Essentials of Aesthetic Surgery

422
Part VII Facial Surgery
TIP:
fascia lining the forehead flap and not by the skin level of the flap. Tension-free
reapproximation of the scalp skin wound edges will minimize local ischemia, which will
preserve hair follicles and result in less scalp scarring.






reposition redundant skin rather than excise it, but no studies have




Fixation section).








DISSECTION PLANES FOR ELEVATION OF A FOREHEAD FLAP
SUBCUTANEOUS


the eyebrow
• Used relatively infrequently today

• Simple anatomic dissection
• Preserves scalp sensation because deep division of the supraorbital nerve is deep to
the level of dissection
• No requirement to release soft tissues from bone because transposed skin plane
elevates the eyebrows
• Treatment of deep transverse forehead rhytids is facilitated with skin redraping.
• Hairline position can be lowered or raised.

423
Chapter 33 Browlift

, which may increase risks of skin slough and
scalp alopecia.
• Sensibility of the central forehead can be decreased by trauma to branches of the

the subcutaneous plane. This sensory loss is usually only temporary, however.
• Transition to a deeper plane is required to treat the corrugator and procerus
muscles.
SUBGALEAL

• Historically, this “natural cleft” in the forehead soft tissues invites its use for
dissection.

• Relatively avascular dissection plane
• Allows excellent exposure of the deep surface of the frontalis muscle for scoring and



plane into the “glide plane” space
TIP: The glide plane space exists within the layers of the deep galeal plane over the

surfaces for the movement of the overlying transverse head of the corrugator supercilii
muscle.

• Will place the deep division of the supraorbital nerve at risk of transection (see
Sensory Innervation section).
SUBPERIOSTEAL

• Developed as an alternative to the subgaleal plane
• Most frequently used in endoscopic-assisted and limited-incision techniques

• Plane relatively avascular
• Avoids deep division of the supraorbital nerve

• Some authors argue that the inelasticity of the periosteum allows a more sustained


• Periosteal and galeal attachments along the superior and lateroorbital rims must be

• Periosteum must be penetrated to treat the muscles that act on glabellar skin.

424
Part VII Facial Surgery
METHODS OF FIXATION




18 whereas others suggest the need to
secure at multiple locations.19
TIP:





• When skin is excised immediately superior to the eyebrow using the “direct”
technique, the amount of eyebrow elevation is usually
, and the tension of the wound closure is



method. In contrast to the “direct” technique, however, the scalp tissue must be
advanced approximately to obtain 1 mm of eyebrow elevation because of


ischemia and secondary wound-healing issues, including scalp alopecia.

• The eyebrow can be elevated when the galeal plane superior to the eyelid is
vertically shortened using a plication suture technique and produces a stable

• Suturing the galea to periosteum can elevate the eyebrow with long-term

• A screw placed into the skull or a short tunnel made in the outer cortex of the skull
can serve as an anchor point for a suture to suspend the galea plane to elevate and

(see Chapter 26)

to bone.

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Chapter 33 Browlift
SURGICAL MODIFICATION OF MUSCLE

• Skin lines and grooves occur in a perpendicular orientation to the direction of

muscle can be expected to make the rhytid less deep and make the skin smoother.
Although chemodenervation of muscle with botulinum toxin yields excellent, but


• This muscle can be “scored” (incised) either horizontally, vertically, or both to
denervate the muscle; however, this technique is infrequently used today.
• A strip of the muscle can be excised to weaken its capacity to contract.
• When these techniques are used, care must be taken to preserve the inferior 2 cm
of frontalis muscle to maintain enough residual function to move the eyebrows.
SENIOR AUTHOR TIP: These techniques often produce a forehead with a “frozen’”
appearance and are uncommonly done today. The transverse forehead line formation
can often be remarkably improved, while retaining normal frontalis muscle function,
simply by removing excess upper eyelid skin with a blepharoplasty. The presence of




a lower eyebrow level in the absence of the induced frontalis muscle tone that had
suspended them. Performing an upper blepharoplasty without also planning for
management of eyebrow position can result in the cosmetic problem of undesirably
low positioned eyebrows. This issue should always be considered when planning to
do only an upper blepharoplasty procedure on a patient. In my (D.K.) experience, it
is often unwise to do an upper blepharoplasty without also performing some form of
browlift procedure.

• Resection of the corrugator supercilii muscle group
• Transection of the procerus muscle

SENIOR AUTHOR TIP: In my experience, complete rather than partial excision of the
corrugator supercilii muscle group is advisable. When the corrugator muscle is only

produces the appearance of small “horns” in the glabellar area. In contrast, simple
transection of the procerus muscle has proved adequate treatment to weaken this
muscle’s function with its production of transverse lines across the root of the nose.

glabellar skin lines can be controlled with a 1 x 1 cm myotomy directly under the medial
head of the eyebrow.

