■ to improve on the vision of those who notice any
partial field block or interference in their visual
field as a result of the lashes, whether it is
secondary trichiasis, or visual awareness of the
lashes, which is like seeing through a picket fence
when they are down-turned;
■ to allow freedom from cosmetic application for
those who desire it that way; and
■ to free the patient from the continued need for
application of other non-surgical adjunctive
means in order to achieve the goals mentioned
above.
Of these, some are aesthetically based and others
have a true functional basis.
There are some patients who spend 30 minutes to
2 hours in the morning using adhesive glue, various
tissue tapes, and even physical manipulations using
wires, hairpins, and tooth picks in order to create a
temporary crease. Some have been doing it for years
and are plainly tired of it.
8
Chapter 2: Eyelid Anatomy

A nasally tapered crease tends to have a medially
converging upper lid crease that may or may not
completely join or touch the medial canthal skin
(Fig. 2.5).
A parallel crease runs parallel across the upper lid
margin, staying concentric to the upper lid margin,
but does not converge medially (Fig. 2.6).
The crease of a Eurasian may retain one of the two
Asian crease shapes but at a wider separation from
the lid margin; such subjects often have a lager tarsal
plate like their parent on the non-Asian side.
Partial crease, segmented crease, and multiple
creases (usually no more than two) are further sub-sets
of the ethnic variants and may be seen in one or in
both upper eyelids. It may create asymmetry issues
for patients when one side has this condition while
the other upper lid is either with or without a crease.
Terminology with respect to Asian lid structures
Commonly, Chinese refer to a nasally tapered crease as
an ‘inner crease’ (converging inward to inner canthus),
and the parallel crease as an ‘outer crease’ (‘away’
from inner: ‘outer’ also means to deviate from).
9
Upper Eyelid of Asians Without Crease
Figure 2.6 Asian upper eyelid with parallel crease.
Figure 2.5 Asian upper eyelid with nasally tapered crease.

Anatomy of Upper Eyelid in
Caucasians and Non-Asians
The so-called ‘Western’ or European upper eyelid is
distinguished from the ‘Asian’ upper eyelid by sev eral
anatomic differences which produce a ‘Western’
eyelid crease that is higher and more defined (Figs
2.7–2.9, Table 2.1). These differences may reflect
several features typical to the ‘Western’ eyelid:
■ absence of pretarsal descent of the preseptal fat
pad;
■ fusion of the orbital septum with the levator
aponeurosis above the tarsal plate;
■ a tarsal plate of greater vertical dimension; and
■ a lid crease that begins in the medial upper eyelid
rather than extending from the medial canthal
area.
10
Chapter 2: Eyelid Anatomy
These eyelid changes correlate broadly with racial
phenotypes. Of course, these differences represent gen-
eralizations and are only broadly representative rather
than specific to individuals of various ethnicities.
The epidermis and dermis of the human eyelid is
among the thinnest of the human body and is charac-
terized by loose underlying connective tissue and an
absence of subcutaneous fat. It is this combination of
an easily engorged layer of loose connective tissue and
the impermeable yet highly distensible overlying eyelid
skin that permits the exaggerated accumulation of
edema that characterizes the postoperative eyelid. The
upper eyelid skin is divided into a pretarsal area, a
preseptal, and a periorbital area. Since the pre septal
skin is not anchored to underlying structures, a fold of
preseptal skin often overhangs the pretarsal skin and
obscures the eyelid crease. The upper eyelid crease is
formed by an anterior leaflet of the levator aponeuro-
sis which inserts within the orbicularis oculi. In youth,
there is good apposition of the pretarsal eyelid skin to
the underlying orbicularis, levator, and tarsus.
Table 2.1: Anatomic differences between the
‘Western’ and ‘Asian’ eyelid.
Anatomic feature
‘Western’ eyelid
‘Asian’ eyelid
Preseptal fat pad
Preseptal
Preseptal and
location

pretarsal
Septum–levator
Above tarsus
As low as
fusion point

pretarsal


plane
Tarsal height
9–10.5mm
6.5–8.0mm
Medial lid
Medial eyelid
Medial
crease origin

canthus
Presence of
100%
50%
crease
Figure 2.7 Sagital cross-section of the ‘Western’ upper eyelid.
(Reproduced with permission from Chen WP. Oculoplastic surgery:
the essentials. New York: Thieme; 2001:212.)
Sub-brow fat
(ROOF)
Orbital septum

11
Anatomy of Upper Eyelid in Caucasians and Non-Asians
Human eyelid skin
■ Epidermis may be only three to four cell layers thick
■ Combined epidermis and dermis is less than 1mm
thick
■ Partially translucent
Figure 2.8 The surface features of a
youthful ‘Western’ eyelid.
Figure 2.9 The surface features of an aged
‘Western’ eyelid.

12
Chapter 2: Eyelid Anatomy
Deep to the loose subcutaneous connective tissue
layer lies the orbicularis oculi muscle (Fig. 2.10). The
orbicularis oculi serves to close the eyelids and is
divided into three contiguous portions: pretarsal, pre-
septal, and orbital. Each of these layers functions
slightly differently, as is demonstrated by their differ-
ing origins and insertions. The muscle of Riolan is a
specialized portion of the pretarsal orbicularis oculi
that corresponds to the gray line and helps to main-
tain eversion of the eyelashes.
Figure 2.10 The orbicularis oculi and
muscles of facial expression. (Reproduced
with permission from Chen WP. Oculoplastic
surgery: the essentials. New York: Thieme;
2001:5.)
Frontalis muscle
Orbicularis oculi
muscle
Infraorbital nerve
Levator labii superioris
Zygomaticus minor
muscle
Zygomaticus major
muscle
Supraorbital
artery and nerve
Supratrochlear
nerve
Temporal branch
of facial nerve
Zygomatic
branches of
facial nerve
Buccal
branches
of facial nerve
Mandibular
branch of
facial nerve
Cervical
branch of
facial nerve

13
Anatomy of Upper Eyelid in Caucasians and Non-Asians
Posterior to the orbicularis oculi muscle is the sub-
muscular fascia (also termed the retro-orbicularis
fascia and the orbicularis fascia). Running within this
well-defined surgical plane are vertically oriented
blood vessels and the motor and sensory nerves to the
orbicularis and skin. This fascia creates a moderate
adherence between the orbicularis and the underlying
septum or levator aponeurosis. This fascial plane may
be readily divided with strong traction and sharp
dissection – thus dividing the eyelid into anterior
and posterior lamellae (Fig. 2.11).
Figure 2.11 Cross-section of upper lid, showing
orbital septum, preseptal fat, and preaponeurotic
(postseptal) fat. (Reproduced with permission
from Chen WP. Oculoplastic surgery:
the essentials. New York: Thieme; 2001:4.)
Conjunctiva
Superior tarsus
Levator aponeurosis
Müller's muscle
Orbicularis oculi muscle
Preseptal fat (ROOF)
Orbital septum
Preaponeurortic fat
Frontalis muscle
Deep galea
Superficial galea
Anterior and posterior
deep galea
Inferior tarsus
Orbital septum
Orbital fat
Orbicularis muscle
Malar fat pad
Suborbicularis oculi
fat (SOOF)
Inferior tarsal muscle
Capsulopalpebral
fascia (CPF)
Sub-brow fat pad (ROOF)

The orbital septum (septum orbitale) restrains the
central preaponeurotic fat and nasal fat pad of the
upper eyelid both anteriorly and inferiorly (Fig. 2.12).
In the ‘Western’ upper eyelid, the inferior extent of
the orbital septum fuses with the levator aponeurosis
at the height of the upper border of the tarsal plate. It
is the fusion of these two structures that is believed
to limit the inferior descent of the preponeurotic fat
pads. Hence, the relatively high point of fusion of
the aponeurosis and levator in the ‘Western’ eyelid
contributes to a broader and higher visible pretarsal
platform than is seen in the ‘Asian’ eyelid.
The levator palpebrae superioris is the retractor of
the upper eyelid. The distal 14–20mm of the levator
muscle is tendinous. The transition from skeletal mus-
cle fibers to glistening white aponeurosis occurs at the
level of Whitnall’s ligament. Beyond the point of
fusion with the orbital septum, the aponeurosis con-
tinues inferiorly to insert onto the tarsal plate, pretar-
sal orbicularis oculi, and pretarsal eyelid skin – thus
maintaining apposition of the anterior and posterior
eyelid lamella below the eyelid crease. The medial and
lateral horns of the levator muscle are attachments
towards the medial and lateral canthi.
14
Chapter 2: Eyelid Anatomy
Figure 2.12 This well-defined plane of the orbital
septum is revealed following removal of the overlying
skin and preseptal orbicularis oculi.

