Cosmetic Facial Surgery

Chapter 7  •  Cosmetic Blepharoplasty
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Xanthelasma is an accumulation of yellowish plaques in the
upper eyelid skin (Figure 7-14). This condition is related to
increased blood levels of cholesterol or hyperlipidemia and
sometimes with diabetes. These lesions are treated by surgical
excision or laser ablation and frequently recur.
Actinic damage is a big contributor to elastosis and texture
changes in the eyelids. Excess and wrinkled skin is referred to
as dermatochalasis.
Fat pseudoherniation (steatoblepharon) is the next most
common cosmetic problem occurring in the eyelids. Much
discussion about whether this is a herniation or pseudohernia-
tion exists; I think a more accurate word is prolapse. Most clini-
cians agree that the orbital septum becomes weakened with age,
and the periorbital fat pads protrude though this weakened
septum and cause the fat bags. To view the extent of prolapse,
gentle pressure is placed on the globe while the patient closes
the eye. This maneuver, called retropulsion, will cause the herni-
ated fat pads to become evident. Additionally, asking a patient
to look upward and open their mouth will accentuate the herni-
ated fat. This condition is frequently familial and hereditary,
with some patients developing protruding fat bags in their
late teens. Eyelid fat collections are sensitive to fluid shifts
and gravity, so they appear worse in the morning. Frequently,
affected patients will present with the chief complaint of dark
circles under their eyes. In reality, these “dark circles” may rep-
resent shadows cast by protruding fat bags; in a room with
overhead lighting, the circles are much more apparent from
shadowing. This can be illustrated by taking a photograph with
the patient standing under an overhead light source and taking
a photo with and without flash. The flashless picture will accen-
tuate dark circles.
Dark circles or periorbital pigmentation can be multifactorial
and sometimes represent true pigmentation. This may be from
sun damage and if superficial will respond to skin resurfacing
or excision. Some ethnic populations such as Indo-Pakistanis
have extremely deep pigment that is difficult to improve. Venous
congestion and hemosiderin pigment that has extravasated into
the skin can also produce dark circles under the eyes.
Some patients will present with a chief complaint of “fat
bags,” but in reality they have hypertrophic orbicularis oculi
muscles in the lower lids. Patients with orbicularis hypertrophy
show increased lower lid bulges when asked to smile and squint.
Figure 7-13 shows a patient with lower eyelid orbicularis oculi
hypertrophy.
A
B
FIGURE 7-12.  Aging changes of the eyelids and periorbital tissues include brow descent, pseudoherniation (prolapse) of peri-
orbital fat pads, and actinic changes to the thin eyelid skin.
FIGURE 7-13.  Orbicularis hypertrophy results in muscle bulges in the lower
eyelid.
FIGURE 7-14.  Xanthelasma of the upper eyelids.

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Chapter 7  •  Cosmetic Blepharoplasty
your prospective patients is a very useful adjunct. Additional
information such as brochures, websites, before-and-after
images, slide shows, and the like are very useful in supplement-
ing patient information.
It is rare that a patient would only have one evaluation; all
patients should return to the office for final preparation. In our
office, this includes visual acuity, signing consents, making a
down payment, obtaining forms for physician history and phys-
ical (if necessary), lab work, postoperative prescriptions, preo­
perative photographs, and finalizing surgery plans and questions.
The more times you can see a patient before operating on them,
the better your communication will be.
Several critical observations and instructions must be made
by the doctor and staff, including the following:
1. Visual acuity test
2. Screening the patient for any medications that may affect
coagulation:
a. Aspirin or aspirin-containing compounds
b. Ibuprofen (Advil) or other common meds that may
affect coagulation
c. Herbs such as garlic, ginkgo, ginseng, St. John’s Wort,
and so forth that may affect coagulation
3. Screening for health problems, including uncontrolled
hypertension or diabetes
4. Screening for anesthesia problems
5. Ophthalmic problems, including recent corneal correc-
tive procedures
6. Dry eyes
7. Brow position
8. Symmetry of brows, lids, orbits
Preoperative prescriptions, including antibiotics, antivirals
(if resurfacing is planned), and analgesics are given at the final
preoperative appointment.
Several tests assist the surgeon in assessing the risks of cos-
metic blepharoplasty for specific patients and are a requirement
prior to blepharoplasty:
1. Visual acuity testing (Everyone should have a Snellen
chart in the office.)
2. Tear production
3. Tests for lid laxity
a. Snap test
b. Pull test
4. Bell’s phenomenon
5. Extraocular muscle function
Visual acuity is easily performed in the office by having
the patient read an eye chart with and without eyeglasses. Some
Periorbital festoons are swellings from skin damage and fat
in the infraorbital or midface area (Figure 7-15). These are
challenging areas to correct. They are frequently treated with
skin resurfacing or direct excision.
Eyelid laxity is condition that can be critical to function and
aesthetics and must be recognized preoperatively. This condition
results from supporting-structure laxity and elastosis of the sur-
rounding tissues. The eyelids lose their normal tight approxi­
mation to the globe and sag like an overloaded clothesline. This
can be especially significant in the senescent population and is
frequently seen in longtime contact lens wearers. Patients with
significant laxity may show sclera below the inferior pupil, or
in extreme cases, the lid margin is everted with visible conjunc-
tiva. The lax lid can be permanently retracted by excessive skin
excision or skin resurfacing and must be critically accessed in
preoperative consultation. This will be discussed in the evalua-
tion section of this chapter.
Diagnosis and Patient Selection
Some cosmetic facial surgery procedures can be done with
minimal preoperative scrutiny and have limited complications,
but eyelid surgery gone wrong can lead to serious consequences,
including blindness. Some of the most important time spent
with a patient is at the consultation, when the patient is shop-
ping for a doctor, and the doctor is evaluating the patient surgi-
cally and psychologically. The primary considerations are the
patient’s expectations and appreciation of the reality of the situ-
ation. An elderly patient who presents with a magazine picture
of a young model may have unrealistic expectations. A patient
who presents with an obsession over a minor flaw may have
body dysmorphic disorder. It is the duty of the surgeon to give
the patient an accurate presentation of what to expect in terms
of diagnosis, treatment, recovery, and result. The more informa-
tion presented up front the easier it is to deal with problems
that occur postop. It is our job to present “typical scenario” as
well as best and worse scenario options. As they say, a postop
problem is a sequella if it was discussed preoperatively and a
complication of it was not discussed preoperatively.
Adequate time must be scheduled for eyelid evaluation—
on average 30 to 45 minutes. During that time, health history,
procedures, complications, pre- and postoperative consider-
ations, fees, and anesthesia evaluation must be discussed (Box
7-2). Pictures are everything in cosmetic surgery, and represen-
tative before-and-after images should be shown to give the
patient an idea of what to expect. Having a list of patients who
will serve as references to discuss their surgical experience with
FIGURE 7-15.  Festoons are infraorbital or midfacial swellings due to aging
changes, lymphedema, and actinic damage.
Box 7-2  Summary of Important Information the Patient Must
Understand After Cosmetic Blepharoplasty Consultation
• Understand their diagnosis
• Understand surgical options and alternatives
• Understand preoperative requirements (history, physical examination,
lab work, anesthesia considerations)
• Understand postoperative care
• Understand possible complications
• Understand the need for possible revision surgery
• Understand scheduling and payment options

Chapter 7  •  Cosmetic Blepharoplasty
135
1 second (Figure 7-16). Failure to snap back into position or an
elapsed time over a second to return to position indicates a lax
lower eyelid and merits caution (Figure 7-17).
An additional test to evaluate eyelid laxity involves stretching
the lower eyelid laterally and assessing the distance of travel of
the punctum. When the normal lower eyelid is stretched later-
ally, the punctum does not move beyond the medial limbus
(Figure 7-18, A). In the lax lower eyelid, the same maneuver
will cause the punctum to move lateral to the medial limbus
(see Figure 7-18, B).
The pull test also assesses lower eyelid laxity and is performed
by pulling the lower eyelid anteriorly from the globe and mea-
suring the distance (Figure 7-19). A gap of over 7 mm indicates
lower lid laxity and again merits caution and conservative bleph-
aroplasty if not an adjunctive tightening procedure such as
canthopexy.
patients will claim their vision has changed after eyelid surgery,
so for clinical as well as medicolegal reasons, this testing is
paramount.
Dry eyes are very problematic, and if a patient cannot close
his or her eyes after surgery, irreversible corneal damage may
result. A Schirmer test may be performed, but an ophthalmol-
ogy consult is recommended for patients who require eye drops
on a regular basis before eyelid surgery.
Lower lid laxity can cause significant functional and cosmetic
problems. The patient must be warned about this preoperatively,
and the surgery must be modified to avoid postoperative lower
lid malposition or ectropion.
Several simple exams can be performed to evaluate the func-
tion of integral functions of related anatomy. The snap test
involves pulling the lower eyelid inferiorly away from the globe
and letting it go. The lid should snap back into position within
A
B
FIGURE 7-16.  A snap test on a patient with a normal lid. Note return to normal lid position.
A
B
FIGURE 7-17.  A snap test on a patient with very lax lids. Note the lid does not return to normal position.

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Chapter 7  •  Cosmetic Blepharoplasty
open, showing the white sclera. A patient with dry eyes or
without a protective Bell’s phenomenon could have catastrophic
corneal damage from corneal exposure and drying if a lagoph-
thalmos (inability to close the lids) should occur post blepharo-
plasty. To check for the presence of Bell’s phenomenon, the
patient is asked to close the eyes, and the examiner gently pries
the lid open with their fingers; the eyeball should roll back and
protect the cornea, and the examiner should see only the white
sclera (Figure 7-20, A). A patient with an abnormal Bell’s phe-
nomenon has their corneal surface exposed and visible with eyes
closed and pried open (see Figure 7-20, B).
Needless to say, any patient with even a hint of an ophthal-
mologic problem should have an ophthalmology consult
preoperatively.
The need for preoperative images cannot be overemphasized.
Patients rarely pay attention to their eyes until you operate on
them, then they become very critical. It is not unusual for a
patient to complain about something that “was not there before
the surgery.” They may focus on the tiniest skin excess or asym-
metry and blame you, the surgeon, for this problem. Any asym-
metry or other variable that may affect the outcome should be
documented in writing preoperatively and signed by the patient.
This practice has saved the author time and again. The fact is
that soon after surgery, the surgeon and patient typically forget
what the patient looked like preoperatively.
Besides being chart records and medicolegal documentation,
consented before-and-after images are invaluable marketing
tools. Cosmetic surgery is all about before-and-after pictures
and they can be used (with consent) in the office, on the
Internet, and for many other marketing purposes. The surgeon
and staff must be meticulous about obtaining legal written
permission from the patient. Significant lawsuits have been
lost for improper use of patient images, which can be a Health
Insurance Portability and Accountability Act (HIPAA) viola-
tion. Since this may vary from state to state, legal consultation
should be obtained that clearly details the uncompensated use
of images for educational and promotional purposes. Some
patients are honored to allow their images to be used, but
others are very private about this; consent should never be taken
lightly.
As we addressed in depth in Chapter 3, photographic images
should be standardized or they are useless. Common back-
ground, position, lighting, and pose are requirements.
A minimum preoperative series should include:
1. Full frontal face
2. Close-up frontal face
3. Right and left oblique views
4. Eyes-closed views (to prove the patient could close their
eyes)
5. Eyes looking upward (to accentuate lower fat pad
herniation)
Figure 7-21 shows a typical preoperative series used by the
author.
Treatment Planning
Blepharoplasty is not a simple procedure. Much of its success
or failure lies in meticulous attention to planning the procedure.
There are many loose ends to tie up before the scalpel touches
A mechanism exists to protect the cornea during sleep or
unconsciousness. This phenomenon causes the globe to rotate
superiorly and cover the cornea behind the upper eyelid to
prevent desiccation and is known as Bell’s phenomenon. It can
be witnessed in some patients who sleep with their eyes partially
A
B
FIGURE 7-18.  Moderately stretching the lower eyelid laterally in a normal
patient will not move the punctum past the medial limbus (A), but the
same maneuver in the lax lid will move the punctum lateral to the medial
limbus (B).
7 mm
FIGURE 7-19.  The pull test assesses lower lid laxity in the horizontal plane.

Chapter 7  •  Cosmetic Blepharoplasty
137
the skin. Attention to previously mentioned details cannot be
overstated and must be reinforced with staff so nothing falls
between the cracks.
Although some patients will present for isolated upper or
lower eyelid procedures, many patients will request four-
quadrant blepharoplasty with browlift and possibly other
A
B
FIGURE 7-20.  A, Normal Bell’s phenomenon. B, Abnormal Bell’s phenomenon; the eyeball does not rotate superiorly and
therefore does not afford protection to the cornea.
A
B
C
D
FIGURE 7-21.  These poses represent the minimal photographic series required for cosmetic blepharoplasty.
cosmetic facial procedures. Upper eyelid blepharoplasty is
pretty standard in technique, but lower lid approaches vary in
internal and external approaches to the fat. For years, external
skin-muscle approaches were used with a subciliary incision.
This involves violating the middle lamella (orbital septum) and
excising skin and/or muscle from the external surface. This

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Chapter 7  •  Cosmetic Blepharoplasty
removed. Removing too little skin may necessitate a revision
surgery and be an inconvenience to the surgeon and patient,
but over-resection can cause serious health and cosmetic pro­
blems and lead to lawsuits! My supreme word of advice to all
blepharoplasty surgeons is to be conservative. You will never
go wrong with this pearl. I tell all of my blepharoplasty patients
in the preoperative period (and in the consent) that a small
percentage will need some touch-up surgery. If they do, I told
them, and they are not shocked. If they don’t, I am a hero.
The biggest challenge for novice blepharoplasty surgeons is
learning how to properly mark the eyelids. Once you under-
stand the marking procedure, the surgery is relatively straight-
forward, but there is no cookbook technique to marking the
upper eyelid; each lid (even on the same patient) is different.
It is imperative to mark the eyelids with the patient
relaxed in the upright position. When the patient is lying
down, the brows and lids are not in a natural position, and
the markings can be inaccurate. Also remember to take
preop photographs before marking the patient.
The lids are wiped with alcohol before marking to degrease
them for better adherence of the marking ink. These marks must
remain visible through surgical scrub, local anesthesia, and
manipulation, and some marking pens do not do the job. I have
found the retractable ultrafine-point Sharpie markers to be the
best for ink longevity on the skin. I have done several thousand
eyelids without any problem of surgical tattoo with these
markers.
The first step is to decide where to locate the upper lid crease.
Most males (non-Asian) have an upper lid crease of about 8 mm
above the lashes, and most females (non-Asian) have upper lid
creases of 10 to 12 mm above the lashes. Generally the lid crease
is marked using the patient’s existing lid crease. Females desire
a high lid crease to have a significant lid shelf on which to apply
eye shadow. A high crease in males can feminize the result;
8 mm is an average position in the Caucasian male. The posi-
tion of the upper lid crease can be discussed preoperatively, but
I prefer 10 to 12 mm for females and 8 mm for males. I elevate
the brow to a normal position (at the orbital rim for males,
above the orbital rim for females) and have the patient open
and close their eyelid to visualize the crease. The crease is then
marked from the lateral canthus to the lacrimal punctum (Figure
approach is still utilized, but most contemporary oculoplastic
surgeons maintain that violating the middle lamella can be a
prime cause of lower lid malposition, which can result in lid
retraction with scleral show, ectropion, and dry eyes (Figure
7-22). Transconjunctival approaches have become more popular
because the orbital septum is spared, there is no external inci-
sion, and lower lid malposition is rare. The conventional trans-
conjunctival approach is a retroseptal surgical approach and
spares violation of the orbital septum. When dealing with trans-
conjunctival approaches, alternate methods are used to address
excess skin. In young patients, no ancillary skin removal may
be required. In older patients, carbon dioxide (CO2) laser resur-
facing of the eyelid skin is my treatment of choice. My second
most common choice is 30% trichloroacetic acid (TCA), and
skin-pinch techniques are my third choice and can address the
skin excess without invading the lower septum. These tech-
niques will be discussed in detail later in the chapter.
In terms of comprehensive treatment planning, brow posi-
tion must be addressed preoperatively. If concomitant endo-
scopic or open brow lift and upper blepharoplasty is planned,
the sum of both procedures can stretch the upper lid skin to a
point where the eyelids cannot be closed, so both of these pro-
cedures must be tempered to account for adequate residual
upper eyelid skin in order to close the eyes fully. I typically
remove about 7 to 10 mm of skin in the upper eyelid, but this
can vary significantly from patient to patient. When performing
simultaneous upper lid blepharoplasty and brow lift, this
amount is reduced by 50%. If skin resurfacing of the eyelids is
planned with blepharoplasty and brow lift, even more caution
is used. It should be kept in mind that the surgeon can always
take more skin away later, but it is difficult to replace! For
the novice surgeon contemplating both brow lift and simultane-
ous upper blepharoplasty, it may be best for safety reasons to
perform the brow lift first and address the upper lids at a later
procedure.
Preoperative Marking
Upper Eyelid
Blepharoplasty is a technique of finesse. Successful blepharo-
plasty surgery is more about what is left behind than what is
A
B
FIGURE 7-22.  A, A normal lower eyelid and septum tight to the globe.
B, Septal retraction (pink) with the lower eyelid being pulled away
from the globe.