426
Part VII Facial Surgery
• To prevent excessive brow widening, the medial retaining structures must not be
overly released.20
SENIOR AUTHOR TIP: The existence of medial retaining ligaments is not agreed on

with the overlying deep galeal plane. However, there is no anatomic evidence that

orbicularis oculi muscle, much less into the dermis under the medial end of the eyebrow.
To “retain” the medial eyebrows from bone, any retaining ligament would have to pass
through the frontalis muscle to the overlying dermis. Widening of the medial ends of

resection of the transverse head of the corrugator supercilii muscle, whose contraction
causes the medial ends of the eyebrows to move closer together. When this muscle is
excised, the medial eyebrows would be expected to move apart, perhaps to the level
that they were before hypertonicity of the corrugator supercilii muscle developed over
time.
POSTOPERATIVE CARE
FOCUSED ON LIMITING EDEMA AND PROTECTING THE EYES
Elevate head above the level of the heart.
Apply continuous cool compresses over the eyes.
Saline eye drops and protective ointments are important when blepharoplasty is
performed concurrently with a browlift procedure, because temporary lagophthalmos

Drains are often placed and are usually removed in 24 hours.
• Sutures in the eyelids are removed in 5-7 days, and surgical staples or sutures in the
scalp are removed in 7-14 days.
COMPLICATIONS

• Dissection with the limited incision, endoscopic-assisted, and subcutaneous browlift
technique can protect the deep division of the supraorbital nerve from permanent
injury, although temporary paresthesias of the forehead skin and/or scalp occur
often.
• With or incisions, the deep division of the supraorbital
nerve is usually transected, producing posterior to the level
of the incision.
• Injury to the deep division of the supraorbital nerve is more common with subgaleal
dissection.
• When this outcome is expected, it should be explained to patients as part of
appropriate informed consent.
• Byun et al
21 conducted a systematic review and reported technique-associated
complications:
: Alopecia (8.5%),
paresthesia (5.4%), scar revision (2.1%), skin necrosis (1.8%)
Nerve injury (6.4%), scar
revision (2.5%), hematoma (1.0%)

427
Chapter 33 Browlift
had the highest number
of complications overall: Asymmetry (3.6%), lagophthalmos (2.7%), recurrence
(2.4%).

• Thinning or loss of scalp hair can result from excessively tight wound closure, which
can produce local ischemia.

Use of bipolar cautery might limit the zone of thermal injury.

• The frontal (temporal) branch of the facial nerve is vulnerable to injury from
excessive traction or transection during dissection in the temporal fossa area.
• A working knowledge of the anatomy of this nerve is essential for browlift
procedures.

• Excessive elevation of the eyebrow produces a “surprised” appearance, and this

TIP: Although the lateral eyebrow segment must always be elevated, elevation of the
medial segment is rarely indicated.

• Skin surface deformities can result from aggressive scoring or excision of the
frontalis muscle.
• A skin depression across the root of the nose at the level of transection of the
procerus muscle can occur. A small graft of fascia placed across the transected

• Resection of the corrugator supercilii rarely leaves a skin depression or deformity.
Some surgeons have placed soft tissue grafts, such as fat, in the area of the resected
corrugator muscle, but this is usually unnecessary.
TOP TAKEAWAYS

Surgeons who become students of forehead and temporal fossa anatomy will


complication.

Surgeons should know the advantages and limitations of each browlift
procedure and apply the appropriate procedure to each patient based on the


Each patient should be carefully evaluated for appropriate indications for
undergoing a surgical procedure and provided with appropriate informed
consent to proceed with the surgical procedure.

Every browlift procedure (except direct excision) requires adequate release
of the soft tissues from their deep attachments before the tissues can be
transposed cephalad.


stability of the surgical result.

There is no clear evidence showing the superiority of either the open or
endoscopic browlift technique.22,23

428
Part VII Facial Surgery
REFERENCES
1. Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr Surg 99:1807, 1997.
2. Fruend RM, Nolan WB. Correlation between brow lift outcomes and aesthetic ideals for eye-
brow height and shape in females. Plast Reconstr Surg 97:1343, 1996.
3. Codner MA, Kikkawa DO, Korn BS, et al. Blepharoplasty and brow lift. Plast Reconstr Surg
126:1e, 2010.
-

5. Knize DM. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty.
Plast Reconstr Surg 102:478, 1998.
6. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconst
Surg 97:1321, 1996.
7. Byrd HS, Burt JD. Achieving aesthetic balance in the brow, eyelids, and midface. Plast Reconstr
Surg 110:926, 2002.