The orbital and palpebral lobes of the lacrimal
gland straddle the lateral segment of the levator mus-
cle (Fig. 2.13). The tarsal plate of the upper eyelid
is 9–10.5mm high and 29mm wide in the ‘Western’
eyelid. Extending from the lateral commissure to
the punctum medially, the tarsus is anchored by
the medial and lateral canthal tendons. These three
structures (the tarsus and the canthal tendons) form a
tarsoligamentous band or sling that helps maintain
apposition of the upper eyelid to the globe. The tarsus
contains the meibomian glands and their orifices.
Müller’s sympathetically innervated smooth muscle
arises from the undersurface of the levator palpebrae
superioris and descends 15mm to insert on the supe -
rior border of the tarsus. Müller’s muscle provides
2–3mm of eyelid lift in primary gaze.
Müller’s muscle and the tarsus are lined posteriorly
by the tarsal and palpebral conjunctiva. The conjunc-
tiva is rich in mucus-secreting goblet cells. Access-
ory lacrimal glands of Krause and Wolfring reside
between the upper tarsal border and the superior
fornix. Laterally, the superior fornix is penetrated by
the lacrimal gland ductules.
15
Anatomy of Upper Eyelid in Caucasians and Non-Asians
Figure 2.13 Lateral portion of upper lid, showing
lacrimal gland. (Reproduced with permission from
Chen WP. Oculoplastic surgery: the essentials.
New York: Thieme; 2001:17.)
Orbital lobe
of lacrimal gland
Palpebral lobe
of lacrimal gland
Ductules
Levator
aponeurosis

Anatomy of the Lower Lid
Clinically, we do not observe a significant difference
between the lower eyelid of Caucasians, Blacks,
16
Chapter 2: Eyelid Anatomy
Hispanics and that of Asians; therefore it will be dis-
cussed as one topic. The anatomy of the lower eyelid
is very ill defined and is best shown using a series of
layered illustrations (Figs 2.14–2.22).
Figure 2.14 The facial changes and cheek
laxity that occur with aging.

17
Anatomy of the Lower Lid
Figure 2.15 The periorbital foraminas, where nerves and blood vessels
exit at the deepest plane. (Reproduced with permission of Dr Clinton
D McCord, Jr)
Zygomatic facial nerve
and vessels
Infraorbital
nerve and
vessels
Figure 2.17 The next layer of tissues, which is the suborbicularis oculi fat
of the lower eyelid. It extends to the brow and becomes the retro-
orbicularis oculi fat (ROOF) under the upper lid. (Reproduced with
permission of Dr Clinton D McCord, Jr)
SOOF
ROOF
Figure 2.18 The next layer, comprising the pretarsal, preseptal, and
periorbital orbicularis oculi muscles. It functions as a closure muscle for
the eyelids. (Reproduced with permission of Dr Clinton D McCord, Jr)
SOOF
Orbicularis
Figure 2.16 The origins of the deep mimetic muscles in the area of the
maxilla. (Reproduced with permission of Dr Clinton D McCord, Jr)
Zygomaticus
major, minor
Levator labii
superioris
Levator labii
superior
ala nasi
Levator
anguli oris

18
Chapter 2: Eyelid Anatomy
Figure 2.19 The deep portion of the malar fat pads lying over the
orbicularis muscles. It is just under and permeated by the superficial
musculo-aponeurotic system (SMAS). (Reproduced with permission of
Dr Clinton D McCord, Jr)
(pre-orbicularis)
Deep portion of
malar fat pad
Figure 2.20 The location of the midfacial extent of the superficial
musculo-aponeurotic system (SMAS). It lies over the deep portion of the
malar fat. The superficial portion of the malar fat lies over the SMAS. The
SMAS is blocked inferiorly by the nasolabial fold. (Reproduced with
permission of Dr Clinton D McCord, Jr)
(pre-SMAS)
Superficial portion
of malar fat)
Nasolabial
fold
SMAS
Figure 2.21 Overlying skin and formation of the nasolabial fold.
(Reproduced with permission of Dr Clinton D McCord, Jr)
Nasolabial fold
Skin
Figure 2.22 The orbital malar ligament. It originates from the orbital rim
and combines with (and is considered to be part of) the superficial
musculo-aponeurotic system. (Reproduced with permission of Dr Clinton
D McCord, Jr)
Orbital fat
SOOF
Orbito-malar ligament

19
Chapter 3
Dr Chen’s Preoperative Regimen
For cosmetic blepharoplasty, Dr Chen routinely pre-
scribes 10mg of Valium plus one tablet of Vicodin
at 60–90 minutes prior to the procedure. This allows
a good period of time for the sedative and analgesic
effect to take place. Patients may have been nervous
and sleepless the night prior to coming in, or they
may have had to travel from a distance, and most will
enjoy the relaxation.
About 10 minutes before the scheduled time, he
greets his patient and goes through the following
check list:
1. Reaffirm the physical findings previously
observed and discussed with the patient.
2. Reaffirm the goals of the patient for the surgery
that day.
3. Ask if there are any unanswered questions.
4. Take photographs.
The patient is positioned on the operating table in
a supine position. A soft foam cushion headrest as
well as knee and back support are provided. The
nursing staff attach the appropriate monitoring leads,
including electrocardiographic, pulse oximetry, as
well as grounding pads for monopolar cautery or a
radiofrequency transmitter lead.
Intraoperative Regimen
Dr Chen uses 2% xylocaine with 1:100 000 epine ph-
rine, mixing 10mL with 150 units of hyaluronidase, if
available. He then mixes 1mL of the 2% xylocaine
with 9mL of injectable saline to yield a relatively
painless injection (pH balanced, diluted to 0.2%
xylocaine and 1:1 000 000 epinephrine).
A dose of 0.5mL of 0.2% xylocaine is applied
subcutaneously per eyelid. He then waits 2 minutes.
Clinical blanching of the skin is observed. Further
infiltration of about 0.75–1.5mL of 2% xylo caine
(full concentration) per eyelid is then given
submuscularly.
A drop of proparacaine is applied per eye for
top ical anesthesia of the cornea, conjunctiva, and
inner surface of the eyelids. The nursing staff prepare
the operative field with the appropriate disinfective
soap or solutions.
Via a pre-placed butterfly, intravenous aliquots
of Versed (midazolam) 0.5mg may be utilized, should
further sedation be necessary. Nasal oxygen or room
air may be supplied.
Surgical drapes are applied. Dr Chen uses
paper drapes as well as an operculated 3M #1020
adhesive drape to minimize any potential gaseous
communication between the operative field and the
rest of the face under the paper drape. A drop
of tetracaine is applied per eye for longer lasting
effect.
A black corneo-scleral shell that conforms to the
curvature of the cornea and sclera is lubricated with
sterile Lacrilube ophthalmic ointment and then
applied over the eye to be operated on. The procedure
commences.
Ice-cold saline solution is used on the operative
field.
In selected patients or those who prefer a deeper level
of conscious sedation or general anesthesia, the use of
an anesthesiologist may be prearranged. This category
includes those patients who required cheeklift/midface
repositioning, as well as a significant number of those
requiring revisions.
Preoperative Regimen of Dr Khan
Most incisional cosmetic procedures are performed
in an ambulatory surgery center where monitored
anesthesia care is delivered by certified registered
Preoperative Preparation,
Anesthesia, and Postoperative
Considerations
William PD Chen and Jemshed A Khan