Chapter 7  •  Cosmetic Blepharoplasty
139
leaves 10 mm from the forehead/eyelid skin junction, this will
give a total of 20 mm of upper eyelid skin preserved and enable
lid closure. Always leave at least 20 mm of upper eyelid skin
intact for normal lid function (Figure 7-25). This is, in the
author’s opinion, the most critical point of successful upper
eyelid blepharoplasty. Failure to observe can result in overexci-
sion of upper eyelid skin with permanent lagophthalmos.
The final step is to connect the incision at the lateral canthal
area. If a brow lift is not planned, then a “Bird beak” incision
is used with a lateral extension of extra lid skin excised to correct
hooding (see Figure 7-26, A). If simultaneous brow lift is
planned, lateral hooding of the upper lid is corrected, and a
“Napoleon’s hat” incision is used for the lid skin (Figure 7-26,
B). Since the brow lift elevates the lateral lid skin, excision of
lateral lid skin is unnecessary. (These nicknames are used by the
author for teaching purposes and are not official nomenclature
in the ophthalmologic literature.) It can be of value to extend
the lateral excision into a natural crow’s-foot wrinkle; this may
better blend the scar. Although some authors recommend
extending the lateral incision up to 15 mm lateral to the orbit,
this can leave a scar that looks unnatural and takes much longer
to heal. I personally do not extend the lateral portion of the
incision past the bony lateral orbital in most patients. When I
do, it is generally not more than 5 mm or so. Another important
pearl is that this lateral incision extension should always taper
up (like a smile) and never inferiorly (like a frown). The latter
can look unnatural.
When addressing the medial junction of the upper and lower
marks, it is important to avoid the multicontoured depression
lateral to the nose. Generally, the medial corner of this incision
ends at the punctum. If the excision is carried out laterally onto
the nose, an obvious scar will be apparent, and scar webbing of
this multicontoured area can occur (Figure 7-27).
7-23). Generally the center of the crease is at the 8 to 10 mm
mark, and the ends of the crease taper to 4 to 5 mm high, creat-
ing an arc. But in many patients, their natural crease is almost
a straight line, so attempting to make too high an arch can cause
an artificial look.
The next step is to mark the upper extent of the blepharo-
plasty incision. The upper portion of the upper eyelid marking
is made approximately 10 mm inferior to the junction of the
forehead and eyelid skin. If one closely examines the skin infe-
rior to the eyebrow, an area (generally corresponding to the
bony orbit) where the smooth, thicker forehead skin meets the
thinner crinkly upper eyelid skin can be seen. This is usually
just below the finest hairs of the eyebrow but can be lower in
some patients. A mark is made 10 mm below this junction; this
defines the upper extent of the skin excision (Figure 7-24). If
the surgeon leaves 10 mm from the lash to the lid crease and
FIGURE 7-23.  Female patient has a normal crease of 10 mm, which is
traced with surgical marker from the punctum to the lateral canthus. If her
normal crease had not been discernable, a “new” crease would be marked
10 to 12 mm above the ciliary margin.
FIGURE 7-24.  Upper extent of the eyelid incision is marked 10 mm inferior
to the junction of forehead and eyelid skin.
10 mm
10 mm
Excess
FIGURE 7-25.  The cardinal tenet of blepharoplasty incision planning is to
leave at least 20 mm of residual eyelid skin to ensure the ability to close
the eyelid. The top mark is 10 mm inferior to the forehead skin/eyelid skin
junction, and the bottom line is 10 mm above the ciliary margin, which
leaves a total of 20 mm of skin. The remaining excess (between the upper
and lower marks) can usually be safely excised.

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Chapter 7  •  Cosmetic Blepharoplasty
accommodate patient height. The point is to have the patient
look straight ahead with a focused gaze, brows relaxed. I then
use the surgical marker to make dots on the bottom of the
overhanging skin fold of the upper lid (Figure 7-29). These dots
are amazingly accurate in relation to what will become the
superior extent of the upper blepharoplasty incision and will
usually correspond to the line marked in Figure 7-24.
I generally use both of these methods to mark my superior
extent of the upper blepharoplasty incision. First I use the “stare
at my finger” technique and make a series of dots across the
bottom of the upper lid fold, as shown in Figure 7-29. Then
with the patient seated and the brow elevated, I reconfirm these
marks by measuring 10 mm below the junction of the forehead/
eyelid skin, as shown in Figure 7-24. These dots and lines
After the lid markings are made, a “pinch test” is made to
check that the lids can still be closed with the prospective skin
excised. With the brow elevated to a normal position, the skin
is pinched with a forceps; the lashes should just evert, but the
eyes should still be able to remain closed (Figure 7-28). This test
reinforces that excessive skin is not removed and is especially
critical when simultaneous brow lift is planned. If simultaneous
brow lift is planned, much less skin should be removed relative
to the amount of anticipated lift.
An additional means of marking the upper eyelid is to mark
the upper lid fold. This not only provides an alternative means
of determining the superior extent of the upper lid incision but
can serve to verify other marking methods for accuracy. This is
done by having the patient stand in front of the surgeon and
stare at a fixed point. I generally place my index finger on the
tip of my nose and ask the patient to focus on that point. The
patient must be able to stare straight ahead at my fingertip
without looking up or down, so I adjust my position to
A
B
FIGURE 7-26.  If simultaneous brow lift is not
planned, a “Bird beak” incision is made to compen-
sate for additional lateral skin removal in patients
with lateral hooding (A). If simultaneous brow lift is
planned, a “Napoleon’s hat” incision is made; no
lateral brow skin need be excised because it is
addressed by the brow lift (B).
FIGURE 7-27.  The medial extent of the upper blepharoplasty incision should
stop at or just beyond the lacrimal punctum and not extend onto the
multicontoured skin of the nose. Otherwise, unfavorable scarring can
occur.
FIGURE 7-28.  A “pinch test” is made to check that the lids can still be
closed with the prospective skin excised. With the brow elevated to a
normal position, the skin is pinched with a forceps; the lashes should just
evert, but the eyes should still be able to remain closed.

Chapter 7  •  Cosmetic Blepharoplasty
141
If a transconjunctival incision is to be used instead of a
subciliary approach, no external markings are necessary, although
it is helpful to mark the protruding fat pads to remind the
surgeon of their position.
If laser or chemical peel is planned, it is also helpful to mark
the periorbital extent of the area to be resurfaced to insure
bilateral symmetry.
Surgical Preparation and Anesthesia
Although eyelid surgery is frequently performed in a sterile
hospital environment, it can also be safely done in a “clean
antiseptic” environment. The generous vascularity of the peri-
orbita makes postoperative infection rare. The lids are wiped
with a suitable prep that is not caustic to the cornea. I prefer
usually correspond very closely and serve as affirmation of the
proper excision of the superior margin.
A third means of determining the upper extent of the inci-
sion is usually reserved for the experienced blepharoplasty
surgeon. With the patient lying down (or the brow manually
elevated to its normal position), the center of the upper lid is
pinched with a forceps until the upper lashes just begin to evert
(Figure 7-30). A mark is made at the pinch point. This is
repeated on the lateral and medial portions of the upper lid,
and these marks are then connected. This ensures adequate skin
preservation to close the lids. Again, this technique is best
reserved for the experienced blepharoplasty surgeon.
All of the aforementioned techniques can be accurately used,
but will not work on every single patient due to anatomic varia-
tion and experience may be necessary to accurately mark some
patients. When in doubt, error on the conservative side.
Lower Eyelid Markings
If an external skin-muscle incision is planned for the lower lid,
a line is marked 2 mm below the ciliary margin. This mark is
then extended just to the orbital rim in a horizontal direction
(Figure 7-31). This lateral incision can be incorporated in a
natural crow’s-foot wrinkle, but if extended too far beyond the
orbital rim, an unsightly scar may result that takes months to
resolve. It is important to leave at least 5 to 7 mm of intact skin
between the upper and lower lateral incisions (see Figure 7-31).
A
B
C
FIGURE 7-29.  A, The patient is asked to stare at a fixed point (e.g., sur-
geon’s finger touching his or her nose), with the brows relaxed. B, Dots
are then marked on the inferior surface of the overhanging skin fold in the
neutral gaze. C, These dots will correspond to the upper extent of the
upper lid incision margin (brow elevated).
FIGURE 7-30.  A method of marking the upper extent of the blepharoplasty
incision is to mark the normal eyelid crease, then lift the brow (or place
the patient in the supine position without lifting the brow). Next, the surgeon
pinches the skin with a forceps until the lashes begin to evert; this is done
at several points from medial to lateral. The area where the skin is pinched
together is marked with a dot, the dots are then connected, and this forms
the superior extent of the upper blepharoplasty incision.
5 mm
FIGURE 7-31.  A subciliary incision is marked 2 mm below the ciliary margin,
with a lateral extension to or slightly past the orbital rim. A minimum of 5
to 7 mm of tissue must be preserved between the upper and lower lid
incisions.

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Chapter 7  •  Cosmetic Blepharoplasty
Lower Eyelid Anesthesia
If the transconjunctival approach is to be used, a 32-gauge
needle is placed through the conjunctiva, and 1-2 mL of local
anesthetic is split between the medial, central, and lateral fat
pads (Figure 7-33). Caution is always used to stay anterior to
the globe.
If a skin/muscle approach is used, the needle is inserted at
the lateral orbital rim to the bone. Since the periosteum of the
lateral orbit is contiguous with the orbital septum, the needle
is positioned parallel to the lower eyelid in the plane of the
periosteum and advanced from lateral to medial. A natural space
is created over the orbital septum and orbicularis muscle which
is easy to inject and balloons this area, facilitating dissection.
Some type of eyelid shield is always used when performing
blepharoplasty. If the laser will be utilized for incision, metal
corneal shields are required; when using electrosurgery, plastic
shields prevent conduction to the cornea. Prior to shield inser-
tion, 2 drops of ophthalmic local anesthesia (proparacaine
hydrochloride) is placed in each eye. Alternatively several drops
of 2% lidocaine with 1 : 100,000 epinephrine can be used. Some
surgeons coat the eye shields with an antibiotic ointment, but
I have found the incidence of corneal irritation to be greater
when doing this and only use anesthetic drops without addi-
tional ointment. The shields are placed in the fornix to fit inside
the lid to cover the cornea (Figure 7-34). Even when resurfacing
is not contemplated, it is a good idea to use some type of shield
because it is possible to perforate through the thin deeper eyelid
tissues (especially medially) and injure the cornea or other
anatomy.
Blepharoplasty Instrumentation
A plethora of specialized instrumentation is available for oph-
thalmic surgery, but most common blepharoplasty procedures
can be performed with minimal specialized instrumentation.
Figure 7-35 shows the author’s typical blepharoplasty tray. Only
several instruments really are necessary:
Techni-Care (Care-Tech Laboratories, Inc., St. Louis, MO). A
surgical cap is placed on the patient to cover the hair.
I generally sedate all patients, but many blepharoplasty sur-
geons prefer local anesthesia. An advantage to local anesthesia
is that the patient can open and close the eyelids during ptosis
surgery. For routine cosmetic blepharoplasty, I truly believe that
intravenous (IV) sedation makes the procedure easier for both
the surgeon and patient.
Next, local anesthesia is administered. The standard tech-
nique is to sedate the patient, inject the lids, then scrub. An
injection of 2% lidocaine, 1 : 100,000 epinephrine administered
through a 1/2 inch 32-gauge needle is utilized. In the upper lid,
the injection is very superficial, just beneath the skin. The needle
is placed through the lateral lid and the anesthetic injected as
the needle is withdrawn from medial to lateral. About 1-2 mL
of local anesthesia is injected in each upper lid. Figure 7-32
shows local anesthetic infiltration of the upper eyelid.
FIGURE 7-32.  A 1- to 2-mL injection of local anesthesia is deposited just
beneath the upper lid skin.
A
B
C
FIGURE 7-33.  A 1-mL injection of local anesthesia, divided among the lower three fat pads, is deposited through the
conjunctiva.

Chapter 7  •  Cosmetic Blepharoplasty
143
Ltd., Yokneam, Israel), and the Ellman radiofrequency system
with the Ellman Empire microneedle and VariTip (Ellman
International Inc., Oceanside, NY).
Upper Lid Incision
Although some surgeons use scalpel or scissors for incision, I
routinely use either CO2 laser or radiofrequency microneedle
(see Figure 7-36) for all upper and lower blepharoplasty. These
modalities, especially the CO2 laser, produce minimal bleeding
which translates into less bleeding, bruising, and faster recovery.
I have done formal research using a Lumenis CO2 laser cutting
handpiece with a 0.2-mm spot size on one upper eyelid and the
Ellman radiofrequency microneedle on the other upper lid.1
Basically, these instruments perform similarly, although the
CO2 laser is more efficient at hemostasis. Both of these inci-
sional modalities produced aesthetic surgical scars that could
not be differentiated by trained observers at 90 days.
In my experience, it is rare for a patient to lose more than 1
or 2 mL of blood in routine four-lid blepharoplasty. Both of the
above modalities provide excellent healing.
Once the upper lid has been marked, prepped, and anesthe-
tized, a full-thickness skin ellipse is made. This skin is extremely
thin, and attention is paid to dissect the skin only, although
experienced surgeons will sometimes excise skin and muscle in
the same flap. After the outlined skin is incised, the medial
corner is grasped with forceps, and the thin skin is dissected
from the underlying muscle in the same manner as peeling the
skin from a grape (Figure 7-37). I use the CO2 laser straight
handpiece with a 0.2-mm spot size. When incising skin with
the Ellman radiowave system, I use a straight fine-wire (VariTip)
electrode because it produces the least heat. For the most aes-
thetic scar when using radiowave surgery, I make the skin inci-
sion on the pure cutting mode. Since this is 90% cut and only
10% coagulation, there is more bleeding than when using the
same electrode on pure coagulation. For pigmented skin, I
always use the pure cutting, but for light-skinned patients, I
believe the pure coag is the most advantageous. With either
modality, I generally begin at 7 watts. The radiowave electrode
should glide through the tissues. If it is sticking, the power can
be increased to the 10 to 12 watt range.
1. Plastic and/or metal corneal shields (metal if laser is used)
2. Jaeger lid plate (metal if laser is used, plastic if electrosur-
gery is used)
3. Desmarres retractor
4. Measuring caliper
5. Fine pick ups with teeth
6. Small hemostat
7. Small skin hooks
8. Fine-tip suction
9. Tenotomy, Wescott, or iris scissors
Even with normal vision, surgical loupes and a headlight
make blepharoplasty surgery more precise. Hemostasis is the key
to safe blepharoplasty. When the fat pads are incised, it is not
unusual for a bleeding vessel to retract deeper into the orbit. If
this occurs, the bleeding vessel could cause a retrobulbar hema-
toma. Sometimes these vessels are quite small, and wearing
loupes is a significant advantage. There are many other small
structures to be avoided, and surgical magnification and con-
centrated headlight provide superior visualization.
Incisional modalities include scalpel, scissors, CO2 laser, and
radiofrequency microneedle. The author utilizes the later two
exclusively. Figure 7-36 shows a picture of scalpel incision, the
0.2-mm laser handpiece for the Lumenis CO2 laser (Lumenis
A
B
C
FIGURE 7-34.  Placement of protective stainless steel corneal shields.
FIGURE 7-35.  Common blepharoplasty instruments used by the author.