Corrugator topography. Plast Reconstr Surg 120:1647, 2007.
9. Janis JE, Hatef DA, Hagan R, et al. Anatomy of the supratrochlear nerve: implications for the
surgical treatment of migraine headaches. Plast Reconstr Surg 131:743, 2013.

II. Supraorbital nerve branching patterns. Plast Reconstr Surg 121:233, 2008.
11. Janis JE, Potter JK, Rohrich RJ. Brow lift techniques. In Fagien S, ed. Putterman's Cosmetic
Oculoplastic Surgery, ed 4. Philadelphia: Elsevier, 2007.

Plast Reconstr Surg 134:426, 2014.
13. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg 124:2118, 2009.
14. Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast
Reconstr Surg 95:52; discussion 61, 1995.
15. Guyuron B. Corrugator supercilii resection through blepharoplasty incision. Plast Reconstr Surg
107:606, 2001.
16. Camirand A, Doucet J. A comparison between parallel hairline incisions and perpendicular
incision when performing a facelift. Plast Reconstr Surg 99:10, 1997.

Plast Reconstr Surg 97:1334, 1996.

controversies and rationale. Plast Reconstr Surg 100:1575, 1997.

-
cepts, including endoscopic methods. Plast Reconstr Surg 134:1141, 2014.
21. Byun S, Mukovozov I, Farrokhyar F, et al. Complications in brow lift techniques: a systematic
review. Plast Reconstr Surg 130(5S-1):S90, 2012.
22. Sullivan PK, Saloman JA, Woo AS, et al. The importance of the retaining ligamentous attach-
ments of the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast Re-
constr Surg 117:95, 2006.
23. Graham DW, Heller J, Kurkjian TJ, et al. Brow lift in facial rejuvenation: a systematic literature
review of open versus endoscopic techniques. Plast Reconstr Surg 128:335e, 2011.

429
RELEVANT ANATOMY
Capsulopalpebral fascia

superioris muscle
Superior rectus muscle
Inferior rectus muscle
Inferior oblique muscle
Inferior tarsal muscle
Orbital septum
Arcus marginalis

Conjunctiva
Müller muscle
Superior tarsus
Inferior tarsus
Orbicularis oculi muscle
Orbital septum
Whitnall ligament

Cross section of the upper and lower eyelids.
UPPER EYELID LAYERS
Skin, subcutaneous tissue (retroorbicularis oculi fat [ROOF] and
suborbicularis oculi fat [SOOF]), and orbicularis oculi muscle (OOM)
Orbital septum
NOTE:

Tarsus and conjunctiva

430
Part VII Facial Surgery
ORBICULARIS OCULI MUSCLE
(Fig. 34-2)
• Frontal, zygomatic, and buccal contributions from facial nerve (CN VII)
• Medial and lateral innervation points
Zygomatic nerve
branches
Buccal nerve
branches
Frontal nerve
branches
Medial and lateral innervation points warrant consideration of orbicularis oculi muscle

(Fig. 34-3)
Infraorbital nerve
Zygomaticus minor
muscle
Lateral raphe
Zygomaticus major
muscle
Depressor septi nasi
muscle
Frontalis muscle
Orbital orbicularis muscle
Preseptal orbicularis muscle
Anterior reflection of
medial canthal tendon
Levator labii superioris
alaeque nasi muscle
Pretarsal orbicularis muscle
Transverse part of
nasalis muscle
Levator labii superioris
muscle
Muscular anatomy of the periorbital region.
TIP: Considering the OOM as a sphincter muscle with three segments facilitates
understanding the consequences of eyelid surgery, botulinum toxin administration,
ligament release, and preservation of muscle innervation.

431
Chapter 34 Upper Blepharoplasty



– Interdigitates laterally and medially with CSM under dermis and with













TIP: The preseptal orbicularis is adherent to the septum, and careful dissection in the


plane. At least a strip of pretarsal orbicularis must be preserved for proper eyelid
“sphincter” function.
TARSOLIGAMENTOUS COMPLEX

• 7-11 mm wide
• Müller muscle inserts onto superior border of tarsal plate.