nurse anesthetists (CRNA). Patients are greeted and
reassured preoperatively and the procedures are con-
firmed. In the preoperative holding area, supplemen-
tal oxygen is provided via nasal cannulae, pulse
oximetry and cardiac telemetry are monitored and a
heparin lock is placed for intravenous access. In the
holding area, patients are rendered amnestic and
briefly unconscious with intravenous Versed and
Propofol prior to injection with local anesthetic.
Usually, the local anesthetic consists of lidocaine 2%
with epinephrine 1:100 000 mixed 1:1 with Marcaine
0.75%.
In the operating room, the patient is prepped and
then draped with cloth towels. Metal protective eye
shields and wet cloth towels are placed if CO2 laser is
to be used. Supplemental oxygen is provided via
nasal cannulae, and pulse oximetry, blood pressure
monitoring, and cardiac telemetry are continued.
Propofol is delivered intraoperatively by the CRNA,
if needed. In patients in whom deeper levels of seda-
tion or even unconsciousness are required, supple-
mental oxygen is delivered to the nasopharynx via a
nasal trumpet so as to maintain pO2 levels despite res-
piratory depression. This technique allows CO2 laser
resurfacing to be performed without any local anes-
thetic or endotracheal intubation. Supplemental local
anesthetic is often used intraoperatively.
For in-office upper eyelid blepharoplasty, anesthetic
discomfort is reduced when each eyelid is pre-injected
subcutaneously with 0.75mL solution lidocaine 2%
with epinephrine 1:100 000 mixed 1:1 with non-
preserved saline. This is followed by an injection of
0.75mL lidocaine 2% with epinephrine 1:100 000.
The subcutaneous anesthetic bolus is then milked and
manipulated to cover the entire surgical site.
Following surgery, erythromycin ophthalmic oint-
ment may be placed on the eyes or incisions. Patients
generally are recovered and discharged within 30
minutes. The eyes and incisions are not usually
patched. Stitches (usually 6-0 Prolene) are usually
removed 9–12 days after surgery.
Postoperative Considerations
The following is a sample of Dr McCord’s
postoperative instructions for his patients:
Scars
Incisions for a blepharoplasty are made in the natural
crease of the upper lid, which disguises the final thin
scar so that one would have to look very closely
in the mirror to determine where an incision had
been made, if one can see it at all. In the lower lid,
the skin incision is made as close as possible beneath
the lash line, and many times extends past the corner
of the eye for several millimeters if needed. These
incisions leave imperceptible scars. The only area of
incision that may be noticeable for a period of time is
the outside corner of the eye, in the laugh line area.
Some people may require a longer incision or stitch
line at the outside corner of the eye in a slightly
downsloping direction. This is needed so that the skin
may be tensed in the proper way to get good cheek-
bone definition, and this is true particularly if they
have extra folds in the lower cheekbone or mid cheek
area. If it is necessary to carry the incision into this
area, there usually occurs a small red line, which will
fade with time. If one does require an incision above
the eyebrow, as will be discussed with the direct brow
lift, the incision line is more conspicuous but can be
covered with cosmetics until the incision line fades.
Although it is unusual to have to do so, dermabrasion
can smooth out incision lines that are more conspicu-
ous than one would like, if they do not smooth out
on their own. Incisions behind the hairline leave no
visible scars and, with the newer techniques, little if
any hair loss.
It is important to understand the natural history of
healing and scar formation. Tissue glue causes
enough healing within a week or 10 days such that
the incision is strong enough and the stitches can be
removed at that time. The incision lines, however,
then begin to ‘knit’. This process includes the
ingrowth of many blood vessels, extracellular mate-
rial, and other tissue that goes into those areas to
strengthen the tissue. During this period of ‘knitting’
(5–6 weeks), the incision lines will become tight,
firm, and reddened, which is the body’s response to
any cut or incision. This process may not be notice-
able to other people but may be noticeable to the
patient, and is more a source of frustration than any
discomfort. When the body finally recognizes the fact
that the tissues are healed enough to suit its purpose
20
Chapter 3: Preoperative Preparation, Anesthesia, and Postoperative Considerations

(6–7 weeks), the extra blood vessels and cellular mate-
rial will leave and the incision lines will soften, bleach,
and then fade. The maximum relaxation occurs in
about 4 to 5 months. During this period of time – or,
for that matter, any time after – it is extremely
important to avoid any sunburn or exposure to ultra-
violet light in those areas, as this may aggravate and
intensify the activity in the incision line.
Stitches
The stitches used are generally nylon stitches or very
fine silk sutures, which are removed in 5 to 7 days.
Immediately after removal of the stitches, no creams
or cosmetics should be used, to avoid tiny cysts that
may form along the stitch tracks. About 7–10 days
must go by to allow smoothing over of the stitch
holes; after this time, one may use cosmetics and
cover-up creams, if desired, over the incision lines.
Surgical staples or the mini screws associated with
the endoscopic eyebrow–forehead lift are usually
removed at 10–14 days.
Anesthesia
For the standard eyelid surgery – either upper lids or
lower lids by themselves, or upper and lower lids at
the same time – usually the surgery can be done with
deep sedation (twilight sleep) and local anesthesia
that numbs the eyelids. Most people sleep through
the procedure. Dr McCord prefers general anesthesia.
If one is going to have eyelid surgery combined with
the mini-lift of the forehead, or a cheeklift performed
with a lower lid blepharoplasty, then a very light ‘gen-
eral’ anesthetic is preferred because of the length of
the procedure and patient comfort. These procedures
can easily be performed on an outpatient basis;
however, some people may elect to spend the night
after surgery in hospital, for which most hospitals
will provide a special rate.
What to expect immediately after surgery
Accentuated appearance
It is normal in the lower lid to have an accentuated
tightness in the outside corners, giving an upslant
appearance, in the immediate postoperative period
and for a while thereafter (usually 3–4 weeks). This
is necessary because of the need to strengthen the
lower lid tendon to prevent a pulling down of the
lower lid in the swollen period after surgery. This
appearance is temporary, but is necessary to prevent
the complication of scleral show (excessive white
showing under the eye).
Bruising and swelling
There is great variation among individuals with
regards to bruising and swelling. It is very rare for
a person to get no bruising or swelling at all.
Most people will have a puffy and purplish appear-
ance to the eyelids. With the ‘standard amount’ of
bruising and swelling usually seen, most people are
presentable for public appearances (with make-up) in
10–14 days.
It is very important for patients to avoid all medica-
tions containing aspirin, aspirin-like medications, or
any true blood thinners before surgery and for a week
after surgery. It is also important to have their blood
pressure controlled, in that if the blood pressure is
elevated at the time of surgery, they will most certainly
bruise more. The most important thing to do to
reduce postoperative bruising and swelling is to use
ice compresses continuously for the first 48 hours
after surgery and as much as possible thereafter. On
no occasion should heat compresses be applied to the
eyelids during this period. Sometimes, before and after
surgery, special medications are given, such as low-
dose cortisone, to help prevent the tissue reacting so
much to the surgery.
Eye lubrication and blurred vision
Our main concern for the health of the eye is the pre-
vention of ‘dry spots’ that can occur after surgery.
Because there will be some ‘tightness’ of the eyelids
following surgery, we require the patient to apply
lubricants to his or her eyes, particularly at nighttime,
to avoid any dryness or symptoms of dryness. All tear
production is examined before surgery; however, in
some rare situations, a person may be required to use
lubricating drops after surgery to allow his or her
eyes to be comfortable. Immediately after surgery,
we prefer the use of ointments, which are much
more effective at preventing dry spots; however, most
people do not like them because they do blur the
vision. This extra lubrication is needed right after the
21
Postoperative Considerations