144
Chapter 7  •  Cosmetic Blepharoplasty
if the incision is placed too inferiorly. When in doubt as to
where the upper lid fat pads are located, always err towards the
superior orbital rim. Remember, these fat pads cushion the
globe within the bony orbit and lie close to the orbital rim.
Gentle pressure on the globe (retropulsion) will accentuate the
prolapsed fat pads, making them visible. Again, the fat pads can
frequently be seen moving beneath the thin septum. The septum
is incised with the CO2 laser or Ellman radiofrequency micronee-
dle in the center of the orbit just below the orbital rim. The
central fat pad generally prolapses and can be dissected to its
lateral extent, which sometimes may go all the way to the lateral
portion of the incision (Figure 7-39). It is unusual but not
impossible to encounter a third fat pad in the upper lid, as
shown in Figure 7-40. A good surgeon must always anticipate
anatomic aberrations.
Remember that the lacrimal gland lies in the superior
lateral portion of the orbit and can been inadvertently mis-
taken for a fat pad. There are usually only two fat pads in
the upper eyelid, a central and a medial. The lacrimal glands
are pinker (similar to parotid tissue) than the yellow central fat
pad. If the lacrimal glands are slightly prolapsed, they can be
tucked backed into the orbit or if significantly prolapsed, they
are suspended to the orbital periosteum with a nonresorbable
suture (Figure 7-41).
Once the skin ellipse is removed, the orbicularis oculi muscle
is visualized. This muscle is very vascular and frequently has a
superficial network of large vessels on its surface. These can be
cauterized for convenience and to prevent more bleeding during
muscle excision. The next step is to excise and/or sculpt the
orbicularis muscle. Some surgeons remove no muscle in the
upper lid, whereas others advocate removing the same amount
of orbicularis as skin excision. I have found that by being more
conservative in muscle resection, I have a better sculpted lid
sulcus, faster return of eyelid function, and less bruising. About
4 to 5 mm of orbicularis muscle is excised, using either the CO2
laser or the Ellman radiowave system. When using the radio-
wave modality, I use the fine-wire or the microneedle electrode
on pure coagulation. Figure 7-38 shows the orbicularis oculi
muscle in the upper eyelid being resected with laser and radio-
frequency modalities.
If the orbicularis oculi muscle is dissected in the proper
plane, the orbital septum is visible. This is frequently translu-
cent, and one can see the underlying fat pads moving under the
septum when lightly pressing on the globe. The septum can be
incised with a small rent over the central and medial fat pads
or incised totally from medial to lateral. For the novice surgeon,
the orbital septum may not be apparent, and there is risk of
incising through the levator aponeurosis (and deeper structures)
A
B
D
C
FIGURE 7-36.  The thin upper eyelid skin is excised with scalpel (A), CO2 laser (B), Ellman radiofrequency microneedle (C), or
Ellman radiowave fine-wire tip (VariTip) (D).

Chapter 7  •  Cosmetic Blepharoplasty
145
CO2
CO2
RF
RF
A
B
C
D
FIGURE 7-37.  The thin upper eyelid skin is incised with CO2 laser and radiofrequency (RF; synonym for radiowave) in parts A
and B and dissected off of the orbicularis oculi muscle with the same modalities in C and D.
CO2
RF
A
B
FIGURE 7-38.  Laser and radiofrequency resection of the orbicularis oculi muscle in the upper eyelid. The orbital septum is visible
under the muscle.

146
Chapter 7  •  Cosmetic Blepharoplasty
FIGURE 7-39.  Intraoperative image showing the right eye after incisions
were made through the septum over the nasal (medial) and central fat
pads. The fat pads can be seen protruding through the incisions. I usually
open the septum along the entirety of the fat pads but made small rent
incisions in this case to illustrate fat pad position.
L
C
M
FIGURE 7-40.  Although unusual, this patient exhibits a third (lateral) fat pad
in the upper eyelid. This is in the same position as the lacrimal gland, so
caution must always be used to differentiate between gland and fat.
Remember, this is not the norm! C, Central fat pad; L, lateral fat pad;
M, medial fat pad.
A
B
C
D
FIGURE 7-41.  A, Prolapsed lacrimal gland. B, Gland being secured with a suture. C, Needle engaging the orbital periosteum.
D, Gland tucked into a more superior position in the superolateral orbit.

Chapter 7  •  Cosmetic Blepharoplasty
147
take care to avoid aggressively pulling, stretching, or retracting
the fat pads. Many vessels traverse them from deep within
the orbit. If the fat pads are overly stretched from the orbit,
one could lacerate a deep vessel, and when the fat pad is released,
it can retract deep into the orbit along with the bleeding vessel.
If uncontrolled bleeding occurs deep in the orbit, a hematoma
can form, compress the retinal artery, and cause permanent
blindness.
Extreme caution should be used when handling the fat pads.
For the novice surgeon, the question “How much fat should I
remove?” arises. Although each case is different, one should only
excise the amount of fat that easily protrudes with gentle pres-
sure on the globe (retropulsion). As one of my friends once said,
“Only take the fat that calls your name!” In addition, the
surgeon or assistant should never “tug” on the fat pads or view
the fat pads as “the enemy” and remove as much as can be
found. Remember, blepharoplasty is an operation of what
tissue you leave, not what tissue you remove. Excessive fat
resection will cause a hollow-looking orbit and give the patient
an older, gaunt appearance. Always be conservative. More fat
can be removed, but a hollowed orbit is difficult to revise. The
result of too-aggressive fat removal may not show up for a
number of years, so a good rule of thumb is to take only the fat
the orbit “gives up” and not be overly aggressive in searching
for or removing deep fat.
Some surgeons prefer to “melt” the fat pads back with laser
or radiofrequency instead of resecting or recontouring portions
of the fat pad. Classically, fat pad removal has been described
as teasing out the protruding fat then clamping the base of the
fat pad with a hemostat before resecting. Although it makes
sense to clamp and crimp the base of the fat pad to assist in
hemostasis, the hemostat can also exert a lever effect on the fat
pat and inadvertently stretch the base of the fat pad and lacerate
a vessel. This can happen when the assistant takes hold of the
hemostat while the surgeon incises the fat pad. When a modality
is used that provides incision and hemostasis, such as the CO2
laser or the radiofrequency microneedle, there is adequate
hemostasis and no need to clamp the fat pads (Figure 7-43).
Since I use laser or radiowave for all blepharoplasty, I do not
clamp the fat pads, but anyone using nonhemostatic incisional
modalities must take this extra step (Figure 7-44). When using
Once the orbital septum is incised in the upper lid, it is
generally easy to locate the central fat pad. Sometimes this fat
is continuous with the medial fat, but these two fat pads are
generally separated by the superior oblique muscle. This can
be an important landmark in the upper eyelid when searching
for the medial fat compartment (see Figure 7-10, 2). For the
novice surgeon, it can be difficult in some patients to locate the
medial (nasal) fat pad. Gently pushing on the globe can assist
by protruding the medial fat pad. Blunt dissection can be per-
formed to safely locate the medial fat pad by spreading the
tissues with a small blunt hemostat or spreading with two cot-
ton-tipped applicators (Figure 7-42). Once the medial fat pad
is located and teased out, it will frequently balloon out to sur-
prising proportions. The medial fat pad is frequently whiter
than the other fat pads, presumably due to increased fibrous
tissue. This fat pad is also more innervated than the central fat
pad. When operating on the medial fat pad, it is not unusual
for the patient to react to stimulation even while under general
anesthesia. It is a good idea to inject local anesthesia at the base
of the medial fat pad prior to manipulation.
Many surgical techniques exist to reduce or recontour the
orbital fat pads. Whatever technique is used, the surgeon must
FIGURE 7-42.  The medial fat pad located after blunt dissection and gentle
pressure on the globe.
CO2
RW
A
B
FIGURE 7-43.  A, Central fat pad in the left upper eyelid being reduced by the CO2 laser handpiece. B, Same procedure using
the Ellman radiowave microneedle on pure coagulation.

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Chapter 7  •  Cosmetic Blepharoplasty
the CO2 laser, the beam is defocused by moving the handpiece
away from the tissue, which increases the spot size and provides
excellent hemostasis. This is the technique I use with the laser
when reducing or sculpting the protruding fat pads (Figure
7-45). When using the radiowave system, the muscle and fat
are always treated with the pure coagulation setting, which is
90% coagulation and 10% cutting. Although I prefer radiowave
surgery over standard electrosurgery, many surgeons use tradi-
tional electrosurgery, and it can be equally substituted in this
context.
Another means of cutting through the fat pads is the use of
the radiowave small bipolar forceps. The fine tips on this instru-
ment make teasing out the herniated fat easy and provide
FIGURE 7-44.  The base of the fat pad is clamped if a nonhemostatic modal-
ity such as scissors or scalpel is used to cut the fat pads. The base of
the incised pad is then cauterized prior to releasing.
A
B
FIGURE 7-45.  The medial fat pad is reduced with a CO2 laser (A), and the central fat pad is reduced with the Ellman radiofre-
quency microneedle (B).
excellent hemostasis (Figure 7-46). This instrument should
always be on the tray. It can be invaluable when brisk bleeding
is encountered and will be discussed later in this chapter.
As skin, muscle, and fat are removed from each eye, they are
placed on a gauze or towel to approximate similar volume
removal on both eyes as well as to serve as part of the chart
record. (Figure 7-47).
Once the medial and central fat pads are recontoured, the
entire surgical site is reinspected for bleeding. When the surgeon
is sure the surgical field is dry, the incision is closed. Numerous
means exist to suture the upper eyelid incisions. I prefer to first
use several 6-0 fast-absorbing gut sutures with a P3 needle to
“tack” the incision in the medial, central, and lateral regions.
This takes some tension off the final sutures and also helps line
up the incision margins for easier closure with the running
suture. Although interrupted or running closures can be accom-
plished, I personally think that a running 6-0 nylon suture will
produce the most aesthetic scar. In reality, the scar will look the
same if resorbable suture is used, but it takes longer to reach the
same cosmetic result. After using the 6-0 fast-absorbing gut
tacking sutures, I do a simple running (baseball) suture with 6-0
nylon suture with a P3 needle (Figure 7-48). Although some
surgeons advocate a subcuticular closure, I think the running
nylon is excellent. I only take thin bites of the skin with my
running suture and do not incorporate any muscle in the
closure, although some surgeons do close the muscle with the
skin. Interrupted sutures are also adequate but are more time
consuming to remove, and unpleasant to the patient. There are
many times when I close the upper incision with my 6-0 fast-
absorbing gut suture and then perform my running suture with
6-0 fast-absorbing gut as well. I see many out-of-town patients
and have not had problems with wound dehiscence. I do not
use gut suture for final closure if I feel there is tension on the
suture line or in big men. I also do not use gut for final closure
when I perform blepharoplasty with simultaneous brow lift; I
believe it can place tension on the suture lines. It can be men-
tioned at this point that when performing simultaneous upper
and lower blepharoplasty, the lower lids are usually done first so

Chapter 7  •  Cosmetic Blepharoplasty
149
as not to disturb the upper incisions with retraction and manip-
ulation. The surgical site is then covered with triple antibiotic
ointment and iced saline gauze. If nylon sutures are used, they
are removed at 5 days. I have experimented with removing
sutures in as little as 3 days and as long as 10 days; 5 days seems
to work best. There is no significant problem with waiting a few
extra days, and sometimes the sutures will come out of the thin
skin by themselves after a week.
Upper blepharoplasty may be performed before or after brow
lift, depending upon the desire of the surgeon. For endoscopic
(subperiosteal) brow lift, I typically perform the upper blepha-
roplasty first and while the incision is open, perform much of
my subperiosteal dissection through the upper lid incision
(Figure 7-49). This makes the endoscopic portion of the surgery
easier and faster, since the lateral orbital rim area is one of the
most difficult areas to properly dissect under endoscopic vision.
In addition, it is easier to deal with this area directly through
the eyelid incision than from 5 cm above with the scope. This
is especially true in patients with long or convex foreheads.
Technically, if the surgeon can view, isolate, and protect the
supraorbital and supratrochlear nerves from the blepharoplasty
incision, more of the “endoscopic brow lift” can be performed
without using an endoscope. Regardless, it is a great time saver
and makes the endoscopic procedure easier when much of the
dissection can be done through the blepharoplasty incision. If
the sensory neurovascular bundles are identified, much of the
medial brow dissection can also be performed (Figure 7-50).
Lower Eyelid Blepharoplasty
Transconjunctival Technique
Numerous approaches exist to the lower eyelid fat compart-
ment. I prefer the transconjunctival (TC) approach to the lower
eyelid fat because it does not violate the orbital septum, does
not cause lower lid retraction, and leaves no visible scar. The
common approach to TC blepharoplasty is retroseptal, meaning
that the fat compartments are entered posterior to the septum
(Figure 7-51). Some surgeons use the transconjunctival approach
and do a preseptal dissection, which requires septal incision and
negates the septal-sparing component of this approach.
A
B
FIGURE 7-46.  The radiowave small bipolar forceps is an excellent means of transecting and reducing fat pads in upper (A) and
lower (B) blepharoplasty.
Skin
Muscle
Fat
FIGURE 7-47.  To ensure symmetry and keep track of excised tissue, the
surgical specimens are rearranged and photographed.
A
B
FIGURE 7-48.  A, Incision closure with 6-0 fast-absorbing gut suture.
B, Postblepharoplasty patient 5 days after surgery. This patient also had
CO2 skin resurfacing on the lower lids and is still healing.