• Help to form shape, position, and magnitude of upper eyelid crease

• Orbital septum
Firmly attached at posterior surface of orbicularis “sphincter”; fuses

lymphatic) support
4
5-9
Present between the eyelid fold and lash line (deep to orbicularis and

levator aponeurosis at a variable location superior to the tarsus.



and lateral raphe.
• Contributes to against the lateral orbital rim, where the

5-7
• Acts as lateral anchor (fulcrum) for eyelids

432
Part VII Facial Surgery
(Fig. 34-4)
• Formed by:




Deep limb of
lateral canthal tendon
Lateral orbital tubercle
Superficial limb of
lateral canthal tendon
The lateral canthal tendon has posterior and anterior limbs.
MEDIAL CANTHAL TENDON
Tripartite structure (anterior horizontal, posterior horizontal, and vertical components)
Formed by:
• Deep head of pretarsal orbicularis

• Check ligament of medial rectus muscle
• Whitnall ligament
ORBICULARIS RETAINING LIGAMENT
Also known as 8 or
9 in lower periorbita
“Near-circumferential” retaining structure encircling upper and lower orbit7


• Medial tightness may be the reason for lack of medial hooding and tear trough
phenomenon (medial depression/line at inferomedial periorbita).
Extends from OOM to the periosteum
True retaining ligament
May have lymphatic properties
Protects ocular contents: Semipermeable membrane
TIP:

browlifting. Medial preservation in the corrugator region may minimize medial brow
splaying.

433
Chapter 34 Upper Blepharoplasty
PRESEPTAL FAT
Between orbital septum and orbicularis muscle
Can contribute to upper eyelid lateral hooding
ROOF
SOOF
ORBITAL SEPTUM
Protective function
Extension of orbital periosteum
• Fuses with periosteum to form the in upper and lower periorbita
Extends from superior orbital rim to insertion on levator aponeurosis at
varying levels (10-15 mm above superior tarsal border)
Extends from inferior orbital rim to the capsulopalpebral fascia (5 mm
below lower tarsal border)

LEVATOR PALPEBRAE MUSCLE

Superior edge of tarsus (conjoined fascia)
CN III
10-15 mm upper lid excursion and sustained lid elevation from contractile tone
NOTE:

Fascial condensation 14-20 mm from superior edge of tarsus.
translates posterior vector of pull into a superior direction
TIP: The main cause of postoperative upper eyelid ptosis is “unrecognized”
preoperative ptosis. Examination for upper eyelid ptosis preoperatively is essential.
Orbicularis retaining ligament (ORL). Orbicularis oculi muscle (OOM).
Capsulopalpebral fascia
Orbital Septum
O
ularis retaining ligament
Orbic
bicularis oculi Muscle
Orb
icularis oculi fat (SOOF)
Suborbi
omatic space
Prezygo
osteal fat
Preperio

434
Part VII Facial Surgery
MÜLLER MUSCLE
Posterior lamella of levator palpebrae muscle

Superior edge of tarsus
Sympathetic system
2-3 mm of upper lid lift
TIP:

that stimulate the Müller muscle can help until full levator function returns.
ORBITAL FAT PADS
(Fig. 34-6)
compartments in lid (medial and middle)


compartments.

in lid (medial, central, and lateral)

Eisler fat pad
Lacrimal gland
Arcuate expansion
of Lockwood ligament
Lateral canthal tendon
Lateral fat pad
Nasal fat pad
Inferior oblique muscle
Medial canthal tendon
Interpad septum
Nasal fat pad
Central fat pad
Central fat pad
Controversy exists regarding the true distinction of separate fat compartments;
however, preservation of fat volume during blepharoplasty is a hallmark of the modern surgical
approach.
LACRIMAL APPARATUS
Palpebral and orbital segments separated by levator aponeurosis



nasolacrimal duct.

435
Chapter 34 Upper Blepharoplasty


through the punctum and canaliculus into the sac.

duct.
TEARS


• Antibacterial properties
• Oxygenation of corneal epithelium
• Smooth, refractive globe surface



Thicker, secreted from lacrimal gland and accessory glands of Wolfring
and Krause
Maintains lid contact with globe; produced by mucin goblet cells

• Accessory lacrimal glands of Wolfring and Krause, mucin goblet cells, and
meibomian glands

• Main lacrimal gland, parasympathetic
INDICATIONS AND CONTRAINDICATIONS
CLASSIC INDICATIONS PPER EYELID
Excess upper eyelid skin
Upper eyelid fold excess

• Asian ethnicity with indistinct lid crease (see Chapter 34)
NOTE:

Fine periorbital or eyelid rhytids
TIP: A brow evaluation is critical in all patients (see Chapter 33). Often, a browlift

EYELID PATHOLOGY AND DEFORMITIES
True excess of upper eyelid skin
Excess fat protruding through septum

436
Part VII Facial Surgery

• Thin upper and lower lid skin allows presentation of cyclical lid edema (with or
without erythema).
• IgE and histamine are released.
• In 80% of patients, onset is before 20 years of age.
• Edema is refractory to antihistamines and steroids.