operation for protection of the eye from dry spots
and chemosis. To reduce postoperative chemosis, we
apply a 6-0 nylon tarsorrhaphy suture through the
upper and lower tarsal plates 1mm lateral to temp o-
ral limbus prior to completion of the case. After the
stitches are removed, one can, in most cases, switch
to artificial teardrops, which do not blur the vision.
Physical activity
The first 2 days are completely devoted to ice com-
presses and head elevation and remaining quiet.
Walking around and sedentary activity can take place
following the first 2 days until suture removal. The
ice compresses can be used intermittently during this
period (usually 30 minutes, four to five times a day).
It would be possible to drive a car during this period
if there was a definite need; however, the vision will
be very blurred from the use of the ointment and the
stiffness of the eyelids. There should be no exercise
(aerobics, jogging, etc.) the first week. In the second
week, no exercise should occur that places a strain on
the incisions; however, some walking and stretching
can be done.
Only after the first 2 weeks should exercise that
raises the heart rate be undertaken. The ‘extra blood’
that may be pumped through the operated area might
cause swelling. If this occurs, then the patient should
stop and apply ice to the area.
Common patient worries
The two things that generally concern people the
most immediately after surgery are:
■ body image; and
■ blurred vision.
Body image Most people have a puffy and purp-
lish look to their eyelids immediately after surgery.
There will also be the overly tight or very tense look
in the corners of their eyes if they have had lower lid
surgery. This appearance can cause initial ‘patient
remorse’ since they may not have seen themselves
with this appearance unless they have had previous
surgery. This is, of course, the normal appearance
following this type of surgery, and, with time, the
puffiness and bruising will go away and their eyelid
contours will resume to the desired appearance.
Blurred vision Immediately after surgery, the pa-
tients’ vision will be blurred to the point that they will
not be able to read very well. The reasons are that
their eyelids, which are basically windshield wipers,
will be stiff for a period of time and will not be able
to wipe (their cornea) properly. Also, they will be
using lubricating ointment in their eyes to prevent dry
spots, which will add to the blurring.
It is very important that the patient’s family or
those who will be caring for the patient after surgery
know and expect these changes so they will not have
concern.
Safety With Blepharoplasty Surgery
Our goal is to try to have the happiest patient possi-
ble following surgery, with the best possible improve-
ment in the person’s appearance, but not at the
expense of eye safety. The eyelids are not decorations
and their purpose is to protect the eye. They must
function properly following any eyelid surgery. There
is always some stiffness after eyelid surgery of this
type, which may persist for a while; however, patients
who have good eye moisture and good eye move-
ments usually do fine. Many patients do use some
artificial teardrops after surgery. Our approach is to
be safe and conservative in the amount of skin that is
removed. If there are some residual folds after healing
(not quite enough skin taken), they can easily be
trimmed later in the office. If too much skin is
removed, it is not an easy situation to rectify, as this
may require skin recruitment from elsewhere.
Secondary Surgery or ‘Touch-up’
Surgery
For primary patients who require secondary or
‘touch-up’ surgery, if it seems appropriate, there is no
surgical charge, but medical supplies (stitches, etc.) are
charged for. If it is established that there is no con-
traindication, residual folds can be removed, or, if
needed, adjustment of the lower lid can be done. The
most common touch-up is removal of folds of skin in
the upper lid at the outside corner just under the brow,
or adjustment of the outside corner of the lower lid. If
the adjustment is more than minor, it must be done on
an outpatient basis at a surgical facility.
22
Chapter 3: Preoperative Preparation, Anesthesia, and Postoperative Considerations

Complications of Surgery
Fortunately, there are few true complications – most
of the postoperative concerns are whether or not to
do any ‘touch-up’ work – however, it is important to
discuss here some of the complications associated
with any eyelid surgery. A very serious complication
would be some unfavorable reaction to the anesthetic
medicine, either the local or the other agents that are
used. Eyelid complications, as mentioned before, are
usually a lower lid pull down or out turning follow-
ing surgery, owing to shrinkage of skin or excessive
skin removal in that area. This is much more of a risk
in people who have extremely lax lower lids and can
be aggravated if, in addition, the person has serious
bruising or hematoma formation. In such people,
additional tightening of the ligaments in the lower lid
is deemed necessary to prevent this complication.
Other possible complications include infection and
hemorrhage.
Insurance Claims and Office Policy
Patients should not expect any insurance company
to pay the surgical fee for surgery that may be con-
sidered cosmetic or medically unnecessary in nature.
If patients feel that they would like to involve
their insurance company, they are strongly advised
to attempt to get a ‘prior approval’ from such.
Unfortunately, many insurance companies will only
give equivocal statements regarding possible future
coverage of surgery. If, in the ‘prior approval’, the
insurance company indicates a specific amount they
will pay for the surgery, then that amount will be sub-
tracted from the patient’s presurgical deposit. If the
insurance company will not commit to a definite
amount, then the patient will be responsible for the
full surgical deposit, and, after surgery, any amount
the insurance pays will be reimbursed to the patient.
Other Interested Parties
As mentioned previously, in many cases a spouse
or close friend will be involved in a patient’s post-
operative care and observe the patient in his or her
postoperative course. If they have not had the oppor-
tunity to make the preoperative consultation visits
with the patient, they will be unfamiliar with the
usual side effects of surgery and what is normal after
surgery. For their awareness, they should read the
information sheets provided. In most cases, it may be
appropriate for them to see the preoperative videos in
the office or have consultation with the surgeon
before surgery, for better understanding of blepharo-
plasty surgery and its possible postoperative side
effects.
23
Other Interested Parties

25
Chapter 4
The upper lid and the eyebrow behave as a unit and
are interdependent. Commonly, eyebrow procedures
are needed for stabilization before performing the
upper lid blepharoplasty. Because of this sequence,
the eyebrow procedures are discussed first.
Normally, eyebrows are positioned above the level
of the superior orbital rim, but, with age, may
migrate below the rim, causing redundancy and fold-
ing of the upper eyelid skin. This process also pro-
duces a narrowed spacing between the eyebrow hairs
and the lashes, which can cause a frowning appear-
ance in the patient. The mechanics of brow ptosis are
similar to those of a curtain rod that has loosened and
fallen, causing folding in the curtain.
It is important to recognize the problem of eyebrow
laxity before performing upper lid blepharoplasty,
because failure to correct brow laxity or displacement
before the blepharoplasty will impair the result.
The aim of upper lid blepharoplasty is to remove
redundant skinfolds and produce a clear strip of skin
above the eyelash line (the eye-shadow space in females).
In order for the surgeon to achieve this, any pre-existing
laxity or ptosis of the eyebrows must be surgically cor-
rected. Eyebrow procedures, in most cases, must be
performed before the blepharoplasty procedure.
Anatomy
It is important to have firm knowledge of anatomy in
the eyebrow area to avoid complications and to pro-
duce the best possible result with eyebrow surgery.
Appreciation of the anatomic relationship of the
frontal branch of the facial nerve to the fascial layers
is important to define the safe level of dissection for
protecting the nerve when operating in the brow and
temporal region.
Endoscopic-assisted Eyebrow
Surgery
Clinton D McCord Jr

Fascia and attachments
There are three fascial layers in the temporal region
that are important landmarks for localization of the
frontal branch of the facial nerve. The superficial
temporal fascia is the most superficial layer. The deep
temporal fascia is made up of a superficial layer and a
deep layer (Fig. 4.1).
The superficial temporal fascia is the layer that
contains the frontal branch of the facial nerve on its
deep subaponeurotic surface. This layer represents an
extension of the submuscular aponeurotic system
(SMAS). The subaponeurotic plane consists of loose
areolar tissue that separates the superficial temporal
fascia from the deep temporal fascia. The subapo-
neurotic plane is avascular and extends inferiorly to
the zygomatic arch. The temporal region of the subap-
oneurotic space and the subperiosteal space are
connected by division of the periosteal reflection
along the superior temporal line that marks the origin
of the deep temporal fascia. This transition zone lies
along the anterior crest of the temporal bone.
The deep temporal fascia is a dense double-layered
fascia covering the temporalis muscle. The temporal
line of fusion is a transverse line at the level of the
superior orbital rim, extending laterally over the fas-
cia, and represents fusion of the two layers superior
to this line. The fascia is separated inferior to the line
by the superficial temporal fat pad, which is located
between the superficial and deep layers of the deep
temporal fascia and extends to the level of the zygo-
matic arch. The deep temporal fat pad lies beneath
the deep temporal fascia 2cm above the zygomatic
arch and overlies the temporalis muscle and tendon;
it is an extension of the buccal fat pad through the
zygomatic arch.
26
Chapter 4: Endoscopic-assisted Eyebrow Surgery
Figure 4.1 (A) The fascial and muscular planes in the scalp
and forehead area. The course of the frontal branch of the
facial nerve is shown traveling through the superficial
temporal fascia. (Reproduced with permission from Chen
WP. Oculoplastic surgery: the essentials. New York: Thieme;
2001:127.)
Galea
Periosteum
Superficial
temporal
fascia
Temporal fusion line
Frontalis muscle
Fusion point
(orbital ligament)
Frontal branch
facial nerve
Deep temporal
fascia
A