150
Chapter 7  •  Cosmetic Blepharoplasty
difficult, especially access to the lateral fat pad. To carry the
incision far enough laterally, the assistant must pull the lateral
canthus laterally. Doing this provides access to the conjunctiva
in the lateral corner of the eye. The CO2 laser or Ellman
microneedle is used to incise through conjunctiva and capsulo-
palpebral fascia (lower lid retractors) in very gentle, sweeping
motions (Figure 7-52). An important note is to wipe off trans-
conjunctival incision char from the laser or electrosurgery with
a wet cotton-tipped applicator after making the incision. Oth-
erwise these hard crusts can contribute to corneal abrasion or
irritation after surgery.
A retraction suture is placed next. A 5-0 gut suture on a P3
cutting needle is passed through the posterior incision margin,
draped over the head, and suspended with the weight of a
The lower lids are injected as shown in Figure 7-33, and the
surgical technique proceeds as follows. The assistant, using their
thumb and index finger, retracts the lower eyelid. The surgeon
gently depresses the globe with a Jaeger lid plate retractor, which
prolapses the herniated fat. Technically the incision should be
made about 4 mm inferior to the inferior tarsal margin or about
8 mm from the lower lid margin (since the lower tarsus is about
4 mm, placing the incision 4 mm below this equals the 8 mm).
In reality, the incision is made directly through the middle of
the conjunctival bulge that forms from the assistant’s retraction
and the surgeon’s pressure from the Jaeger lid plate. This almost
always corresponds to the same distance as 4 mm below the
inferior tarsal margin. If ever in doubt, the surgeon should err
toward the orbital rim and not the globe. A transconjunctival
incision too deep in the fornix can damage the extraocular
muscles as well as initiate unnecessary bleeding. The incision is
made from the lacrimal punctum medially to the lateral canthus
laterally. Failure to carry the incision far enough laterally causes
the surgeon to operate in a hole and makes surgery more
A
B
FIGURE 7-49.  Endoscopic brow lift can be greatly facilitated by direct subperiosteal dissection of the lateral orbital rim and
forehead through the upper blepharoplasty incision.
FIGURE 7-50.  The supraorbital nerve during open dissection for subperi-
osteal brow lift, as performed through the blepharoplasty incision.
FIGURE 7-51.  The transconjunctival approach is retroseptal (right arrows).
The incision is made approximately 4 mm below the lower tarsus (left
arrow).

Chapter 7  •  Cosmetic Blepharoplasty
151
A
B
FIGURE 7-52.  The transconjunctival incision (dashed blue line) is made from the lacrimal punctum to the lateral canthus approxi-
mately 8 mm below the lower lid ciliary margin. A, Ellman radiowave microneedle. B, CO2 laser handpiece. This position also
corresponds to the bulge in the conjunctiva when the assistant retracts the lower lid, and the surgeon puts pressure on the
globe with the Jaeger lid plate.
A
B
FIGURE 7-53.  A retraction suture improves surgical access and can serve to protect the cornea.
hemostat (Figure 7-53). This serves to retract the incision for
facilitated view and instrumentation.
The next step is to perform the incision, which is made with
the Ellman radiowave microneedle on a pure coagulation setting
or with the CO2 laser at 8 watts. The incision is made through
the conjunctiva and the capsulopalpebral fascia (lower lid retrac-
tors). In most patients, this layer is relatively thick, to the sur-
prise of the novice surgeon. If ever unsure about the correct
tissue plane while incising or dissecting, the surgeon should err
towards the orbital rim and not towards the globe. If ever dis-
oriented in a tissue plane, using an instrument to feel the infe-
rior orbital rim will confirm a safe position. In many patients,
when the conjunctiva and capsulopalpebral fascia are incised,
the central fat pad will herniate into the wound. If fat is not
visualized during the incision, it is identified by placing pressure
on the globe, accompanied by blunt dissection. After each level
of incision, the fine hemostat is inserted, and right-to-left
spreading is gently done (as opposed to anterior-posterior
spreading, which could damage the globe; Figure 7-54). An
alternate method of finding the pads is to use the soft end of
two cotton-tipped applicators and spread the tissues until the
yellow fat is visualized. As this dissection is performed, gentle
pressure is placed on the globe, and the fat pads can be visual-
ized. As the fat pads come into view, their capsule is incised by
laser or radiofrequency, usually allowing the herniated fat to
billow out of the incision (Figure 7-55).
As described earlier in this chapter, the fat is teased out, never
stretched or pulled with significant traction. Figure 7-56 shows
the individual fat pads being teased out of the orbit with gentle
traction. The lower lid fat is similarly incised with the laser or
radiofrequency electrode (Figure 7-57). This can be done with
scalpel or scissors, but with coagulative modalities, the proce-
dure is virtually bloodless and easier.
The central fat pad is usually the first encountered and
the easiest to reduce. The medial fat pad, as in the upper lid,
frequently takes some blunt dissection to locate but once

152
Chapter 7  •  Cosmetic Blepharoplasty
FIGURE 7-54.  After the incision is made, blunt dissection is performed to
spread the tissue to reveal the underlying fat pads.
FIGURE 7-55.  The lower eyelid has three fat pads: central, medial, and
lateral.
A
B
C
FIGURE 7-56.  Using gentle traction, the lateral (A), central (B), and medial (C) fat pats are teased out of the orbit.
B
A
FIGURE 7-57.  The lower fat pads are incised with radiowave surgery microneedle (A) and the CO2 laser (B).
incised gives up an impressive amount of fat. Blunt dissection
is used with globe pressure to locate the medial pad. As
stated earlier, this fat is more fibrous and whiter. The inferior
oblique muscle divides the central and medial fat pads, and
this muscle is sometimes encountered in lower transconjunc­
tival blepharoplasty (Figure 7-58). The muscle must be handled
with care to avoid damage. It is not a problem to gently retract
the muscle, but damage could result in extraocular muscle
dysfunction.
The lateral fat pad in the lower lid may be difficult to deliver
into the surgical field and takes some exploration to find. It is
usually located more lateral than the lateral extent of the trans-
conjunctival incision. The surgeon should continually look at
the external lid skin while pressing on the globe to verify ade-
quate fat removal (Figure 7-59). The lateral fat pad is the most
frequently undertreated area in lower lid transconjunctival
blepharoplasty, so judicious location and reduction is integral
to successful results.

Chapter 7  •  Cosmetic Blepharoplasty
153
A
B
FIGURE 7-58.  A, Inferior oblique muscle (white arrow) separating the medial and central fat pads. B, Inferior oblique muscle
isolated with a hemostat.
A
B
FIGURE 7-59.  A, Residual fat bulge from recalcitrant lateral fat pad. B, Lateral fat pad exposed after blunt dissection. The lateral
fat pad is the most commonly undertreated fat pad in transconjunctival blepharoplasty.
I cannot overemphasize the need for conservative removal of
fat. Only excise the amount of fat that freely herniates into the
wound or fat that can be gently teased out with gentle traction.
Another alternative is to recontour the fat. This involves shrink-
ing the fat to make it retract into the orbit, as opposed to
actively excising it. I generally perform conservative excision and
recontouring at the same time. Recontouring is performed by
defocusing the laser or by using the radiowave needle on pure
coagulation. Both of these modalities will shrink the fat. After
the three lower fat pads have been recontoured, the surgical site
is checked for hemostasis. Generally the incision is not closed
unless gaping. Usually by picking up the anterior and posterior
portions with small forceps and approximating them, they stay
together very nicely and rarely if ever require suturing (Figures
7-60 and 7-61). In cases of lower-lid laxity, a canthopexy pro-
cedure is performed to tighten the lax lower eyelid and will be
discussed later in this chapter.
With all the pluses of TC blepharoplasty, one negative is that
this procedure does nothing to address the aging skin of the
lower eyelid. From time to time, patients as young as their late
twenties present for hereditary-related fat bags of the lower
eyelids. In this cohort, the lower eyelid skin rarely needs address-
ing, but in the 99.9% of TC blepharoplasty patients, the aging
eyelid is accompanied by aging skin, and most patients who
present with fat pseudoherniation also require some skin-tight-
ening procedure. There are numerous ways to address this
sagging, crepey skin, including laser resurfacing, chemical peel,
and skin excision techniques. My personal preference is CO2
laser resurfacing of the periorbital areas using the Lumenis ultra-
pulse Encore laser with a computer pattern generator (CPG).
For periorbital resurfacing, a setting of 80 mJ, 600 Hz, a
number 1 pattern (circle) size 6 to 7, and a density of 6 (30%
overlap) is selected. Readers should be aware that this setting is
only relevant to this specific laser and may vary with other
manufacturers. Use appropriate settings for your machine. A full
pass is made over the eyelids (and crow’s-feet areas if required;
see Figure 7-38). Without débriding the laser char, a second pass
is made on the average patient at the same settings on the lower
lid only. The upper lid is treated with only a single pass with
lower fluence—usually a setting of 70 mJ with a density of 5.

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Chapter 7  •  Cosmetic Blepharoplasty
After the upper and/or lower blepharoplasty and laser resur-
facing, the laser shields are removed and the eyes copiously
irrigated with basic saline solution. Some surgeons place eryth-
romycin ointment in the fornix after TC blepharoplasty.
Chemical peeling of the lower eyelid (and upper lid) skin is
also an affordable, predictable, safe, and convenient means of
addressing dermatochalasis after TC blepharoplasty. Although
not as clinically effective as aggressive laser resurfacing, the
recovery is much less complicated. Whereas aggressively lasered
lower eyelid skin can take up to 2 weeks to heal, most patients
are back in makeup in 7 days with a chemical peel. I favor 30%
TCA. The lower lid skin is first degreased with alcohol pads to
enhance acid penetration. The eyelid shields are removed; on
the remote chance acid should get in the eye, the shield would
entrap it. When using TCA around the eye, it is spread on thinly
with a cotton-tipped applicator for an even coat over the entire
lower (and/or upper lid). The skin will begin to frost almost
immediately; the operator should wait at least 2 minutes before
applying a second coat. The number of coats is proportional to
the amount of damage. Generally most patients need and can
tolerate two coats. The endpoint is a dense white frost over the
treated area. In thicker-skinned patients or those with more skin
damage, a third coat can be applied, but this should not be
attempted by inexperienced peelers. A third coat will rival the
results and recovery of CO2 laser. If acid inadvertently enters
the eye, it must be immediately flushed with copious water. It
is also important to use small amounts of acid so it does not
drip into the eye or down the cheek. An upward tilt of the
operating table can prevent leakage into the eye. The upper lids
are generally only treated with a single coat of TCA unless
blepharoplasty is not performed on the upper lids. After the skin
is frosted to the desired endpoint, the peeled areas are covered
with a petrolatum ointment such as Vaseline. Postoperatively,
the skin will turn dark after several days, usually begin peeling
at day 3 to 4, and be healed by day 7. The only wound care
needed for the peel is petrolatum applied continuously until
reepithelialization occurs.
In the case of retreating the eyelids with laser or chemical
peel, a 90-day healing period is recommended. Figure 7-62
shows a TC blepharoplasty patient treated with chemical peel
and laser resurfacing.
Alternative Treatment of the Lower Eyelid
Just as there are many ways to skin the proverbial cat, there exist
numerous described techniques to address lower eyelid fat pseu-
doherniation. Fat transpositioning is a procedure that has gained
popularity with oculoplastic surgeons over the past decade.2
Due to the fact that fat removal can produce orbital hollowing
the transposition technique prevents volume loss. The basis of
fat transpositioning is to dissect and free the fat pads and reposi-
tion them without resection. After the fat pads are dissected and
freed, the arcus marginalis at the orbital rim is incised and a
pocket is created to accept the fat pads. An infra-SOOF (sub
orbicularis oculi fat) approach is frequently used to avoid septal
violation. The dissected fat pedicle is then tucked into the
pocket, which fills in the tear trough deformity. A bolster suture
is placed through the skin and the fat to hold the transposi-
tioned pedicle in place (Figure 7-63). Proponents claim that the
Try to keep the lasered areas within the confines of the orbital
rim; laser redness outside the orbital rims is very hard to conceal.
Inside the confines of the orbital rims, the treated area is an
isolated anatomic unit and one of the few places on the face
where isolated laser resurfacing can be performed without tran-
sitional differences between treated and untreated areas. In addi-
tion, patients can cover this smaller treated area with sunglasses
during recovery. If a patient desires resurfacing of larger areas
(outside the orbital rims), it is a good idea to convert the pro-
cedure to full-face resurfacing to better blend the treated and
untreated areas and not end up with relative hypopigmentation
of the treated skin compared to the surrounding skin.
Adding aggressive laser resurfacing can cause lid retraction,
especially in the lax lid, so conservative treatment is prudent,
especially for the novice surgeon. If severe wrinkling exists, two
passes are used on the lower lids.
FIGURE 7-60.  Transconjunctival incisions do not require suturing. The inci-
sion margins are approximated with forceps, and the lid tension will keep
them in approximation.
FIGURE 7-61.  The approximated incision margins are shown. If laser or
electrosurgery is used to incise, using a wet cotton-tipped applicator to
remove the char will reduce corneal abrasion and irritation from the rough
margins.

Chapter 7  •  Cosmetic Blepharoplasty
155
A
B
FIGURE 7-63.  A, The fat posterior to the orbital septum in the aging lower eyelid (note tear trough depression). B, Fat transposi-
tion technique, showing fat repositioned to fill in the infraorbital region to restore youthful volume. Note the retention suture,
which is left in place 5 to 7 days.
A
B
FIGURE 7-62.  A, Transconjunctival (TC) blepharoplasty patient treated
with two coats of 30% trichloroacetic acid to resurface the lower lid skin.
B, Different patient immediately after TC blepharoplasty and two passes
of high-fluence CO2 laser resurfacing.
tear trough region (nasojugal fold) is filled with the repositioned
fat, and this corrects not only the fat bags but also provides
youthful volume. I have performed this procedure but was not
happy with the result. Admittedly I may not be proficient in
the technique, but I also know some very well-respected aca-
demic oculoplastic surgeons who initially performed this proce-
dure and have since abandoned it. But I know other surgeons
who swear by it. Different procedures work better in the hands
of some surgeons. If the technique is safe and effective and
produces longevity and happy patients, it surely deserves a place
in the armamentarium of the cosmetic facial surgeon. Alterna-
tively, some surgeons routinely use fat transfer to fill the tear
trough region simultaneously with the lower blepharoplasty. I
have found that conservative lower blepharoplasty with skin
tightening will prevent a hollowed look in the average lower
blepharoplasty patient.
Another technique that has been described is a septal reset
procedure where the lose septum is tightened to simulate the
youthful septum and thereby pushes the herniated fat back into
the orbit.3 The confines of this chapter prohibit in-depth discus-
sion of this technique.
Skin Pinch Technique
Not every patient is a candidate for skin resurfacing procedures
when TC blepharoplasty is performed. Some male patients
do not want the extended erythema that comes with the laser,
and a chemical peel is not effective enough for their amount
of dermatochalasis. Some patients have orbicularis oculi