• Drooping of upper eyelid

• See Chapter 39 for further details.

• Eyelid margin is in normal position; however, excess upper lid and/or brow weight is
ptotic (MRD is within normal limits).
• This may indicate blepharoplasty in conjunction with a browlift procedure.
Excess attenuation of canthus and septum
TIP: Blepharoptosis is not a contraindication to blepharoplasty, but it must be fully
evaluated, informed, discussed, and treated.
SENIOR AUTHOR TIP: Eyelid ptosis should be corrected during blepharoplasty.
PREOPERATIVE EVALUATION
HISTORY
Patient expectations
• Functional versus aesthetic
• Detailed discussion is needed to inform patients of the cause of the problem (with
the aid of a handheld mirror) and what can be done to correct it.
• Unrealistic expectations are unmasked and discussed.
• Video imaging has been most helpful in discussing patients’ expectations and
whether they are realistic.
SENIOR AUTHOR TIP: With the Internet and media as a prevailing “pseudoeduca-
tional” force, patients may come in telling the doctor what procedure they need or
want, as if ordering at a restaurant (e.g., “I don’t want a browlift or anything fancy, just a
little of this excess skin removed.”) Patient education is more and more critical in today’s
practice environment. Surgeons should always recommend and do what they think is
correct. Our job is to inform patients, make the recommendations that we think are
best, and discuss the procedure or procedures, risks, and expected outcomes, including
the quality of the result and the expected recovery. With this information, patients can
make a truly informed decision.
PERTINENT MEDICAL CONDITIONS

Grave disease
Benign essential blepharospasm

437
Chapter 34 Upper Blepharoplasty
Dry eye syndrome
• Ask about eyedrop use and probe for details about dry eye symptomalogy.
• Contact lens use
• Bell phenomenon test
• Consider Schirmer test
TIP: A history of dry eyes with decreased tear production (frequent use of eye

can lead to corneal exposure (keratoconjunctivitis or ulceration). An abnormal Bell
phenomenon increases the risk of corneal complications. A more conservative
blepharoplasty with possible temporary tarsorrhaphy may be best versus no surgery
at all for this group of patients.

• Best to to allow corneal incision time to heal
SENIOR AUTHOR TIP: Some ophthalmologists even recommend allowing 24 months

Epiphora: Excess tearing
• History of Bell palsy (crocodile tearing)
• Gustatory epiphora
Blepharoptosis
• Discussed previously and in Chapter 39.
General medical conditions
• Coagulopathies

CAUTION:

• Severe “periorbital” allergic symptomatology
• Thyroid dysfunction
• Hypertension
• Renal or cardiac abnormalities
• Neurologic


OCULAR EXAMINATION
The best for each eye is recorded.
• May require a more accurate assessment by an ophthalmologist (especially with
insurance-related cases)

If lids are forcibly held open while patient attempts to close them,
then globe should rotate upward.
• Built-in protective mechanism
• When not present, patient more susceptible to dry eye exacerbation with even
minimal postoperative lagophthalmos

438
Part VII Facial Surgery
LACRIMAL FUNCTION TEST
Most important in elderly and patients with a history of dry eyes
• May consider ophthalmologic referral preoperatively


on lateral sclera
• More than 10 mm wetting after 5 minutes is normal.
Basic secretion

• Usually <40% of Schirmer test I

electrophoresis
AESTHETIC EVALUATION
Orbital rim
indentation
Malar
mound
Tear trough and
nasojugal fold
Medial fat
Brow ptosis

Youthful
Aged
Characteristics of the aging periorbital region.






with gentle to moderate pressure/massage. Patient is then asked to open
both eyes.

is diagnosed.
NOTE:

Indicate excessive frontalis hyperactivity

frontalis muscle activity

439
Chapter 34 Upper Blepharoplasty

muscle bulging will produce imbalanced periorbital rejuvenation.





injection.

detailed sculpting of the sulcus.


an awkward appearance.

relation)

from lateral orbital rim.
TIP: Transpalpebral corrugator muscle resection is a powerful adjunct to upper
blepharoplasty when a full browlift is not indicated or desired by the patient. Recent
anatomic details on the corrugator may assist in a more thorough and accurate
resection.10,11

(Fig. 34-8)
12-14 mm
vertically, 28-30 mm horizontally
At level of upper
limbus (may be slightly below;
can be attractive in certain faces).
Highest point is just medial to pupil.
3-6 mm
(may be cultural). Makeup

show.