27
Anatomy
Figure 4.1 (B) On the temporal side of the face, the galea aponeurosis covers the fascia of the temporalis muscle as the superficial temporal fascia
(SMAS, superficial musculo-aponeurotic system). Just superior to the zygomatic arch, the temporal branch of the facial nerve and the anterior branch
of the superficial temporal artery lie within this plane of the SMAS. The galea splits into the superficial and deep temporal fasciae (DTF) at the superior
origin of the temporalis muscle on the skull. Further inferiorly, at the line of fusion, the deep temporal fascia splits into a superficial and a deep layer, with
both attaching to the zygoma. The superficial temporal fat pad lies deep to the superficial layer of the DTF, whereas the deep temporal fat pad beneath
the deep layer of the DTF is a superior extension for the buccal fat pad. Below the zygoma, the parotid gland lies between the SMAS and the masseter
muscle. Further inferiorly, the SMAS is contiguous with the platysma muscle. The masticatory muscles of the temporalis and medial pterygoid insert
onto the medial side of the mandible, whereas the masseter inserts onto the lateral side. (Reproduced with permission from Chen WP. Oculoplastic
surgery: the essentials. New York: Thieme; 2001:127.)
Temporal fusion line
(orbital ligament)
Superficial
layer DTF
Deep layer DTF
Temporalis muscle
Deep temporal fat pad
(buccal fat pad)
Medial pterygoid muscle
Superficial temporal
fat pad
Mandible
Masseter muscle
Platysma muscle
(continuous with SMAS)
Galea
aponeurosis
Scalp skin
Deep
temporal
fascia
(DTP)
periosteum
Temporal branch
facial nerve
Anterior branch superficial
temporal artery
Parotid duct
Parotid gland
Buccal branch
facial nerve
Superficial temporal fascia
(SMAS) galea
Sub-aponeurotic
plane (loose-areolar)
Zygomatic arch
B

28
Chapter 4: Endoscopic-assisted Eyebrow Surgery
The galea is contiguous with the superficial tem-
poral fascia, and the periosteum of the skull is con-
tinuous with the deep temporal fascia. The con fluence
of these fascial planes to the skull and attachment to
the brow tissue have a characteristic configuration
known as the fusion line and orbital ligament. This
confluence produces a vertical band 5–6mm wide just
medial to the temporal fusion line of the skull, which
has a continuation as the superior temporal line. In
this area, the deep layers of the superficial temporal
fascia and the galea are bonded to the periosteum and
fixed to the bone (Fig. 4.2). At the edge of the orbital
rim in this fusion line is a fibrous band attached to
the bone, called the orbital ligament, which can limit
superficial temporal fascia movement and effectively
tethers the lateral eyebrow to the orbital rim.
Figure 4.2 The insertion lines of the fascia planes on the
skull in the placement of the temporal fusion line and
orbital ligament. (Reproduced with permission from Chen
WP. Oculoplastic surgery: the essentials. New York:
Thieme; 2001:127.)
Inferior
temporal line
Temporal fusion line
(orbital ligament)
Superior
temporal line
Parietal
bone
Temporal
bone
Zygomatic
bone

29
Anatomy
Motor and sensory nerves
The frontal branch of the facial nerve provides motor
innervation to the frontalis and corrugator muscles.
The course and depth of the nerve has been well
defined and extends along a line beginning 0.5cm
below the tragus to 1.5cm above the lateral aspect of
the brow.
The frontal branch lies within the superficial tem-
poral fascia as it traverses the zygomatic arch, and is
at greatest risk for injury at this level.
Superior to the zygomatic arch, the nerve is super-
ficial to the superficial layer of the deep temporal
fascia, within the superficial temporal fascia.
The supratrochlear and supraorbital nerves provide
sensory innervation to the scalp, forehead, and eyelid
region. The ophthalmic (V1) division of the trigeminal
nerve traverses the cavernous sinus and enters the orbit
through the superior orbital fissure. The ophthalmic
nerve has three divisions: frontal, nasociliary, and
lacrimal. The frontal nerve runs along the superior
aspect of the orbit and divides into the supratrochlear
and supraorbital nerves. The supratrochlear nerve
emerges from the medial aspect of the superior orbital
rim and provides sensory innervation to the glabella,
medial forehead, medial upper eyelid, and conjunc-
tiva. The supraorbital nerve exits the orbit in the cen-
tral aspect of the superior orbital rim most commonly
through a notch. A true supraorbital foramen exists
as an anatomic variant in 25% of orbits. The supra-
orbital nerve provides sensory innervation to the scalp,
lateral forehead, lateral upper eyelid, and conjunctiva.
Muscles of animation
The musculature in the forehead and brow that con-
tributes to animation in the forehead and glabella
region includes the frontalis, procerus, and corruga-
tor supercilii muscles (Fig. 4.3).
The frontalis muscle travels above the galea and is
the elevator of the eyebrow and glabella area. Its
insertion does not extend past the fusion line and has
reduced effect in the lateral brow. It is a paired muscle
that is an extension of the galea aponeurotica and
occipitalis muscle. The vertically oriented fibers insert
into the supraorbital dermis and elevate the eyebrow
during contraction. Increased frontalis activity, which
is needed to maintain an elevated brow position in
response to brow ptosis, can cause transverse lines
across the forehead. The frontalis muscle is a primary
brow elevator and should therefore not be weakened
during a procedure aimed at brow elevation.
The procerus muscle is a midline muscle that
originates from the nasal bones and upper lateral
cartilages. The vertically oriented fibers insert into the
dermis of the glabella at the medial border of the
frontalis. Contraction of the procerus causes inferior
and medial displacement of the medial eyebrow and
a transverse line at the nasal radix. The procerus
muscle has innervation from the buccal branch of
the facial nerve. The procerus is a primary brow
depressor and therefore should be weakened to
achieve medial brow elevation.
The corrugator supercilii muscle is a paired muscle
that originates from the periosteum of the superior
medial orbital rim. The fibers are oriented in an
oblique direction, inserting into the dermis of the
medial eyebrow skin with lateral interdigitations with
the medial portion of the orbicularis oculi muscle.
Contraction of the corrugator muscles causes inferior
and medial displacement of the eyebrow and the ver-
tical oblique lines of the glabella. Weakening the
medial portion of the corrugator contributes to
medial brow elevation and correction of glabellar
frown lines. The lateral portion of the corrugator is
felt to produce slight lateral brow elevation and
should be preserved. Motor innervation of the cor-
rugator is from the frontal branch of the facial nerve.
Figure 4.3 The protractor muscles of the brow and eyelid area. The
corrugator and procerus muscles together with a portion of orbicularis
nasally are brow depressors. Laterally, orbicularis fibers act as depressors
of the tail of the brow. (Reproduced with permission from Chen WP.
Oculoplastic surgery: the essentials. New York: Thieme; 2001:128.)
Corrugator
Orbicularis
(orbital and preseptal)
Procerus

30
Chapter 4: Endoscopic-assisted Eyebrow Surgery
Changes in the Eyebrow with Age
The development of eyebrow laxity and ptosis with
aging is attributed to the progressive laxity of the
scalp and forehead soft tissues over time. This mech-
anism, aided by gravity, can produce an overall sym-
metrical downward displacement of the eyebrow
with narrowing of the spacing between the eyebrows
and eyelashes (decreased brow–lash distance). There
are specific forces and tissue conditions in the lateral
and nasal eyebrow that may allow selective depres-
sion of those areas. In the lateral portion or tail of
the eyebrow, the force of orbicularis contracture, and
increased mobility, allowed by fatty layers in the area,
are added to the forces of gravity and laxity, causing
more selective brow ptosis in that area. In the nasal
portion of the brow, the depressor muscles, corru-
gator supraciliaris, and procerus, together with con-
tracture of some local orbicularis fibers, serve to
counteract the lifting effect of the frontalis muscle
and bring the nasal brow downward (Fig. 4.4). The
shape of the eyebrow is usually more arched in
females and flatter in males, and may remain so
with age.
Figure 4.4 The normal brow spacing and position (left)
and the downward displacement of the brow from
forces counteracting the frontalis muscle elevation
(right). (Reproduced with permission from Chen WP.
Oculoplastic surgery: the essentials. New York: Thieme;
2001:131.)
Standard brow–lash distance
Narrow brow–lash distance
Laxity and gravity
Corrugator
contracture
Orbicularis
contracture