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Chapter 7  •  Cosmetic Blepharoplasty
radiowave small-ball electrode (see Figure 7-64, E). Since the
skin has been crushed and cut at several points, a jagged incision
may result. The radiowave fine-wire electrode is used to gently
even out the ragged incision to a semilunar shape (see Figure
7-64, F–G). The final step is to close the incision with five to
six 6-0 fast-absorbing gut sutures (see Figure 7-64, H–I ). The
sutures dissolve between 5 and 7 days, and the incision heals
quickly (see Figure 7-64, J).
Alternately, I sometimes perform the transconjunctival
blepharoplasty then perform a subciliary incision with the laser
or radiowave microneedle and dissect a preseptal suborbicularis
oculi flap that extends 5-7 mm inferiorly. This allows the orbital
septum to remain intact. The excess skin and muscle are con-
servatively excised and sutured. This approach is similar to the
external skin muscle approach but differ significantly because
the fat is removed through the inner eyelid and the skin and
muscle are trimmed from outside the lid. The main difference
is that the septum is not violated and hence, lower lip malposi-
tion is less of a concern.
Skin-Muscle Approach for Lower Blepharoplasty
As I have mentioned numerous times, I attempt to avoid this
approach because of the increased incidence of lower lid mal-
position (from septal violation) and a visible scar. There are,
however, times when a patient has very hypertrophic orbicularis
oculi muscle prominence in the lower lid, and this approach is
required.
As stated earlier, the periosteum of the lateral orbital rim is
contiguous with the orbital septum. Local anesthesia is injected
at the lateral orbital rim, then the needle is angled horizontally
to the lashes and traverses the plane between the septum and
orbicularis muscle, which is ballooned with local anesthetic
solution (Figure 7-65, A).
Next, a skin incision is made at the lateral extent of the inci-
sion (in a crow’s-foot wrinkle if possible), and tenotomy or other
fine scissors are used to bluntly dissect to the periosteum over
the rim (see Figure 7-65, B). Once this plane is reached, the
scissors are turned horizontally and aimed toward the medial
aspect of the lower lid. With the surgical plane ballooned
between the septum and the muscle, it is very easily dissected
by merely spreading the scissors from the lateral lid to the
medial lid.
The next step is to angle the scissors up parallel with the
lower lid and make a cut through the skin and muscle (see
Figure 7-65, C–D). The cut should leave several millimeters of
orbicularis muscle inferior to the incision which preserves the
pretarsal muscle structure, thereby decreasing the chance of
lower lid ectropion.
When the subciliary incision is completed, the surgeon has
an excellent open view of the orbital septum (see Figure 7-65,
D). The septum is then incised by the preferred modality, and
the three lower fat pads are identified and reduced and recon-
toured with the surgeon’s preferential instrumentation (see
Figure 7-65, E–G).
The final and most technique-sensitive step is to trim the
excess skin and muscle from the lower incision margin. This is
hypertrophy and require some orbicularis excision to reduce the
bulge that occurs when they smile. Although a skin-muscle
blepharoplasty with a subciliary incision will address the fat,
muscle, and skin of the lower lid, the chance of eyelid malposi-
tion is greater with this procedure.
The skin pinch technique is a convenient, minimally invasive
procedure to deal with excess skin in the lower eyelid without
violating the middle lamella (septum). It also compliments the
transconjunctival approach for those individuals who cannot
tolerate laser erythema. I use this technique mostly in men or
patients with pigmented skin for whom the laser is contraindi-
cated. Women can cover laser redness with makeup, but since
this erythema can persist for months, it is prohibitive in many
men. African American, Asian, Latino, or others with pig-
mented skin tend to have post laser pigmentation problems, and
the skin pinch technique is a favorable adjunct for that popula-
tion, although chemical peel is still an option.
The procedure is quite simple and involves crimping the
excess skin with a hemostat, then resecting and suturing the
skin. In sedated patients, no local anesthesia is necessary, which
enables more accurate surgery. In a non-sedated patient, local
anesthesia infiltration is required but distorts the skin, making
the judgment of how much skin to remove more difficult for
the novice surgeon. The skin pinch is performed last, after
completing the transconjunctival removal of herniated perior-
bital fat.
The first step is to mark the patient preoperatively by taking
a forceps or cotton pliers (a common dental instrument) and
simply grasping the excess lower eyelid skin just below the
lashes. Generally, most patients will require removal of approxi-
mately 4 to 5 mm of skin (see Figure 7-40). “Test pinching”
with the cotton pliers can help the surgeon judge how much
skin should be removed. With the patient awake and seated, the
skin is pinched just below the lashes (so that the lower lid skin
is tightened) while gently everting the lower lashes without
retracting the lower eyelid. When satisfied with the correct
amount of skin, the incision is marked with a surgical marker
(Figure 7-64, A). Over resection can occur so it is imperative to
be conservative with the amount of skin removed as revision
can always be performed at a later date.
The surgical technique is begun by taking a curved hemostat
(I prefer the type that curves horizontally instead of vertically)
and crushing the predetermined amount of skin between the
locked beaks of the hemostat. The pinching is begun in the
lateral third of the lower lid, then the central, and finally
the medial (see Figure 7-64, B). By doing this, a raised ridge
of excess skin protrudes from the crushed base (see Figure 7-64,
C). The next step is to use a Wescott or other small scissors to
cut across the crushed skin ridge at its base (see Figure 7-64,
D). Care is used to avoid cutting the lower lashes in close prox-
imity to the pinched skin. Since the skin is crushed, when the
crimped base is cut, little bleeding occurs.
When the base of this incision is separated, the surgeon will
initially notice bleeding that will stop in several minutes. The
incision is then pulled open, exposing the orbicularis oculi
muscle in the lower eyelid. If the muscle is hypertrophic, the
surgeon can trim the excess or shrink it with the CO2 laser or
Text continued on page 161.

Chapter 7  •  Cosmetic Blepharoplasty
157
FIGURE 7-64.  A, Tissue redundancy estimation can be performed by pinching the excess lower lid skin with a cotton pliers
without displacing the lower eyelid. The excess skin to be excised is marked. Generally, 4 to 5 mm of skin is removed. B, A
fine hemostat is used to crush the base of the excess skin from medial to lateral. C, The three areas of elevated, crushed skin
ridge. D, Fine-tipped scissors are then used to cut across the base of the crushed skin ridges. E, Hypertrophic orbicularis
oculi muscle may be shrunk or contracted with laser or radiowave electrode, or excised with scissors. Shown here: indirect
coagulation of the muscle to shrink the minimal excess. An irregular incision margin (F) can occur, which can be smoothed
using a radiowave microneedle (G) (see next page) for even closure.
A
B
C
D
E
F
Continued

158
Chapter 7  •  Cosmetic Blepharoplasty
I
J
G
H
H, Resected skin sitting on the cheek under the incision. I, Skin pinch incision is closed with fast-absorbing
6-0 gut sutures. J, Patient 1 week after upper blepharoplasty with lower transconjunctival blepharoplasty and lower-lid skin
pinch.
FIGURE 7-64, cont’d

Chapter 7  •  Cosmetic Blepharoplasty
159
FIGURE 7-65.  A, Local anesthetic injection in the plane between the orbicularis oculi muscle and the orbital septum of the lower
lid. The pretarsal (PT) orbicularis is shown along with the orbital septal (S) and the preseptal (PS) orbicularis muscle. 1, Local
anesthetic needle through the skin to the level of the periosteum of the lateral orbital rim. The needle is then turned 90 degrees
and follows the periosteal plane (2). Local anesthetic solution is deposited between the orbital septum and the orbicularis oculi.
B, The surgical plane for subciliary transcutaneous blepharoplasty is found by incising to the periosteum and following that
plane medially. The surgical plane is below the orbicularis oculi muscle and above the lower orbital septum and very easy to
dissect by advancing and spreading the scissors. C, Scissors are used to cut the skin/muscle flap of the subciliary incision.
D, After scissors incision is made, the skin/muscle flap is retracted, exposing the intact orbital septum. E–G, The orbital septum
and the herniated fat pads are readily accessible from the skin/muscle approach; E, Septal incision with the Ellman microneedle
through the orbital septum revealing the underlying fat. F, Reduction of the central fat pad with the Ellman radiowave micronee-
dle. G, The same procedure on the medial (nasal) fat pad.
PT
PS
S
2
1
A
C
D
E
F
G
B
Continued

160
Chapter 7  •  Cosmetic Blepharoplasty
H
J
K
L
M
N
O
P
I
H–I, Retracting excess skin in a superolateral vector can lead the surgeon to think there is more skin
excess than actually exists (H). Employing a superomedial vector can produce a more accurate representation of actual skin
excess (I). Although this maneuver is frequently described, some noted oculoplastic surgeons believe the opposite is true.
The bottom line is to be conservative. J–L, After incision, the skin is pulled in the proper vector to determine the excess (J).
The skin is then gently compressed over the lower lid, which allows it to contour to the underlying anatomy (K). Note that the
incised skin triangle in L is less than the skin under traction in J. M–O, The excess skin lies passively over the incision (M).
Scissors are used to excise the excess skin (N), and the wound margins lie passively (O). P, The lower eyelid incision can
be closed with 6-0 nylon or in this case 6-0 fast-absorbing gut sutures.
FIGURE 7-65, cont’d

Chapter 7  •  Cosmetic Blepharoplasty
161
Brad Lemke, MD, a good friend and respected academic
oculoplastic surgeon described a canthopexy technique that is
straightforward, effective, and can be performed by the average
surgeon. This technique is most easily performed on the lax
lower eyelid through the upper blepharoplasty lateral incision.
In the case where no upper blepharoplasty is performed, a small
incision is made at the crow’s-feet region lateral to the lateral
canthus. The procedure involves using a suture to secure the
lateral canthal tissues, which is then secured to the periosteum
of the lateral orbit.
Another variant of this procedure involves drilling a small
bur hole through the lateral orbital rim to secure the sutures.
Although in theory the suture is engaging the lateral canthus,
in reality it may secure the canthal tendons but will also include
other tissues in this area. The first step is to make a small tunnel
from the upper lateral blepharoplasty incision towards the
lateral canthus (Figure 7-66, A). Next, a suture with a small
needle (I prefer a 5-0 nylon or 5-0 with a P2 needle) is used to
engage the soft tissues at the Y of the lateral canthal raphe,
which is the fusion of the orbicularis and tarsus (see Figure 7-66,
B). A deep enough bite of tissue must be engaged to anchor the
suture and support the lateral canthus under tension. A too-
superficial suture bite can cause dimpling of the skin or not
properly engage the lateral canthal tissues. A double throw of
the suture is utilized. When the suture is properly placed, super-
olateral tension on it will pull the lateral canthus in the same
direction, thus tightening the lid against the globe (see Figure
7-66, C–D). Once the suture is successfully placed and tested
for proper vector, it must be anchored. The periosteum of the
lateral orbital rim is exposed by performing an incision through
the lateral orbicularis oculi muscle and the fine connective tissue
overlying the periosteum (see Figure 7-66, E). Some surgeons
make a small flap on the medial side of the lateral orbital rim
just inside the orbit and use the flap to anchor the suspension
suture. I have found that in the average patient, there exists thick
enough periosteum on the lateral orbital rim to simply take a
suture “bite” of the thicker tissue, which is adequate to anchor
this suture with sufficient tension to suspend the lax lid (see
Figure 7-66, F).
Blepharoplasty Complications
Complications are a part of any surgery, and the only surgeons
who do not have them are the ones who do not operate. Blepha-
roplasty complications can be more serious than other types of
surgical compilations. We only have two eyes, and a compro-
mise in function would be devastating. We must always remem-
ber that cosmetic surgery patients are unique in that they present
solely for aesthetic treatment, and to lose function or vision for
an elective procedure carries significant consequences.
One must differentiate true complications from sequelae,
and the purpose of this section is to present some common and
uncommon post-blepharoplasty complications I have encoun-
tered over the past 12 years. It is by no means exhaustive or
inclusive of all complications but representative of a practice
that has treated several thousand eyelids.
The postcosmetic-surgery patient views their early results
with extreme scrutiny. It always amazes me how quickly the
patient and the surgeon forget how the patient actually looked
described in many ways by various authors and is oftentimes
contradictory. I have found the following technique to work
effectively without causing lid retraction. The excess skin is
grasped and pulled in a superomedial vector from the lateral
orbital rim area (see Figure 7-65, H–I ). This produces a triangle
of excess lower lid skin and orbicularis muscle. This triangle is
pulled with minimum traction to prevent over-resection, and
the base of the triangle is trimmed. Caution must be used to
not pull the skin in an excessive superolateral vector; more skin
can be mobilized and an overestimation of the true skin excess
made, especially by novice surgeons. Some surgeons dispute this
and perform the opposite vectors, but regardless of one’s tech-
nique, conservative skin excision should be performed. Over-
treatment is a prime cause of lower lid retraction.
When the skin is pulled to determine the excess, it is taut
over the concave lower lid. To avoid miscalculation of the
amount of skin to remove, it is important to actually allow
the skin to drape over the contours of the lower lid. Pulling
the excess skin then using a cotton-tipped applicator to com-
press the skin against the lower lid complex will provide a more
accurate representation of the actual amount of skin to be
removed. The concave surface of the lower lid complex provides
more surface area, hence requires more skin to fill (see Figure
7-65, J–L). Using a wet cotton tipped applicator to gently
conform the skin into the slight concavity just below the inci-
sion can increase accuracy. At the end of the skin excision
procedure, the skin margins should lie passively without signifi-
cant gap, which can lead to lower lid retraction (see Figure 7-65,
M–O). The skin is then closed with 6-0 nylon or 6-0 fast-
absorbing gut sutures (see Figure 7-65, P).
It is always better to err on the conservative side when
performing this surgery; lower lid retraction from septal viola-
tion and excess skin removal is a problematic complication
that can lead to aesthetic and functional problems or a lawsuit.
A small skin pinch or resurfacing procedure can be performed
at a later date to revise undertreated skin. As I’ve said before,
I tell all my patients at the preoperative consult that a small
percentage will require a revision procedure, and I explain
that I am conservative with the eyes and don’t want to overtreat.
This is met with admiration and respect on the part of the
patient.
Lower Eyelid Canthopexy
As stated many times in this chapter, lower eyelid laxity can
cause significant aesthetic problems that are difficult to correct.
In addition, when the lower lid is pulled away from the globe,
irritation and dryness can occur as well as corneal damage. The
novice surgeon should avoid patients with laxity from aging or
other causes and refer them; it is a good idea to establish a
working relationship with a local oculoplastic surgeon. Such
mutually beneficial relationships can be very useful if and when
a complication arises.
There are many ways to address the loose lower eyelid,
including wedge resections and tarsal strip procedures, but
because of their functional nature, detailed description in this
chapter is prohibitive. It is important for any surgeon who
performs lower eyelid surgery to have some basic technique at
hand to address lower eyelid laxity.

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Chapter 7  •  Cosmetic Blepharoplasty
A
B
C
D
E
F
FIGURE 7-66.  A, To access the canthal raphe, a small pocket is made by bluntly spreading the scissors. B, Approximate
placement and direction of suture that will engage the pericanthal tissue. The suture needle is placed on the skin for illustration
but in reality is deep to the skin. C, Suture engaging the lateral canthus without tension. D, Suture with tension. Note supero-
lateral repositioning of the lateral canthus. E, Incision to the level of the periosteum of the lateral orbital rim on the left eye.
F, A rendition of the position of the suspension suture.