7-8 mm in women and slightly
more in men
1-2 mm above
medial canthus (aesthetic canthal
tilt)

<1-2 mm, which may require
concomitant canthoplasty.






Aesthetic measurements.
28-30 mm
horizontal

12-14 mm vertical
3-6 mm
5-6 cm
1 cm
12-16 mm
M
i
d
p
u
p
i
l
l
a
r
y

l
i
n
e
Hairline
Brow line
Orbital rim
Supratarsal line
Upper lid

Midpupil
line

2.5 cm

440
Part VII Facial Surgery
TIP: As with any aesthetic evaluation, sensitivity to ethnic and specific patient
morphology is critical. For example, some patients may look better with their lid margin
slightly below the upper limbus or a brow tail that is low.



• Pseudoptosis

• Examine this with patient in downward gaze.
• High supratarsal fold indicates disassociation in conjoined fascia and possible levator
malposition or dehiscence.

12
• “Pseudoherniation” of fat contents (weak septum)
• Excess ROOF
• Excess subcutaneous fat
• Preaponeurotic fat (supralevator fat)


NOTE:

ASIAN EYELID see C




between Asian and white eyelid morphology:

13

of fatty lid tissue.

tissues.
INFORMED CONSENT

Swelling: Patients need to know timeline for this to estimate returning to work and
other activities.
Ecchymosis: Often more profound in lower lid
• Some darker-pigmented ethnic patient subgroups can show long-term “staining” of
thin eyelid tissues.
Chemosis, lagophthalmos (normal amount should be discussed)
Infection: Abscess, preseptal and postseptal cellulitis
Hematoma (retrobulbar): Include treatment and severity (i.e., blindness).

441
Chapter 34 Upper Blepharoplasty
Dry eyes: Exacerbation
Epiphora
Worsened or uncorrected asymmetries
Temporary versus permanent injury of innervation to orbicularis, frontalis, and other
muscles
Injury to extraocular muscles
Postblepharoplasty ptosis (temporary versus permanent)
• Some patients with excess dissection and handling in preaponeurotic fat layer may
have mild temporary ptosis from levator muscle edema and/or ecchymosis.

Entropion, ectropion
Vision loss (extremely rare)
TIP: Preoperative asymmetries (brow, lid position) should be pointed out to the
patient, and no guarantees should be made about their correction.
TIP: Even an excellent aesthetic outcome can be thwarted by lack of informed consent
if the usual spectrum of swelling, bruising, and convalescence is not fully discussed.
EQUIPMENT
STANDARD BLEPHAROPLASTY TRAY
Blepharoplasty hooks, tenotomy and iris scissors, mosquito hemostats, cotton-tipped

IMPORTANT SPECIAL EQUIPMENT
Coated, thermoresistant instruments: Desmarres, malleable, and Ragnell
Corneal protectors

Cautery with Colorado needle
1% lidocaine with 1:100,000 epinephrine with 27-gauge needle
SURGICAL TECHNIQUE: UPPER BLEPHAROPLASTY
PATIENT PREPARATION
Critical to avoid NSAIDs, acetylsalicylic acid (ASA), vitamin E
All makeup removed, including creams
Antihypertensive medication taken the morning of surgery
Helpful to position patient in reverse Trendelenburg
position during the procedure
MARKINGS
Use of sharp-cut edge of wooden cotton-tipped applicator
dipped in methylene blue is more precise than marking
pen.


made in holding area.
Blepharoplasty
markings.

442
Part VII Facial Surgery

with brows in a normal position (not compensated or falsely high) (NOTE: Green
forceps are very useful for this and not uncomfortable to patient.)

traction on upper lid to reveal pretarsal line.






TIP: Evaluate the entire periorbita, upper sulcus, aperture, brow position, and makeup
preferences, and determine what position would look best. Many Asian women may
require a low crease position, but some want a higher crease to facilitate makeup
application. A hollow upper lid sulcus may allow a higher crease. The measurements
provided previously are a guideline.




medially, and then extend beyond lower line, laterally as needed.



(middle age), 15 mm (older).

concealable without makeup).
of skin between lateral brow and incision.
TIP: Recognizing and showing patients the fold and brow asymmetries is essential.
Make as symmetrical and precise a crease as possible. Perform asymmetrical skin
resection when necessary. Although measurement and predetermined templates are
useful, surgeons should always individualize the markings based on each patient’s
morphology and quality and amount of excess skin.
UPPER LID BLEPHAROPLASTY

• Upper lid surgery can be done with the patient under straight local, local with
conscious sedation, or general anesthesia.
• The choice depends on surgeon’s preference and concomitant procedures.

• Caveats

staining.