31
Endoscopic-assisted Eyebrow Forehead Lift
Endoscopic-assisted Eyebrow
Forehead Lift
In recent years, it has been more common to perform
the eyebrow forehead lift with endoscopic assistance
through small incisions. I use this procedure primar-
ily in females for correction of ptosis in the nasal two-
thirds of the brow and the frowning contracture lines
in the glabellar area. I also use this procedure, usually
supplemented with an internal browpexy performed
through an upper blepharoplasty incision, to correct
ptosis or laxity in the lateral third of the brow.
Surgical technique and instrumentation
Instrumentation includes a camera and video equip-
ment, endoscope, light source, retractor, and endo-
scopic surgical instruments (graspers and periosteal
elevators with varying curves). These instruments are
used to create the subperiosteal optical space, in
which the procedure is performed. The development
of this space is the primary requirement in endoscopic
surgery, and visibility is maintained by a retractor-
mounted endoscopic system (Fig. 4.5).
Figure 4.5 Endoscopic system and instrumentations.
(A) Variety of periosteal elevators, insulated grasper,
insulated scissors and endoscope in irrigating sleeve.
(B) Endoscope and detached irrigating sleeve, and
endoscope in irrigating sleeve. (Instruments courtesy of
Snowdon Pencer.) (Reproduced with permission from
McCord CD. Eyelid surgery: principles and techniques.
Philadelphia: Lippincott-Raven; 1995:369.)
A
B
4.1

32
Chapter 4: Endoscopic-assisted Eyebrow Surgery
Various camera systems include one-chip, three-
chip, and digital formats. The video cart setup gener-
ally includes a high-resolution video monitor, VCR
and printer, camera source, and a light source with
fiberoptic attachment to the endoscope. The currently
available endoscopes are rigid, glass, Hopkins rod-
type endoscopes. Because the size of the optical cavity
that can be created during endoscopic brow lift is
limited, the 5mm external diameter endoscope size is
recommended. Various angles of visualization with
the endoscope are available, but the 30-degree down-
ward view is most commonly used to view the ana-
tomy in the supraorbital region. The optical cavity
is maintained through tissue retraction using the
retractor-mounted endoscopic system or with the use
of a special sleeve or spoon that extends beyond the
end of the endoscope (Fig. 4.6).
The patient is placed on the operating table with
the head extended slightly beyond the headrest, to
facilitate clearance for the use of the endoscope
and instruments. The procedure is usually performed
under general anesthesia. Generous infiltration with
0.25% Xylocaine with epinephrine (1:400 000) is
used in the scalp and forehead area for hemostasis
(Fig. 4.7).
Figure 4.7 Operating room setup and orientation
of surgeon to patient. (Reproduced with
permission from Chen WP. Oculoplastic surgery:
the essentials. New York: Thieme; 2001:133.)
Figure 4.6 Endoscopic sleeve with retracting spoon extension.
(Reproduced with permission from Chen WP. Oculoplastic surgery: the
essentials. New York: Thieme; 2001:131.)

33
Endoscopic-assisted Eyebrow Forehead Lift
Placement of scalp incisions
Three scalp incisions are made – one midline and two
lateral (Fig. 4.8). The location of the lateral incisions
depends on the desired vector of pull on the eyebrow.
In patients who have unusually severe nasal brow lax-
ity and glabellar folding, the incisions are placed closer
to the midline incision, to gain maximum traction,
and closer to the nasal brow and glabellar area. In
patients with general brow laxity, the lateral incisions
are placed in a wider pattern and slanted to produce
both nasal and some temporal elevation. All incisions
are placed behind the hairline to minimize scar
visibility. If possible, incisions should avoid sites of
maximal hairline recession.
Figure 4.8 Placement of three incisions for endoscopic-
assisted eyebrow forehead lift. The central incision serves as
a port for the endoscope. The lateral incisions serve only as
openings for placement of screw fixation. Position A for the
lateral incisions is used for patients who require maximum
nasal brow and glabellar lift. Position B is for patients who
need more general brow elevation. (Reproduced with
permission from Chen WP. Oculoplastic surgery: the
essentials. New York: Thieme; 2001:131.)
Central incision
A
B
B
A

34
Chapter 4: Endoscopic-assisted Eyebrow Surgery
Creation of an optical space
The initial optical space is created with a subperi-
osteal dissection using a straight elevator through
the three scalp incisions. Undermining in the sub-
periosteal space extends initially to within 1cm of the
supraorbital rim and to the superior temporal line lat-
erally. Undermining behind the scalp incisions is also
performed to prevent redundancy and folding when
the forehead and scalp are advanced posteriorly (Fig.
4.9). The subperiosteal plane has an advantage of
firm postoperative reattachment with healing follow-
ing brow elevation. Initially, subperiosteal dissection
is begun anteriorly through the central incision with-
out using the endoscope, stopping 1–2cm above the
superior orbital rim.
Figure 4.9 Left: Placement of three
incisions for endoscopic-assisted
eyebrow forehead lift. The central incision
serves as a port for the endoscope. The
lateral incisions serve only as openings
for placement of screw fixation. Right:
The area of periosteal undermining
performed for visualization before the
endoscope is inserted. (Reproduced with
permission from Chen WP. Oculoplastic
surgery: the essentials. New York:
Thieme; 2001:132.)
Superior
temporal
line

35
Endoscopic-assisted Eyebrow Forehead Lift
At this point, the endoscope with a retraction
sleeve and spoon is inserted through the central inci-
sion into the optical cavity to continue subperiosteal
dissection in the lower forehead under endoscopic
visualization. The dissection then proceeds down to
the superior orbital rim with direct visualization (Fig.
4.10). Several different sizes and curves of periosteal
elevators are available for use, depending on the con-
tour of the frontal bone and the distance from the
brow to the hairline.
Figure 4.10 Insertion of the
endoscope with retracting spoon
through the central incision and the
insertion of a periosteal elevator (or
other endoscopic tool) through a lateral
incision (left). The spoon extension on
the endoscope allows better retraction
of the brow tissue for visualization
(right). (Reproduced with permission
from Chen WP. Oculoplastic surgery:
the essentials. New York: Thieme;
2001:132.)
Periosteum
Cutting periosteal
elevator
Spoon
sleeve
Endoscope
camera

36
Chapter 4: Endoscopic-assisted Eyebrow Surgery
Periosteal release
Once adequate visualization of the optical cavity to
the orbital rim has been achieved, the surgeon places
a horizontal relaxing incision through the perios-
teum. The periosteum is divided along the edge of the
supraorbital rim transversely with a relaxing incision
using a sharp periosteal elevator (Fig. 4.11). A curved
periosteal hook or curved endoscopic scissors can be
used to divide the periosteum. Periosteal division con-
tinues laterally along the orbital rim to the level of
the lateral canthus using a narrow, curved elevator.
The procerus and corrugator muscles can then be
visualized centrally once the periosteum is divided.
Figure 4.11 Intraoperative endoscopic images showing creation of
relaxing incision through the periosteum at the level of the superior orbital
rim. (A) Insertion of reversed sharp periosteal elevator to the periosteum.
Initial periosteal incision (B) and extension laterally (C). (Reproduced with
permission from Chen WP. Oculoplastic surgery: the essentials. New
York: Thieme; 2001:133.)
A
B
C