Chapter 7  •  Cosmetic Blepharoplasty
163
A
B
C
D
FIGURE 7-67.  Bleeding vessels complicate surgery and have the potential to cause blindness. Uncontrolled bleeding must be
anticipated by the blepharoplasty surgeon. A–B, Large veins in the upper lid. C–D, Vascularity in the periorbital fat pads.
two weeks earlier. Patients can often be too critical in the early
postoperative phase and they must understand that healing may
take weeks to months. Preoperative images are a life saver to
remind patients of their preoperative condition. It is not uncom-
mon for a patient to complain that the surgeon has caused given
problem that actually existed preoperatively and they have to be
educated by showing them their preoperative images and
reminding them of their original condition. Doctors without
pictures are defenseless.
Bleeding
Perhaps the most feared and serious complication of blepharo-
plasty surgery is postoperative hematoma. There are some pro-
cedures where minor bleeding is a lesser problem (chin and
cheek implants, for example), but active bleeding in the post-
blepharoplasty patient can be devastating and lead to blindness.
All blepharoplasty patients in my practice undergo preoperative
coagulation blood studies. In addition, any medication that can
affect platelet function must be discontinued 2 weeks before
surgery. Although it is rumored that homeopathic supplements
such as ginkgo, garlic, St. John’s wort, saw palmetto, and ginseng
can cause bleeding, this has been refuted.4
Blepharoplasty bleeding is generally associated with incised
vessels in the fat pads, but in actuality, most orbital bleeding
occurs from orbicularis oculi hemorrhage. The eye is very vas-
cular, and the supraorbital and supratrochlear veins are signifi-
cant vessels frequently encountered in cosmetic blepharoplasty.
Using coagulative incision modalities is a huge advantage, and
in my experience the incidence of bleeding-related post-bleph-
aroplasty complications is reduced with laser or electrosurgical
instrumentation. Figure 7-67 shows some common vessels I
have encountered in routine blepharoplasty surgery. The surgeon
must always use caution and anticipate the unexpected when it
comes to bleeding. Wearing a headlight and loupes is a major
advantage.
Eyelid bleeding can be problematic because the suture closure
prevents external drainage and the build up of blood can dissect
into the posterior orbit. The occurrence of retrobulbar hema-
toma is frequently cited in the literature as 0.04% for blepha-
roplasties.5 This is a true ophthalmologic emergency because
bleeding can compress the posterior orbital contents and com-
promise the vascular supply of the optic nerve, thereby causing
blindness. In the case of suspected retrobulbar hematoma, an
emergency lateral canthotomy must be performed by using

164
Chapter 7  •  Cosmetic Blepharoplasty
scissors horizontally to cut straight across the lateral canthus,
then turning the scissors vertically to cut the inferior canthal
ligament (inferior cantholysis). This allows the tight canthal
suspension sling to relax, which allows the orbital contents to
decompress. A solitary canthotomy will be expected to decrease
intraocular pressure by 5 mm Hg, whereas a canthotomy with
inferior cantholysis will decrease the intraocular pressure by
20 mm Hg.6 Normal intraocular pressure is less than 22 mm Hg,
and surgical intervention is required when the intraocular pres-
sure exceeds 40 mm Hg or there are signs of visual compromise.
An emergency consult with an ophthalmologist or oculoplastic
surgeon is imperative. In a true retrobulbar hematoma, the eye
becomes proptotic (protrudes) and tense. The inability to see
light or even count fingers are ominous signs. Other indicators
of retrobulbar hemorrhage include decreased ocular motility
(extraocular muscle movement) and afferent pupillary deficit .
In the normal patient, the consensual response is intact, and
when a light is shone in either eye, the contralateral pupil will
constrict. In a retrobulbar hematoma, shining a light in the
affected eye will not elicit pupillary constriction in either eye.
Fortunately, retrobulbar hematoma is a rare complication.
Although treatment is principally surgical, adjunctive medical
treatment may include IV mannitol (500 mg/kg), carbonic
anhydrase inhibitors (e.g., dorzolamide drops), and beta-blocker
eye drops to lower intraocular pressure.
Periorbital bleeding can simulate retrobulbar hematoma in
that the eye can become hard and proptotic. If a tonometer
confirms normal intraocular pressure and there are no visual
changes, no emergency care is necessary, and the swelling will
resolve spontaneously. Figure 7-68 shows a blepharoplasty
patient who had a significant intraoperative bleed that was
initially controlled but recurred after sutures were placed. Intra-
ocular pressure readings were normal, and the swelling and
firmness of the globe resolved over the next week.
When a bleeding vessel is encountered, it can be cauterized
with the defocused laser beam, direct or indirect electrosurgical,
or radiowave cauterization.. One of the best pearls I can offer
the novice blepharoplasty surgeon is the importance of owning
a small bipolar cautery forceps. Whether using traditional elec-
trosurgery or radiowave surgery, the importance of the small
bipolar forceps cannot be overstated. Minor bleeding may stop
spontaneously or is easily controlled, but brisk bleeding from
large vessels is emergent. Laser cauterization is effective with
small vessels or muscle ooze but ineffective in a pool of blood
(due to the laser’s affinity for water). Electrosurgery or radiowave
microneedles can also be ineffective for larger vessel bleeding.
In the case of brisk, uncontrolled bleeding, the surgical team
must shift into critical mode. This includes having larger suc-
tions on the tray to evacuate brisk bleeding and utilizing the
bipolar forceps (Figure 7-69).
Serious bleeding can also occur in the later postoperative
stages as well from various factors including rupture of a vessel
that was previously cauterized. Preoperative consents and post-
operative instructions should include cautions about refraining
from activities that could cause an increase in blood pressure or
strenuous activities such as lifting and bending. Some physicians
tell their patients not to lift anything over 10 pounds for 10
days. Interestingly, some patients actually plan work or sports
A
B
FIGURE 7-68.  This patient developed an orbital bleed after the left lid was
sutured and the right lid was being operated on (A). The left eye was
proptotic and tense, but her vision, reflexes, and intraocular pressure were
normal. The eye returned to normal in 2 weeks (B).
A
B
FIGURE 7-69.  A, Bipolar forceps are a mandatory instrument in blepharo-
plasty surgery and are invaluable in the control of brisk bleeding. They can
also be used to incise fat pads (B).

Chapter 7  •  Cosmetic Blepharoplasty
165
swell while some develop remarkable postoperative edema. The
preoperative consent and evaluation should definitively cover all
common complications including swelling. Generally, perioral
edema begins in the recovery area and will increase for 48 hours
and maximize at about 72 hours. Ice, head elevation, and avoid-
ance of strenuous activity are the first lines of defense against
excessive swelling. It is not uncommon for some patients to
develop chemosis (edema of the bulbar conjunctiva) from the
inflammation of surgery (Figure 7-71). Occasionally patients
can develop impressive chemosis, and this frequently occurs
from a Valsalva incident such as sneezing or coughing or more
frequently from overactivity in the early preoperative phase. This
can be very disconcerting for the patient and family, and they
must be reassured. Chemosis can be treated with dexamethasone
and Neo-Synephrine 2.5% drops, but I usually prescribe oral
steroids. Although very common, I have been unimpressed
with the results of tapering-dose packs. I use a regimen of 60
milligrams of prednisone (three 20-mg tablets) once a day for
5 days. This has proved to be very safe and effective and gener-
ally abates severe chemosis in 48 hours. I also use this regimen
in healthy individuals for other cosmetic-related edema. Warm
around a recovery because they will be off from work! The
surgeon must reinforce the need for limited activity, especially
for the first 48 hours. I have actually had patients tell me on
the day of surgery that they were going to remodel their garage
during recovery. Overactivity in the early postoperative stage
can be a prescription for disaster and the surgeon and staff must
impress this on the patient.
Ecchymosis
Postoperative bruising is not a serious complication but can
extend recovery and be disconcerting to patients. Some patients
will always bruise with any surgery, but some bruising can be
prevented or minimized. As stated earlier, preoperative coagula-
tion studies and the discontinuation of medications that alter
platelet function are essential in reducing bleeding and ecchy-
mosis. Using a hemostatic modality such as laser or radiowave
surgery will reduce postoperative bleeding and hence bruising.
Icing the periorbital areas, keeping the head elevated, and
refraining from strenuous activity in the first week after surgery
will also reduce bruising. Although I am not aware of any sci-
entific studies proving the effects of Arnica montana, many
practitioners swear that it reduces postoperative ecchymosis.
Even when obeying all the rules, some patients will present
with significant bruising, as shown in Figure 7-70. This bruising
can be subcutaneous or subconjunctival. Bruising will resolve
with ice for several days, followed by heat, reassurance, and
“tincture of time.
Postoperative Edema
Postoperative edema is an anticipated sequela of most facial
surgery, including cosmetic blepharoplasty. Swelling exhibits
extreme variability from patient to patient; some patients hardly
A
B
C
FIGURE 7-71.  Patient shown before surgery (A), 4 days after surgery (B),
and 3 weeks after surgery (C) after steroid treatment. Her chemosis was
severe and brought about by working in her yard in the early postoperative
period.
A
B
C
FIGURE 7-70.  All patients shown had normal coagulation studies and were
not taking medications that affect platelet function. They nonetheless
developed impressive periorbital or subconjunctival ecchymosis following
blepharoplasty.

166
Chapter 7  •  Cosmetic Blepharoplasty
A
B
FIGURE 7-72.  A, Patient underwent early wound dehiscence on postoperative day 4. B, The incision was cleansed and reclosed
and is shown 3 weeks later (B).
compresses are also utilized to soothe the eyes and reduce
swelling.
Wound Dehiscence
The eyelid skin is extremely thin, and the suture lines will occa-
sionally dehisce. In other parts of the face, this can be a signifi-
cant complication, but the eyelids are amazingly resilient to
secondary-intention wound healing with minimal scarring.
Small areas of dehiscence (under 3 mm) will generally heal
spontaneously without treatment and without scars. If wound
dehiscence occurs within the first 5 to 6 days, it can usually be
prepped and reclosed (Figure 7-72). Late-occurring dehiscence
can be left to heal, and the scar can be dealt with when mature.
Dry, Irritated Eyes
Blepharoplasty and the associated trauma can cause many tem-
porary changes in tear production, lid and blink dynamics, and
the ability to close the eyelids. In addition, some patients will
experience temporary lagophthalmos after blepharoplasty. Eye
irritation can also be caused by petrolatum or other laser oint-
ment getting into the eye.
When the lids do not close fully and there is decreased tear
production, the eyes can become dry, painful, and irritated.
Epiphora (excessive tearing) can occur from dryness and
irritation as well. Patients are instructed to use wetting drops
throughout the day and a more viscous drop at bedtime. I use
over-the-counter Refresh eye drops (Allergan Inc., Irvine, CA)
for these patients during the day and Refresh Plus eye drops at
night. This usually adequately hydrates the eye until the irrita-
tion or lagophthalmos resolves.
For resistant cases, the patient can cut a piece of cellophane
wrap the size of their palm and coat the periorbital region with
Vaseline and occlude the affected orbit with the wrap to prevent
nighttime dryness. Generally this situation will spontaneously
improve with conservative treatment. In the case of lower lid
retraction or inability to close the eyes (e.g., due to excessive
skin removal), severe corneal ulceration and damage can occur,
and the patient must be treated or referred to an ophthalmolo-
gist or oculoplastic surgeon for consultation.
Lower Lid Malposition
Excessive skin and muscle removal or middle lamellar contrac-
tion are leading causes of lower eyelid retraction. This can result
in aesthetic and functional problems, including ectropion,
canthal roundness, excessive scleral show, eyelid dysfunction,
dry eyes, and corneal damage. Minor lower lid retraction may
spontaneously resolve. In moderate cases of upper or lower lid
excessive skin resection, the patient may be able to massage
(Boxes 7-3 and 7-4) and stretch the skin over a period of time
to enable normal lid closure (Figure 7-73). In extreme cases,
surgical intervention is necessary. Various methods are used to
improve lower lid retraction, including canthopexy, mucosal
Box 7-3  Stretching and Massage Instructions for the Lower Eyelid
• Place inner pad of end of index finger below lashes.
• Push the lower lid up (80%) and roll in towards the eyeball (20%). This
will cover the eyeball with the lower lid and stretch it.
• Hold the pushup for 10 seconds.
• Do 10 lid pushups for 10 seconds (almost 2 minutes).
• Repeat 6 times daily.
• Some discomfort is expected.

Chapter 7  •  Cosmetic Blepharoplasty
167
There is often argument about which incisional modality
produces the most aesthetic postsurgical scar. Any incision
method will disrupt surrounding normal tissue. A scalpel inci-
sion has been shown to leave about 20 microns of lateral tissue
damage. Studies have also shown the Ellman 4.0 MHz radio-
wave system with a fine-wire electrode to be comparable with
scalpel incision. Lower-frequency electrosurgery machines and
CO2 lasers produce significantly greater lateral tissue damage
and hence can theoretically have a greater potential of scar
formation. Given the unique qualities of eyelid skin, most inci-
sions heal similarly by 8 to 12 weeks, regardless. I published a
study comparing 4.0 MHz radiowave surgery versus CO2 laser.
The blinded study followed 30 consecutive patients who had
upper blepharoplasty. One eyelid was incised with 4.0 MHz
radiowave surgery and the other with a 0.8-mm CO2 laser
handpiece. Observers were unable to tell the difference at 90
days, and statistically both had equal results.7 Figure 7-74 shows
a patient who had the left lid incised with 4.0 radiowave surgery
and the right lid incised with the CO2 laser. It is obvious that
they both heal nicely and similarly.
grafts to the lower conjunctiva, skin grafts to the lower lid skin,
and tarsal strip procedures to tighten the lid. Once more, the
best policy is to be conservative with skin removal and avoid
this complication.
Blepharoplasty Scars
Patients present to a cosmetic surgeon to look better. A poor
scar is never tolerated well. Unfortunately, no surgeon can guar-
antee scarless surgery, but fortunately the thin eyelid skin gener-
ally heals well or can be revised to do so.
A
B
C
FIGURE 7-73.  Patient underwent four-quadrant blepharoplasty. The lower
lids were treated with transconjunctival blepharoplasty and skin pinch. The
patient developed lower lid retraction on his right lower eyelid (A). Using
massage and stretching, the condition improved by 6 weeks (B) and was
normalized at the 3-month follow-up appointment (C).
Box 7-4  Stretching and Massage Instructions for the Upper Eyelid
• Put inner pad of the end of the thumb on the upper lid plate under the
lashes, and the index finger just above the thumb at the center of the
pupil.
• Raise the brows, pinch fingers to pull down.
• Pull the upper lid down and out a little.
• Hold down for 10 seconds.
• Repeat pull-down 10 times for 10 seconds (almost 2 minutes).
• Do this 6 times daily.
• The upper lid may also be stretched by spreading with the fingers.
• Some discomfort with this expected.
A
B

168
Chapter 7  •  Cosmetic Blepharoplasty
CO2
RF
1 week
A
CO2
RF
3 months
C
CO2
RF
1 year
D
CO2
RF
1 month
B
FIGURE 7-74.  This patient underwent upper eyelid blepharoplasty and is shown 1 week (A), 1 month (B), 3 months (C), and
12 months (D) after the procedure. The left eye was incised with an Ellman 4.0 MHz radiowave microneedle (RF), and the
right lid was incised with a 0.8-mm CO2 laser handpiece.
A
B
FIGURE 7-75.  The thin eyelid skin undergoes multiple stages of scar maturity, which often worries patients. They must be reas-
sured that the scars will improve in the coming weeks. The pictured patient is shown at 21 days (A) and 90 days (B).
Patients must be forewarned that eyelid incisions (especially
upper) will look worse before they look better; reassurance
throughout the healing process is merited. Wound margins are
frequently erythematous and irregular in the initial weeks post
surgery but undergo impressive healing by 8 to 12 weeks, at
which time many scars are barely perceptible. Figure 7-75 shows
an immature scar at 3 weeks and the same patient at 90 days.
Suture line “cysts” are milia (keratin-filled bumps) that
appear as small, whitish raised areas along the suture line and
often dissipate spontaneously but may take months. If they do
not resolve, they may be ablated with radiowave surgery or
similar ablative modalities.
Occasionally, eyelid scars will become hypertrophic (fre-
quently at the lateral orbit), and injection with triamcinolone
10 mg/mL on a monthly basis will improve these thickened
scars.
Lower Eyelid Conjunctival Granuloma
Although the transconjunctival incision generally heals rapidly,
a granuloma can occasionally occur (Figure 7-76). These are
innocuous lesions buy may be troubling or uncomfortable to
the patient. Although some granulomas will spontaneously
resolve, they are easily treated. The conjunctiva is anesthetized
with topical drops, and the lesion is grasped with a pickup
and its base incised and cauterized with radiowave or
electrosurgery.
Lagophthalmos
Inability to close the eyelids can be a temporary or permanent
situation. It is not unusual to have several millimeters of lag-
ophthalmos immediately after blepharoplasty. This can be a
result of orbicularis paralysis from local anesthesia, muscle