443
Chapter 34 Upper Blepharoplasty

prevent unnecessary ecchymosis.

incision to meet lower incision.

scissors. Preserve orbicularis at this point.
• Excise orbicularis oculi strip (if needed) with scissors.

Can help with postoperative adherence and create sharper
supratarsal crease with closure; necessary in Asian eyelids to allow creation of
conjoined fascia
May distract from a desired more youthful/natural upper lid
fullness in some patients
14,15
• Incise orbital septum.

deeply in superior orbit).

• ROOF or “prelevator” fatty tissue can be removed through OOM incision before
completing orbital septal incisions.
• Excise excess intraorbital fat.




“A-frame” deformity.
1
• Assess lacrimal gland. Consider pexy if it is prolapsed.
• Close skin.

(usually polypropylene or nylon).

added safety.

SENIOR AUTHOR TIP: Although the traditional techniques for upper lid blepharoplasty
always included removal of muscle and fat, the current trend is toward fat and volume
preservation, and more commonly volume is added. I rarely resect fat beyond the nasal
pocket.
CREATION OF SUPRATARSAL CREASE OR LID FOLD

• Asian eyelids
• Preoperative lid fold <4-6 mm that looks awkward
• Secondary blepharoplasty
• Males with brow ptosis
• Asymmetrical supratarsal crease

444
Part VII Facial Surgery

• Fernandez16
surgery.
• Siegel
17: Creation of a new “conjoined fascia” position at a predetermined location,
which becomes the future lid fold location.

location to dermis (three or four sutures only).
• Flowers
18: “Anchor blepharoplasty.” Permanent sutures used to suture dermis to
tarsus and levator.
• Sheen
19 : Suture pretarsal orbicularis to levator.
TRANSCONJUNCTIVAL UPPER LID BLEPHAROPLASTY

• Minimal to no excess upper lid skin, i.e., revision or secondary cases
• Excess fat limited to medial pocket
• In primary cases, can be combined with browlift or skin resurfacing, which may
address minimal skin redundancy

• Incision made in bare area of conjunctiva below medial horn of levator aponeurosis
• Incision medial and opened only to obtain bulging medial fat
• No need to close incision
SENIOR AUTHOR TIP: The procedure is best for patients whose only problem is excess
nasal fat.
ADJUNCTIVE OPERATIONS

• Can be done through same upper eyelid incision
• Technique uses Endotine device (Coapt Systems) or sutures (see Chapter 33)
• Technique

marginalis of upper periorbita



SENIOR AUTHOR TIP: This is a very useful technique for subtle brow elevation. I always
place a suture rather than a device. I also almost always add this to the male upper lid
blepharoplasty.

445
Chapter 34 Upper Blepharoplasty

(Fig. 34-10)
10

preoperatively
• Use loupes.
• Prevent nerve injury.

possible.

or simple transection will likely result in
unpredictable return in CSM activity and
irregularities on animation.
21
• Use same incision.

along medial supraorbital rim.

side.




transverse dynamic rhytids.
SENIOR AUTHOR TIP: This is now my preferred method to modify the corrugator and
procerus muscles. No special equipment is needed, just loupes. If a large amount of
muscle is removed, I advise placing a small piece of fat, usually fat resected from the
nasal pocket, into the defect left in the muscle to prevent a depression.
POSTOPERATIVE CARE
TIP: If the patient is a “cougher,” smokes, or has Valsalva maneuvers during awakening
from anesthesia, placing cold, soaked eye pads on orbits and applying steady pressure
to prevent immediate bleeding complications are helpful.
SUTURES AND DRESSING
Subcuticular suture removed on postoperative day 4-6
Cold compress:
• Swiss Therapy eye mask (Invotec) (excellent)
• Ice-cold, soaked gauze pads in recovery
• Cool compress (pack of frozen peas or corn) or eye mask gel therapy every 4 hours
(20 minutes at a time) for the next 24 hours
ACTIVITY AND POSITION
Instructed to limit activity that increases heart rate for 5-7 days
Head of bed elevated (45 degrees) for 3-5 days
2.9 mm
43.3 mm
32.6 mm
28.8 mm
18 mm
7.6 mm
85%
100%
Comprehensive corruga-
tors supercilii muscle dimensions.

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Part VII Facial Surgery
PROPHYLACTIC ANTIBIOTICS


STEROIDS
Short (5-6 day) steroid taper (Medrol Dosepak)
• Recommended to decrease edema
IV dose (Decadron 8 mg) should be given perioperatively.
EYE LUBRICATION

• Only needed until normal tearing function returns
• Can do as often as needed
Have a low threshold to treat infection or chemosis early.
• Give a combination steroid and ophthalmologic suspension such as tobramycin
(TobraDex).
• Protect eye.