37
Endoscopic-assisted Eyebrow Forehead Lift
Resection of corrugator and procerus muscles
Once the opening of the periosteum has been com-
pleted, biopsy forceps are introduced and used to
resect portions of the procerus and corrugator muscles
that cause the glabellar frown lines. Hypertrophy of
the procerus or corrugator muscles produced by
repeated frowning is improved by the myectomy,
which weakens these muscles. A variety of biopsy
forceps are available; however, blunt-tipped Takahashi
biopsy forceps allow precise muscle resection, which
minimizes the potential overdissection of the under-
lying subcutaneous tissue and dermis, which could
result in a visible deformity in the glabellar region.
Removal of the procerus is first performed in the
midline at the level of the superior orbital rim.
Dissection then proceeds laterally, with removal of
the corrugator on both sides of the supratrochlear
nerve (Fig. 4.12). The supratrochlear nerve crosses
the corrugator and is deep to the orbicularis oculi
fibers. A nerve hook can be used to retract the supra-
trochlear nerve. The supratrochlear nerves can be
seen with the underlying oblique fibers of the corru-
gator muscle and the transverse supratrochlear vein.
Figure 4.12 (A) Insertion
through the opening in the
periosteum of a grasping device for
partial resection of corrugator and
procerus muscles. Branches of the
supratrochlear nerve are contained
within the corrugator and should be
spared. The supraorbital nerve is
usually visualized laterally in the
notch but is away from the resection
area. (Reproduced with permission
from Chen WP. Oculoplastic surgery:
the essentials. New York: Thieme;
2001:134.)
Corrugator
muscle
Procerus
muscle
Supraorbital
nerve
Opening in
periosteum
Supratrochlear
nerve
A

38
Chapter 4: Endoscopic-assisted Eyebrow Surgery
Figure 4.12 (B) Endoscopic images showing excision of corrugator muscles. Top left and right: Stripping of the corrugator on the right side utilizing a
Takahashi biopsy forceps. Bottom left: Forceps pointing at left corrugator, with portion of supratrochlear nerve visible within the muscle. Bottom right:
View of glabellar area after corrugators have been stripped bilaterally.
The supraorbital nerves are visualized laterally.
Following procerus and corrugator myectomy, in spec-
tion for hemostasis is performed. Electrocautery
using an insulated grasper controls any bleeding
points.
B

39
Endoscopic-assisted Eyebrow Forehead Lift
Brow and forehead elevation and fixation
The forehead and scalp are then advanced upward
and retracted to produce brow elevation so that fixa-
tion of the tissue can be performed. Several methods
of fixation have been used. This author favors the
screw fixation methods. Screw fixation methods have
included the permanent placement of surgical screws
that anchor galeal support sutures or are temporary
percutaneous screws that are removed 1 to 2 weeks
after surgery and rely on periosteal adhesions for
permanency. Only the lateral incisions are used for
fixation. A guarded drill bit 4mm in depth (Fig. 4.13)
is used to place a drill hole in the calvarium at the
posterior edge of the lateral incisions. There is some
repositioning of the lateral incisions posteriorly by
traction before the drill holes are made. A 2mm-
diameter titanium screw, 12mm in length, is then
placed in the hole, thereby allowing an 8mm length to
traverse the scalp so that the screw head remains
external to the scalp (Fig. 4.14).
Figure 4.13 A drill bit with a 4mm guard used to create drill holes in the
calvarium at the posterior edges of the lateral scalp incisions. (Reproduced
with permission from Chen WP. Oculoplastic surgery: the essentials. New
York: Thieme; 2001:135.)
Figure 4.14 Placement of screw in the calvarium at the posterior edge of
a lateral incision. (Reproduced with permission from Chen WP.
Oculoplastic surgery: the essentials. New York: Thieme; 2001:135.)
4mm
Calvarium
8mm
A
B
C

40
Chapter 4: Endoscopic-assisted Eyebrow Surgery
Once the screw is secured at the posterior aspect of
the lateral radial incisions (Fig. 4.15), the scalp is
advanced posteriorly along the vector of the incision
with a single-hook retractor (Fig. 4.16).
After the scalp has been advanced to achieve
proper brow elevation with some consideration for
overcorrection, surgical staples are placed posterior
to the screw to close the incision and maintain the
scalp advancement (Fig. 4.17). All remaining scalp
incisions are closed with staples.
Staple and screw removal occurs 10 to 14 days after
surgery. No drains are required. The postoperative
edema is mild and the incidence of hematoma is low.
Figure 4.15 Positioning of the 12mm screw in the calvarium.
(Reproduced with permission from Chen WP. Oculoplastic surgery: the
essentials. New York: Thieme; 2001:135.)
Figure 4.16 Retraction of scalp with large skin hook to advance the
forehead upward and scalp posteriorly, to cause a lift in the brow. Upward
counterforce on the forehead is also used. (Reproduced with permission
from Chen WP. Oculoplastic surgery: the essentials. New York: Thieme;
2001:135.)
Figure 4.17 Placement of staples behind the screw so that the
advanced scalp and forehead position is maintained postoperatively.
(Reproduced with permission from Chen WP. Oculoplastic surgery: the
essentials. New York: Thieme; 2001:136.)

41
Endoscopic-assisted Eyebrow Forehead Lift
Views of a patient before and after endoscopic
eyebrow forehead lift are seen in Figure 4.18.
Lempke BN, Stasior GO. The anatomy of eyebrow
ptosis. Arch Ophthalmic 1982;100:981–6.
Loomis MG. Endoscopic brow fixation without
brow fixation or miniscrews. Plast Reconstr Surg
1996;98:373–4.
McCord CD. Brow surgery. In: McCord CD, ed.
Eyelid surgery: principles and techniques. New
York: Lippincott-Raven; 1995:166–70.
Pakkanen M, Salisbury AV, Ersek RA. Biodegradable
positive fixation for the endoscopic brow lift.
Plast Reconstr Surg 1996;98:1087–90.
Steinsapir KD, Shorr N, Hoenig J, Goldberg RA,
Baylis HI, Morrow D. The endoscopic forehead
lift. Ophthalmic Plast Reconstr Surg
1998;14:107–18.
Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA.
Anatomy of the frontal branch of the facial
nerve: the significance of the temporal fat pad.
Plast Reconstr Surg 1989;83:265–71.
Vasconez LO. Coronal facelift with endoscopic
techniques. Plast Surg Forum 1992;15:229.
Figure 4.18 Views of a patient before and after endoscopic eyebrow forehead lift. (Reproduced with permission from Chen WP. Oculoplastic surgery:
the essentials. New York: Thieme; 2001:136.)
FURTHER READING
Bostwick J, Eaves FF, Nahai F. Endoscopic plastic
surgery. St Louis: Quality Medical Publishing;
1995.
Codner MA. Endoscopic forehead lift. In: McCord
CD, ed. Eyelid surgery: principles and
techniques. New York: Lippincott-Raven;
1995:368–79.
Daniel RK, Tirkantis B. Endoscopic forehead lift: an
operative technique. Plast Reconstr Surg
1996;98:1148–57.
Isse NG. Endoscopic facial rejuvenation:
endoforehead, the functional lift, case reports.
Aesth Plast Surg 1994;18:21–9.
Kinze DM. An anatomically based study of the
mechanism of eyebrow ptosis. Plast Reconstr
Surg 1996;97:1321–32.
Kinze DM. Limited incision forehead lift for
eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg
1996;97:1334–42.
A
B

43
Chapter 5
Upper lid blepharoplasty performed without correc-
tion of a lax or ptotic eyebrow results in postoperative
residual upper lid folds and a narrowing of the spa-
cing between the eyebrow and eyelashes (brow–lash
distance). The goal of upper lid blepharoplasty is to
remove redundant skinfolds and produce a clear strip
of skin above the eyelash line (the eye-shadow space in
females).
The following eyebrow procedures are available in
conjunction with upper lid blepharoplasty:
■ Internal browpexy is performed through the
upper blepharoplasty incision for correction of
laxity in the lateral third of the brow.
■ Endoscopic-assisted eyebrow forehead lift is
used more commonly in females for the nasal
two-thirds of the brow and glabellar area
■ Direct eyebrow lift is used, generally, in males. It
involves direct skin incision over the area above
the brow (Fig. 5.1A & B).
■ Temporal forehead lift (lateral brow lift) is used
for the lateral third of the brow when there is
severe skin laxity lateral to the brow, beyond the
lateral orbital rim.
Upper Blepharoplasty
William PD Chen
Figure 5.1 (A) Male patient with brow ptosis and voluntary compensation
of frontalis muscle.
Figure 5.1 (B) Surgical closure of a direct eyebrow lift.
A
B