Chapter 7  •  Cosmetic Blepharoplasty
169
skin to fill. Failure to appreciate this can lead to excessive skin
removal. It is always important for the novice blepharoplasty
surgeon to remove a little less skin than anticipated.
Postoperative Upper Eyelid Ptosis
Postsurgical ptosis is generally a temporary phenomenon.
It can be caused by intraoperative problems such as direct
laceration of the levator or aponeurosis, as well as stretching
of these tissues. It can also result from local anesthetic effects
on the levator muscle and edema. Ptosis will generally
improve during the first postoperative week. Figure 7-78 shows
typical upper lid ptosis occasionally seen after cosmetic
blepharoplasty.
It is important to recognize and document preoperative
ptosis and inform the patient. Some patients will desire correc-
tion of this condition; others are not interested and only want
cosmetic blepharoplasty. Failure to inform the patient of preex-
isting ptosis during the preop consultation can end in long-
standing ptosis being blamed on the surgeon.
Revision Blepharoplasty
Surgeons who perform blepharoplasty will also perform
revision procedures on their patients. This can involve an
additional procedure to remove excess skin that was underex-
cised, remnant fat pockets, or resurfacing skin that requires
resection, skin resurfacing, or edema. Patients are reassured, and
the eye is kept lubricated until resolution, which is generally
with 1 to 2 weeks. Persistent lagophthalmos can be improved
by eyelid stretching and massage, as shown in Boxes 7-3 and
7-4. Impressive correction can be obtained by a conscientious
stretching regimen. Slight lagophthalmos in patients with
normal tear film mechanisms and Bell’s phenomenon can be
well tolerated, but in patients with compromised function,
severe complications can ensue. If the lagophthalmos is signifi-
cant and the patient is symptomatic (dry, burning, tearing eyes
with sclera injection and possible keratopathy and corneal ulcer-
ation), surgical intervention is necessary. The best means of
avoiding lagophthalmos is conservative surgery. It is better to
operate twice with normal function than to be overly aggressive
and have this complication. This underlines the need to leave
at least 20 mm of intact upper eyelid skin for normal function.
Even with this safety margin, inability to close the lids can result
from overzealous upper or lower skin resurfacing with chemical
peel, laser, or skin pinch procedures. Figure 7-77 shows a patient
who underwent upper blepharoplasty and lower transcon­
junctival blepharoplasty with periorbital laser resurfacing. The
patient shows significant lagophthalmos at postoperative day 4,
with total resolution at postoperative day 8.
Remember that when debulking the upper eyelid, removing
muscle and fat will create a concavity that will require residual
A
B
C
FIGURE 7-76.  This patient presented with a blood-filled granuloma about 10 days after transconjunctival blepharoplasty (A). The
lesion is removed with a radiowave microneedle (B), and the surgical site is shown 5 days later (C).
A
B
FIGURE 7-77.  A patient that underwent upper blepharoplasty and lower transconjunctival blepharoplasty with periorbital laser
resurfacing. The patient shows significant lagophthalmos at postoperative day 4 (A), with total resolution at postoperative day
8 (B).

170
Chapter 7  •  Cosmetic Blepharoplasty
FIGURE 7-78.  Patient with right upper eyelid ptosis 1 week after cosmetic blepharoplasty and perioral laser resurfacing. The
ptosis spontaneously resolved over the next week.
A
B
C
FIGURE 7-79.  A small percentage of patients may be undertreated and require revision blepharoplasty. A, Redundant skin after
blepharoplasty. B, Excess skin is marked for excision. C, The excess skin is excised and the wound is sutured.
Uneven creases present a significant postoperative challenge,
and meticulous attention to crease reconstruction in the preop-
erative marking phase cannot be overemphasized. To raise a low
crease, an ellipse of skin is marked on the lid with the low crease.
The inferior limb of the ellipse should correspond to the height
of the normal crease on the other eye. A skin muscle flap is
dissected inferiorly, and attachments and adhesions from the
previous surgery are freed from the levator aponeurosis inferior
to the new crease. This undermines the inferior tissues and
ablates the old crease. The wound closure incorporates supratar-
sal fixation sutures that capture the skin and muscle and then
pass through the levator aponeurosis to tether and better define
the new crease. When lowering a unilateral high crease, the new
incision is placed inferior to the current crease and the previous
crease is eliminated. Changing a crease is much easier if there is
remnant skin to be excised.
Clinical Cases
Figures 7-80 to 7-86 show before-and-after cases of blepharo-
plasty patients.
additional treatment. It is important not to jump the gun with
revision surgery, since many “problems” will autocorrect with
time. It is a good idea to allow at least 90 days after surgery
to permit spontaneous resolution of common sequelae. Figure
7-79 shows a patient who still had excess skin on the right
upper lid after blepharoplasty. Under local anesthesia, the
excess skin was marked and excised. Figure 7-79, A shows
the patient before revision; 7-79, B shows the marked excess
skin; and Figure 7-79, C shows the suture line immediately
after revision.
Eyelid Crease Problems
The production of symmetric well-placed eyelid creases is the
crux of upper eyelid cosmetic blepharoplasty. As we noted
earlier, most males have creases that average 8 mm, and most
females have creases that average 10 to 12 mm. Producing a
high crease in the male patient can feminize the result and be
quite unsightly. Most patients want to look more defined and
sculpted but not like a different person. Placing lid creases too
high in either sex looks very unnatural.

Chapter 7  •  Cosmetic Blepharoplasty
171
A
B
FIGURE 7-80.  Patient before (A) and after (B) upper blepharoplasty. The goal of this procedure is to sculpt the eyelid and restore
the youthful shelf. It is common for women to present at 2-week follow-up wearing eye shadow; many of them had been
unable to use it for years because of the excess skin obscuring the shelf.
A
B
FIGURE 7-81.  This patient underwent upper blepharoplasty and lower transconjunctival blepharoplasty with full-face CO2 laser
resurfacing.

172
Chapter 7  •  Cosmetic Blepharoplasty
A
B
FIGURE 7-82.  This patient exhibited advanced aging changes, including festoons of the lower lid/cheek complex. She was
treated with upper blepharoplasty and lower transconjunctival blepharoplasty with periorbital CO2 laser resurfacing. For festoons
of this nature, aggressive CO2 laser is quite effective for an otherwise difficult-to-treat area.
A
B
FIGURE 7-83.  This 62-year-old male underwent upper blepharoplasty and lower transconjunctival blepharoplasty with periorbital
CO2 laser resurfacing.

Chapter 7  •  Cosmetic Blepharoplasty
173
A
B
FIGURE 7-85.  This 61-year-old female underwent upper laser-assisted blepharoplasty with lower laser-assisted transconjunctival
blepharoplasty and lower lid skin pinch.
A
B
FIGURE 7-84.  This 47-year-old female underwent upper blepharoplasty and lower transconjunctival blepharoplasty with lower
skin pinch blepharoplasty.

174
Chapter 7  •  Cosmetic Blepharoplasty
A
B
FIGURE 7-86.  This 63-year-old male underwent upper blepharoplasty and lower transconjunctival blepharoplasty with CO2
periorbital resurfacing.
Postoperative Blepharoplasty Care
Postoperative care is centered upon keeping activity and blood
pressure down. Catastrophic complications including blindness
can and have occurred from retrobulbar hematomas with retinal
artery occlusion. Iced saline gauze, cold washcloths, or com-
mercially available cold packs or gel masks are immediately
applied and left on for 24 to 48 hours as much as possible. I
recommend to patients that they fill a salad bowl with ice and
water and chill 4 to 5 washcloths, alternating them on the eye
area as they get warm. The more cold therapy, the better. I ask
all patients to be a “couch potato” for 48 hours and sleep with
the head elevated. It is imperative that they do not Valsalva
or otherwise increase blood pressure to the head. Retrobulbar
bleeds have occurred from coughing, straining with bowel
movements, bending over, sexual intercourse, and other exer-
tion in the immediate postoperative period. The patient is
instructed to not lift anything over 10 pounds for 1 week. It is
also important to make sure that the patient refrains from any
medication that may prolong bleeding.
Medications can include (differing among practitioners)
antibiotics, analgesics, tapering steroids, and ophthalmic drops
(TobraDex or Oculoflox on occasion). The patient can expect
swelling and sometimes bruising. Pain is generally minimal with
routine cosmetic blepharoplasty unless corneal abrasion has
occurred. Patients should be able to see light and count fingers.
Reports of severe pain, throbbing retrobulbar pain, or frank
proptosis may signal retrobulbar hematoma and should be
immediately assessed. This is a true emergency.
If all four lids are done simultaneously or if brow lift or
periorbital laser are performed, the eyelids may swell shut for
24 to 48 hours and the patient should be instructed on that
preoperatively.
Routine wound care with hydrogen peroxide and antibiotic
ointment to the suture line is recommended, and it may be
helpful to wear sunglasses the first week.
Conclusion
Cosmetic blepharoplasty is truly one of the hallmarks of facial
rejuvenation and is very rewarding for both the surgeon and
patient. No other cosmetic procedure is more common in the
40- to 65-year age group. This procedure carries a steep learning
curve, but the training of the oral and maxillofacial surgeon is
adequate to begin learning this procedure. Proper diagnosis and
adherence to strict preoperative, intraoperative, and postopera-
tive pro­tocols are paramount to avoiding complications that
may be serious.
References
1. Niamtu J: Radiowave surgery versus CO2 laser for upper blepharoplasty
incision: which modality produces the most aesthetic incision? Dermatol
Surg 34:912–921, 2008.
2. Goldberg RA, Edelstein C, Shorr N: Fat repositioning in lower blepharo-
plasty to maintain infraorbital rim contour. Facial Plast Surg (3):225–229,
1999.
3. Hamra ST: The role of the septal reset in creating a youthful eyelid-cheek
complex in facial rejuvenation. Plast Reconstr Surg 113(7):2124–2141,
2004 Jun.
4. Beckert BW, et al. The effect of herbal medicines on platelet function: an in
vivo experiment and review of the literature. Plast Reconstr Surg 1:2044,
2007.
5. (accessed 12-3-08).
6. Personal communication: Lauren A. Eckstein MD, PhD; Philadelphia, PA;
November 2008.
7. Niamtu J: To débride or not to débride? That is the question. Rethinking
char removal in ablative CO2 laser skin resurfacing. Dermatol Surg 34:1001–
1012, 2008.
Suggested Readings
Baker TJ, Gordon HL, Stuzin JM: Surgical rejuvenation of the face, ed 2, St.
Louis, 1996, Mosby-Year Book, Inc.
Bozniak SL, Zilkha MC: Cosmetic blepharoplasty and facial rejuvenation, ed
2, Philadelphia, 1999, Lippincott-Raven.
Epker B: Textbook of esthetic maxillofacial surgery, Malvern, PA, 1994, Lea &
Febiger.
Larrabee WD, Makielski KH: Surgical anatomy of the face, New York, 1993,
Raven.
Lemke B, Cook B: Cosmetic blepharoplasty. In Niamtu J, editor: Oral and
Maxillofacial Surgery Clinics of North America, vol 12, Philadelphia, 2004,
Saunders, pp 91–130.
Lemke B, Cook B: Cosmetic facial surgery. In Niamtu J, editor: Oral and
Maxillofacial Surgery Clinics of North America, vol 12, Philadelphia, 2000,
Saunders, pp 673–687.
Owsley JQ: Aesthetic facial surgery, Philadelphia, 1994, Saunders.
Papel ID: Facial plastic and reconstructive surgery, ed 2, New York, 2002,
Thieme Medical.
Putterman A: Cosmetic oculoplastic surgery: eyelid, forehead, and facial
techniques, ed 3, Philadelphia, 1999, Saunders.

175
8 
RHINOPLASTY
ANGELO CUZALINA
R
hinoplasty, the quintessential “nose job,” is considered
the most complex and challenging cosmetic procedure
in aesthetic surgery today. Still, it remains an extremely
popular surgery: the fourth most common procedure in women
and the second most common procedure in men. Its popularity
has increased over the years, although not nearly as rapidly as
newer procedures such as liposuction.
Surgeons who elect to make rhinoplasty part of their reper-
toire must be committed to continued learning and improve-
ment that takes significant dedication. Rhinoplasty deals in
micrometers rather than inches and involves a structure that is
strategically placed in the middle of the face where any mistake
can be extremely obvious. To make matters more challenging,
there is certainly no cookbook method that can work for all
noses. It is important to have a systematic method for evaluating
the nose and planning treatment, but a dogmatic protocol is
impossible to create, since the nose comprises a mixture of
various skin types, cartilaginous shapes, and bony deformities
that can challenge even the most experienced surgeon.
An isolated chapter dedicated to rhinoplasty will certainly be
only an overview and create a good basic general knowledge,
but in no way can it cover the breadth of knowledge required
to be an expert in rhinoplasty. Many giants in the field of rhi-
noplasty have dedicated entire careers to understanding this
exciting procedure: Dean Toriumi, Gilbert Aiach, Jack Sheen,
Jack Gunter, Eugene Tardy, Rod Rohrich, and John Tebbetts.
Their multiple publications on rhinoplasty would be valuable
reading for any aspiring rhinoplasty surgeon.1-7 This chapter
seeks to give a basic understanding of classic rhinoplasty along
with an anatomic basis for typical techniques shown in a step-
by-step fashion.
Undoubtedly, all of the great rhinoplasty surgeons would
likely agree with Leonardo da Vinci who, 500 years ago, dem-
onstrated how important facial proportion is to beauty. Nowhere
is it more critical than in the middle of the face, where the
proportion of the nose is absolutely critical to the success of an
operation.8-10 Understanding correct proportion and how to
achieve this related to all subunits of the nose and the face as a
whole is an absolute necessity before taking on the nuances and
details of rhinoplasty itself (Figure 8-1).
The anatomy of the nose is complex for such a limited and
confined area, and a thorough understanding of nasal anatomy
can elucidate the minutiae of rhinoplasty. The unusual mix of
suspended cartilages that make up the bulk of the nasal structure
bears directly on the desired aesthetic outcome because the nasal
cartilages allow the majority of manipulation during rhino-
plasty. Cartilage and/or bony manipulation are generally
necessary to achieve a harmonious structure of the nose, which
is not only aesthetically pleasing but functional.
Anatomy
Terminology is the area that is most confusing for the novice
rhinoplasty surgeon, particularly because the standard terms for
direction (superior, inferior, anterior, and posterior) are used less
often than the terms cephalad, caudal, and dorsal/basal (Figure
8-2). The confusion is because of the ambulation of the nose in
relationship to the up-and-down position of the head, where
the ease of use—particularly cephalic, dorsal, and caudal—to
describe positioning during rhinoplasty surgery is more spe-
cific.11,12 Various physicians will certainly use terms interchange-
ably, and there are many other anatomic terms used to describe
the nose that may differ among all surgeons. The terms nasal
tip and nasal lobule are used interchangeably, although most
would describe the nasal tip as being the most projected point
of the nose that is positioned between the two domes as well as
between the supratip break and infratip break points. The tip
of the nose is probably the most important area because of its
location and all the finer details that make up its shape (Figure
1/3
1/3
1/3
1/5
1/5
1/5
1/5
1/5
Trichion
Glabella
Subnasale
Menton
FIGURE 8-1.  Nasal and general facial proportion is typically described as
seen here. Achieving harmony from cosmetic surgery often means cor-
recting disproportions. The nose takes up the middle third and middle fifth,
and its strategic location makes proper proportion even more critical.

176
Chapter 8  •  RHINOPLASTY
that make up the nose do function in facial expression and even
help with the function of breathing and animation during
smiling. The muscles can be divided into elevators, depressors,
compressors, and dilators of the nose. Typically the muscles are
paired and are extremely thin and much more superficial than
the other muscles of the body (Figure 8-5). Because a good
portion of the blood vessels course into the muscular layer,
surgical dissection must be limited below the muscular layer that
covers the bony and cartilaginous structures. Staying well below
the nasal musculature helps prevent damage to vessels, nerves,
and lymphatics. It also limits unnecessary bleeding that may
lead to excessive ecchymosis, edema, and scarring.
Certain muscles do occasionally require surgical treatment.
A depressor septi nasi muscle that is overactive can create a
significant ptotic-type displacement of the nasal tip when the
person smiles.14 Transection of this muscle is easily accom-
plished and can dramatically improve this deformity. Similarly,
the dilators of the ala, including the ala and nasalis muscle, may
occasionally be treated if excessive alar smiling is noted on high
smile. In general, the nasal muscles are avoided, particularly to
prevent excessive bleeding. The ideal plane for nasal dissection
is below the muscular position in most cases.
Nasal Blood Supply
The blood supply to the nose and septum is extremely rich and
comes from multiple sources.15-18 The classic interior nosebleed,
for example, comes from the Kiesselbach plexus on the septum,
which is an area where there is convergence of three arterial
sources: one from the branch of the superior labial artery, one
from the branch of the sphenopalatine artery, and the other
from the anterior ethmoidal artery (Figure 8-6).
The rich vascular supply allows the nose to heal well with a
very low risk of infection, as with most aesthetic surgeries of
the face. A specific local anesthetic technique to help cause
vasoconstriction of this rich blood supply during cosmetic
rhinoplasty is critical to allow for a relatively bloodless field
because of the delicate nature of the surgery. The blood supply
to the lateral internal and external nose is as well supplied as the
nasal septum.
The significant blood supply to the nose comes from both
internal and external carotid arteries and ultimately creates a
rich subdermal vascular plexus to the external nose itself.
Branches of the ethmoidal and superior labial artery extend to
the nasal tip, and the lateral nasal artery conveys an even more
robust blood supply to the nasal tip and allows for transection
of the columella without fear of ischemia (Figures 8-7 and 8-8).
Auspiciously, the significant plexus of the vessels arising from
multiple sources creates a venous and lymphatic network that
is largely the same. Many believe a closed rhinoplasty creates
less nasal edema, although arguments can be made that there
are adequate channels of lymphatic and venous drainage for
open or closed rhinoplasty. Therefore, postoperative edema from
rhinoplasty may be similar, since postoperative drainage should
be adequate for either technique if performed carefully.
Nasal Bone and Cartilage Anatomy
The bony vault at the nasion (nasofrontal suture) is the thickest,
most solid portion of the nasal structure. It is made up by the
8-3). The ill-defined nose is simply one that does not have all
its tip-defining points. This is also known as an amorphous nose
and may be due to either ill-defined cartilage or thick skin that
is hiding (camouflaging) the cartilaginous structure (Figure
8-4).
Skin thickness is an important part of the nasal anatomy that
must be recognized preoperatively. Classically, the thickness of
the skin differs along the dorsum compared to the rest of the
nose and nasal tip.13 In the region of the root of the nose, or
radix nasi, the skin is relatively thick and somewhat mobile. The
thinnest skin of the nose is classically over the rhinion, which is
in the mid-dorsal region and is quite mobile in this region as
well. The skin then becomes thick again in the tip region, where
it is most adherent and typically more sebaceous in nature. The
more sebaceous nasal tip skin does not heal well from external
scars. For instance, injury or an external incision on the nasal
tip for removal of a mole leaves a worse scar than on areas of
thin skin. Luckily, the columella has minimal sebaceous glands
compared to the tip and heals nicely from an open transcolu-
mellar rhinoplasty incision.
Nasal Musculature
The layer below the very thin subcutaneous level contains the
muscles that involve the nose. These muscles are commonly
thought of as an extension of the SMAS (superficial musculo-
aponeurotic system), a fibromuscular layer that involves not
only the muscles of the nose but extends laterally into the other
facial musculature and is commonly used laterally for face
lifting. There is some argument whether or not a true SMAS
exists or if it is simply a histologic diagnosis because of the thin
nature of this fibrotic tissue investing the muscle. The muscles
Superior
Inferior
Posterior
Anterior
Dorsal
Basal
Caudal
Cephalic
FIGURE 8-2.  Directional anatomy differs from standard body terminology
and can be confusing initially. In general, superior and inferior are replaced
by cephalic and caudal, respectively. Examples of common use of this
terminology for the colorized regions are: Green, Cephalic strip of the lower
lateral crural cartilage. Blue, Anterior septal angle. Red, Caudal septum.
Yellow, Dorsal hump.

Chapter 8  •  RHINOPLASTY
177
Radix
(root of the nose)
Supra alar
crease
Alar facial
junction
Alar margin
or rim
A
B
Supra alar
crease
Alar facial
junction
Glabella
Nasion
Rhinion
Supratip break
Tip
Infratip break
Subnasale
Facet
Ala
Columella
Footpads
Tip defining points
Infratip
lobule
C
D
E
FIGURE 8-3.  Classic nasal anatomic landmarks. Four tip-defining points that make up a well-defined nose can be seen in C
and D. They are created by the supratip and infratip breaks and the domes of the lower lateral cartilages. Some terms are very
similar (e.g., nasion, radix) but differ slightly; nasion correlates to the nasofrontal suture, whereas radix is the point where the
forehead joins the nasal dorsum.
A
B
FIGURE 8-4.  Examples of ill-defined or amorphous nasal tips. Both noses lack tip-defining points or any specific tip definition.
A, Poor definition due to irregular nasal tip cartilage and thick skin. B, Amorphous nasal tip due to rhinophyma, an overgrowth
of sebaceous subcutaneous tissues often secondary to rosacea.

178
Chapter 8  •  RHINOPLASTY
Medial
canthal
tendon
Orbicularis
oculi
Levator labii
superioris
alaeque nasi
(elevator)
Procerus
(elevator)
Compressor
narium
minor
Orbicularis oris
Dilator naris
anterior
Depressor
septi nasi
Anomalous
nasi
(elevator)
Transverse
nasalis
(a compressor)
Alar nasalis
(a depressor)
FIGURE 8-5.  Nasal musculature is made up of elevators, depressors,
compressors, and dilators. The two nasal depressors act to dilate
the nostrils and lengthen the nose. The two compressors narrow the
nostrils and rotate the nasal tip caudally. The three elevators dilate
the nostrils and rotate the tip cephalically. The nasal muscles in
general are innervated by the zygomatic branch of the facial nerve.
Quadrangular
septal cartilage
Anterior ethmoidal
artery (medial internal
nasal branch)
Septal and
columellar
branches of
the superior
labial artery
Perpendicular plate
of the ethmoid bone
Sphenopalatine
arterial (posterior
septal branch)
Vomer
FIGURE 8-6.  Blood supply to the nasal septum is robust and comes
from three major sources. At the Kiesselbach plexus (highlighted),
three arterial sources converge: one from the branch of the superior
labial artery, one from the branch of the sphenopalatine artery, and
the other from the anterior ethmoidal artery.
External nasal
branch
Anterior ethmoidal
artery (lateral internal
nasal branch)
Lateral nasal
branch of the
angular artery
Posterior ethmoidal artery
(lateral internal nasal branch)
Sphenopalatine
arterial
Greater palatine artery
Descending
palatine artery
FIGURE 8-7.  Blood supply to the lateral internal nasal wall is vigorous
and helps prevent problems when grafting the nose or stretching nasal
tissues. Multiple branches arise from both the internal and external
carotid arteries.

Chapter 8  •  RHINOPLASTY
179
the upper lateral cartilages. This root of the nose, where the bone
is thickest, is a common area for rasping to lower a nasal dorsal
hump in the cephalic portion. A very large nasal dorsal hump
may require the use of a Rubin or other osteotome to reduce
the bony dorsum (Figures 8-10 and 8-11).
The bones of the nose are quite variable in both thickness
and length. Patients with short nasal bones may be more at risk
for internal nasal valve collapse, since more of the middle nasal
paired nasal bones and the frontal process of the maxilla. The
nasofrontal angle, the anatomic position of the junction of the
frontal and nasal bones, is an important clinical landmark
(Figure 8-9). The nasal bones extend various lengths caudally to
connect with the upper lateral cartilage and can overlap the
cartilages by several millimeters.
The nasal bones are most adherent at the root or base of the
nose. The bones thin significantly as they extend caudally toward
Infraorbital
artery
Supraorbital
artery
Lateral
nasal artery
Supratrochlear
artery
Columellar
branch artery
Angular
artery
Septal branch
Dorsal
nasal artery
External nasal
branch of the
anterior ethmoidal
artery
Facial
artery
Superior labial
artery
FIGURE 8-8.  Blood supply to the external nose comes from internal and
external carotid arteries. Venous drainage parallels arterial supply and
drains to the pterygoid plexus and ophthalmic and facial veins. The rich
blood supply allows for multiple flap options for reconstructive rhinoplasty
and helps maintain great perfusion to the nasal tip even during open
rhinoplasty.
Nasolabial angle
95-105 degrees
for females, 90-95
degrees for males
Nasofrontal angle
normal 115-130
degrees
FIGURE 8-9.  Two common nasal-facial angle measurements are the naso-
frontal and nasolabial angles. Achieving angulations within norms for a
given patient will help achieve an aesthetically pleasing nose. Abnormalities
in angulations and facial proportions appear much worse than minor asym-
metries or shape irregularities. The nasofrontal angle is often slightly more
obtuse in females. Likewise, the nasolabial angle is ideally more obtuse in
females compared to males.
Superior limit
A
B
C
FIGURE 8-10.  The cartilaginous portion of a large nasal hump is initially transected (A) using a #15-blade scalpel. A Rubin
osteotome can then be used to remove the entire dorsal hump in one continuous piece, beginning below the upper lateral
cartilages (B) and then finishing just below the nasofrontal suture line (C).

180
Chapter 8  •  RHINOPLASTY
Anterior
septal
angle
Nasal
bone
Septum
ULC
Open
roof
A
C
B
D
E
F
FIGURE 8-11.  A, The anterior septal angle is exposed by pushing down on the lower lateral cartilages prior to dorsal hump
resection. B-D, Reduction of the cartilaginous dorsal hump, using scalpel and scissors. E, Rubin-type osteotome is used to
complete both cartilaginous and bony dorsal hump reduction. The instrument must be used cautiously to avoid overresection
of the bony dorsum. F, Following dorsal hump reduction, an “open roof” deformity is commonly seen, with exposed septum
and separated upper lateral cartilages (ULC) and lateral nasal bone edges.
vault will be formed by long upper lateral cartilages that make
up a portion of the internal valve.19-22
The nasal bones connect caudally to the paired upper lateral
cartilages (Figure 8-12). There is a very firm attachment to the
nasal bone and upper lateral cartilages, particularly along the
medial edge adjacent to the septum. The upper lateral cartilages
extend just over 5 mm beneath the nasal bones to allow for a
firmer attachment. Extreme rasping with a coarser aggressive
rasp can potentially dislodge the upper lateral cartilages from
the nasal bone insertion, creating a significant deformity if
unrecognized. The upper lateral cartilages provide the majority
of support in the middle third of the nasal pyramid, along with

Chapter 8  •  RHINOPLASTY
181
Upper lateral
cartilages
Long nasal
bones
Septum
Short nasal bones
Septum
A
B
FIGURE 8-12.  This resected nasal dorsal hump demonstrates how the
septum, upper lateral cartilages, and nasal bones interdigitate. A Rubin
osteotome was used to remove the nasal dorsal hump in one continuous
piece. Continuous hump excision is often required for large dorsal humps
but can easily be the cause of asymmetry or overreduction if the osteo-
tome is not positioned perfectly.
the anterior border of the nasal septum. The lateral cartilages
continue along the anterior border of the septum, with peri-
chondrium covering both the superficial and deep surface.
The portion of upper lateral cartilages that connect to the
nasal septum in the mid-vault region constitutes a landmark
termed the internal nasal valve. This area is an extremely impor-
tant region with regard to potential breathing compromise
before and after rhinoplasty surgery. The action of the dilating
muscles on the lateral portions of the upper and lower lateral
cartilages play a role in maintaining at least a 10- to 15-degree
angle of the nasal valve to maintain adequate airflow. Damage
to the dilating muscles or direct damage and scarring of the
valve itself can hamper breathing through the nose. Scarring in
the valve from overaggressive resection of overlying lateral car-
tilages is the most common culprit. Patients with a classic high,
narrow vault to begin with are more at risk for nasal vault
problems following rhinoplasty, and this must be noted in the
consultation (see Case 6). A patient with a high, narrow vault
requiring significant hump reduction may require spreader
grafts placed between the resected dorsal septum and upper
lateral cartilages to prevent valve compromise after surgery
(Figure 8-13). To avoid causing breathing or cosmetic problems
from middle vault collapse, caution must always be used when
resecting any portion of the upper lateral cartilages.
The anatomy of the lowest portion of the upper lateral car-
tilage can be quite variable where the upper lateral cartilages
connect to the lower lateral cartilages. This area is considered
the scroll region. The upper and lower lateral cartilage connection
has been described by different authors. One of the most
common describes the cartilages connecting by interlocked
shape 52% of the time, overlapping 20% of the time, end to
end 17% of the time, and opposed 11% of the time (Figure
8-14). The scroll area provides significant support to the nasal
pyramid, particularly the tip.
The lower lateral cartilages form the majority of the nasal tip
and account for the majority of patient complaints with regard
to the shape of the nose.23 The nasal bones and upper lateral
cartilages create the classic nasal dorsal hump, whereas the lower
lateral cartilages create the common complaint of a bulbous or
boxy nose deformity. The structures of the lower lateral carti-
lages involve a medial, intermediate, and lateral crus. They not
only affect the nasal tip appearance but help in function. The
thickness and elasticity of the lower lateral cartilages play a
major role in the external nasal valve and overall tip support.
The lower cartilages, particularly the intermediate crus, help
make up the dome (Figure 8-15).
The angulation of the lower lateral cartilages themselves can
vary tremendously from patient to patient. The axis of the lateral
crus can be very oblique or positioned more medially. In addi-
tion to varying positions of the axis, the cartilage can actually
be concave in shape rather than the more common convex
shape. Often the lateral crus will have an irregular distorted
appearance simply as a congenital anomaly. The relationship of
the caudal edge of the lateral crus adjacent to the anterior septal
angle makes up the very important supratip region (Figure
8-16). The various morphologies of the medial, intermediate,
and lateral crural cartilages can dramatically change the appear-
ance of a nasal tip, which explains why the vast majority of grafts
placed in the nose are used in this region.
The nasal septum, which connects to all the previously men-
tioned structures—nasal bones, upper lateral cartilage, and
lower lateral cartilage—provides significant support to the nose
throughout its entire length and plays a big part in both a nasal
dorsal hump and actual tip projection.24-29 Compared to the
medial crural cartilages that make up a portion of the columella,
the caudal septum itself is a sturdier type of cartilage and must
be addressed for problems such as hanging columella and almost
any other major tip-projection issue. The nasal septum is com-
posed of bone and cartilage, the perpendicular plate of the
ethmoid, the vomer, and the quadrangular cartilage (Figure
8-17). It also has a rich blood supply as previously described
and can have various shapes when it connects to the maxillary
crest, along with multiple deformities and deflection types. An
asymmetric nose is basically impossible to treat without address-
ing the septum, which inevitably plays a major role in a crooked
shape or asymmetries. Also, the nasal septum is one of the best
sources for cartilage or bone for grafting the tip or dorsum in
reconstructing defects. The classic description of cartilaginous
sparing of the nasal septum has to do with leaving a 1-cm caudal
and dorsal strip to provide adequate support of not only the tip
but the dorsum in order to prevent tip grafts or a saddle nose
deformity. While the 1-cm rule is certainly a landmark, multiple
other factors play a role in the amount of septum to leave
behind. Thickness of residual bones, upper and lower cartilages,
and additional grafts all affect the strength of tip projection. The
key is to realize that the septum has a major function in the
aesthetics of rhinoplasty surgery, particularly with support of
the nose, and is invaluable as a source for tissue grafting. The
inferior turbinates are often a source of nasal obstruction and
septal deviation and must be evaluated before and during