It is important, when performing upper lid bleph-
aroplasty, for the surgeon to produce an aesthetically
pleasing upper eyelid in the patient, but also to use
techniques that prevent lagophthalmos of the upper
lid, which may cause postoperative exposure symp-
toms. To achieve this, one may think of the procedure
as a three-dimensional reconstruction and reanchoring
of the subcutaneous tissues, including orbicularis,
orbital septum, preaponeurotic and nasal fat pads, as
well as repair of prolapsed lacrimal gland and repair
of dehiscence, with very selective and limited skin
excision. Figure 5.1C–H shows examples of variation
in upper eyelid crease.
44
Chapter 5: Upper Blepharoplasty
Figure 5.1 (C) Young Caucasian woman with a classical parallel crease in
the upper eyelid.
Figure 5.1 (D) Young Caucasian woman with a semilunar crease.
Figure 5.1 (E) Eurasian woman with broad, nasally tapered crease.
Figure 5.1 (F) Eurasian woman with deep-set eyes and a broad medial
extension of her crease.
Figure 5.1 (G) Caucasian woman with normal brow-to-crease distance.
Figure 5.1 (H) Caucasian woman with high crease (or supratarsal sulcus)
with low brow position.
C
D
E
F
G
H

Figure 5.2 shows a schematic representation of a
cross-sectional view of an upper eyelid with presence
of a natural crease.
Generally, females desire a higher lid crease and
a more well-defined eye-shadow space and crease
than do males. Men, in general, do better with a
45
Upper Blepharoplasty
parallel crease. Adjunctive eyebrow procedures are
commonly needed in patients seeking upper lid
blepharoplasty. It is possible to produce the goal of
crease formation and fold clearance with minimal
skin ex cision when adequate brow stabilization and
debulking of the upper lid are performed.
Figure 5.2 Cross-sectional view of an upper
lid with crease presence. (Reproduced with
permission from Chen WP. Oculoplastic
surgery: the essentials. New York: Thieme;
2001:212.)
Sub-brow fat
(ROOF)
Orbital septum

5.1
5.2
Surgical Technique
At the mid portion of the upper lid crease, the upper
lid is anesthetized through skin subcutaneously with
no more than 2mL of 2% Xylocaine with 1:100 000
dilution epinephrine, through a 30-gauge needle. The
anesthetic solution is lightly massaged several times
46
Chapter 5: Upper Blepharoplasty

Clinical pearls
■ Avoid using large-gauge needles during injection.
■ Avoid any repeated passage through the orbicularis
layers to reduce the chance of bleeding.
■ Inject slowly, from a perpendicular orientation over the
central preseptal area of the orbicularis; then
massage to both sides.
■ Use diluted Xylocaine mix (see Chapter 3), or use
bicarbonate supplement to decrease stinging
sensation from the acidity of the full-strength injection.

Pitfalls
■ Regional nerve block is often unnecessary, as some
patients are bordered by transient torsional diplopia
and ptosis from involvement of the levator muscle
and superior oblique tendon.
to spread it evenly across medially and laterally.
After 2 minutes to allow for vasoconstriction to set
in, the surgical field is draped. A corneal protector is
applied. I prefer to inject the nasal fat pad quadrant
only after I have reached the preaponeurotic space,
with an open view.
Figure 5.3

Designing the skin excision
The central position of the upper lid crease is marked
centrally at 8.5 to 10mm above the lashes in females,
in a semicircular configuration. Medially, it tapers
down to 5mm from the lashes and may angle upward
in the vicinity of the upper punctum. Laterally, the
crease line is carried to about 6mm from the lash line
and then the marking is angled upward, pointing
toward the end of the brow.
In men, I prefer to mark the crease centrally at
8–9mm, and in a parallel shape. The medial extent of
the lower line of incision is about 7mm and the lateral
extent about 8mm from the lash line, rendering it
more of a parallel crease shape.
For Asians, the existing crease is measured. The
central height of the tarsus is similarly measured
by everting the tarsus. If the two measurements are
identical, the patient’s original crease line is used as
the lower marking for incision. If the current crease
measures more than the central tarsal height, this
author prefers to transcribe the tarsal height measure-
ment onto the skin side as a yardstick to the proper
height for the new crease.
47
Surgical Technique

Clinical pearls
■ Allow adequate amount of time for anesthetic solution
to spread out and egress; this will reduce the tissue
distortion.
■ If the tissues are marked before injection, one tends
to make an excessively high incision and often
inadvertently injure the levator. This can cause
cicatricial lagophthalmos on downgaze as well as
upgaze.
■ The use of hyaluronidase (Wydase), when available, is
a helpful adjunct towards achieving the correct
incision height and ultimately the crease height.

Pitfalls
■ In men, the crease looks best if it is close to and
along the superior tarsal border.
■ Avoid excessive fat removal, especially in men, as it
will exaggerate the sulcus.
Figure 5.4

For marking the upper line of the skin excision
ellipse, the bunching technique is used only at the lat-
eral canthus. The proper amount of bunching in this
area should show some slight eversion of lashes. One
may maximize the skin excision laterally and should
minimize the skin excision centrally and nasally. Any
48
Chapter 5: Upper Blepharoplasty
lagophthalmos in the upper lid is poorly tolerated if
it occurs in the central or nasal portion of the lid.
One way of ensuring symmetry in the final upper
lid crease position is to measure the distance of the
superior line of incision from the brow hairs above.
Figure 5.5

Clinical pearls
■ The superior line of the ellipse should be measured
from the inferior edge of the brow hairs and generally
is located at the juncture of the thick and thin skin of
the upper lid (Fig. 5.5). Equal distances from the
upper line of incision to the brow hairs will give even
creases postoperatively if the brow positions are
symmetrical on both sides.
■ To create symmetry in an asymmetric condition, an
asymmetric amount of excision has to be performed
on the two sides. One should match and equalize the
pretarsal distances (crease-to-lashes) as well as the
brow-to-crease distances bilaterally.

Pitfalls
■ Bunching to determine the amount of skin removal
should not be used in the central or nasal portion of
the eyelid because the amount of skin excision in
these areas should be conservative. If bunching is
used medially and centrally, one risks excising too
much tissue, which may result in anterior lamella
shortage.
■ Avoid high incision and fixation as it may impinge on
the levator muscle’s ability to contract (upgaze) and
relax (downgaze).
■ Avoid excessive excision of skin medially, as it will
result in cicatricial ectropion.

Skin incision
Debulking involves removal of the marked area of
skin, muscle, and septum, and removal of eyelid fat.
After the skin incision has been marked, pressure on
the globe allows the eyelid skin to be on stretch and
skin-subcutaneous incisions are carried out with a
49
Surgical Technique
No. 15 blade over the superior as well as the lower
line of incisions. Light application of wetfield cautery
is used to control any bleeding from small vessels
along the skin incisions. I prefer to use a Bovie
cautery with a fine needle tip to traverse through the
orbicularis and septum along the superior incision, in
a slightly beveled fashion.

Clinical pearls
■ The skin incision using a No. 15 blade is only skin
deep, through full-thickness dermis.
■ There is a tendency to make the incision on the skin
based on the outer border of the marked incision
lines. To counteract this tendency, concentrate on
following the incision based on the outer edge of the
lower line of incision (the crease incision), and to go
on the inner border of the upper marked line. This
gives a safer margin of error – the crease-to-lash
distance (pretarsal platform) will not be over-
exaggerated into a very high upper lid crease, nor will
the crease-to-brow distance be overly shortened. The
total amount of resected skin–muscle–septum will
remain the same as what was intended and marked.

Pitfalls
■ Carefully use the radiofrequency unit in making the
skin incision, as one may go through deeper muscular
layers inadvertently.
Figure 5.6