DIET
Patient can resume previous diet as tolerated.
Salt intake is limited to help decrease edema.
Edema, if prolonged, is more common with:

• Browlift procedures
• Supralevator (ROOF) fat resection
HERBS AND OTHER POSTOPERATIVE MEDICATIONS see C

Bromelain (high-dose pineapple extract) may be helpful for ecchymosis and edema.
Management of blood pressure, pain, and nausea in the immediate postoperative
period, as with all facial procedures, will decrease the risk of bleeding and reduce
postoperative swelling and bruising.
COMPLICATIONS
ASYMMETRY


RETROBULBAR HEMATOMA
See algorithm in Fig. 34-11.
Results most often from bleeding vessel during orbital fat excision

447
Chapter 34 Upper Blepharoplasty
Retrobulbar hematoma algorithm.
Symptoms: Severe pain

Visual changes
• Decreased visual acuity
• Amaurosis fugax
• Scintillating scotomas
Signs:
Tense or expanding proptosis

Diminished extraocular movements

Retinal/optic disc pallor

Increased intraocular pressure



Scleral hematoma
Bedside removal of all dressings and sutures
Consult ophthalmology
• 20% mannitol (1.5-2 g/kg IV; 12.5 g over
3 minutes, the remainder over 30 minutes)
• Diamox 500 mg IV
• 95% oxygen/5% carbon dioxide
• Solu-Medrol 100 mg IV
• Betoptic one drop immediately, then twice per day
Visual loss?
• Obtain hemostasis

necessary

Whitnall, and arcuate
ligaments

• Do not drain anterior chamber
• Delayed primary closure
• Obtain hemostasis
• Irrigate with balanced saline
solution
• Wicks to keep wound edges
open for drainage
Head of bed elevation
Frequent monitoring
Visual acuity
Pupil examination
Intraocular pressure
Funduscopic examination
Examination
and
Diagnosis
Medical
Treatment
Operative
Treatment
Postoperative
Management
Yes
No

448
Part VII Facial Surgery












2.





suspected,


TIP: Check on the patient and vision in recovery once he or she is alert. Recognizing
early signs of retrobulbar hematoma is critical.
BLINDNESS
0.04% incidence
Most common cause is a bleeding complication that is untreated or recognized too late.
Pathophysiology:
• Retrobulbar hematoma causes central artery occlusion or optic nerve ischemia from
pressure.

LAGOPHTHALMOS
2-3 mm of lagophthalmos is acceptable immediately intraoperatively, and even desired.
Greater degrees may improve over time.
If not improving, need to treat:
• Taping at night

• If these measures do not help, then consider skin grafting.
TIP: The risk of lagophthalmos is decreased if measurement and a pinch test are
performed preoperatively while the patient is sitting. Surgeons must consider the

CORNEAL INJURY
This may occur during surgery or when removing corneal shields.

449
Chapter 34 Upper Blepharoplasty
Consider ophthalmologic consultation.
Treatment:

patching
• Should resolve within 24-72 hours
DIPLOPIA
Most often from lower lid surgery

Commonly resolves spontaneously
May require corrective muscle surgery by an ophthalmologist
PTOSIS
Most common cause of postoperative ptosis is unrecognized preoperative ptosis.
May occur from direct injury to levator muscle or aponeurosis
Most often a temporary occurrence from manipulation, edema, or ecchymosis of
levator apparatus
• Be cognizant of levator location at all times.
• Minimize levator handling, if at all.
DRY EYE SYNDROME
Keratoconjunctivitis sicca
More common in patients with preoperative signs/symptoms


May be more common in lower lid when patient is “morphologically prone”22
lower lid–cheek relation
• Proptosis or native exophthalmic globe position
May consider Schirmer testing preoperatively
AESTHETIC RESULTS
Prevent “A-frame” deformity medially from overresection of soft tissue between nasal
and central fat pads.
Address brow symmetry to improve results.
Some Asian patients can be very critical of even the slightest asymmetry.
• Creating a symmetrical lid fold position is critical.
TOP TAKEAWAYS

The preseptal orbicularis is adherent to the septum, and careful dissection in the
proper submuscular plane is required.


and blend the lid-cheek junction.

Video imaging has been most helpful in discussing patients’ expectations and
whether they are realistic.

The risk of lagophthalmos is decreased if measurement and a pinch test are
performed preoperatively while the patient is sitting. Surgeons must consider

450
Part VII Facial Surgery
REFERENCES
1. Nahai F. Aesthetic plastic surgery. In Nahai F, ed. The Art of Aesthetic Surgery: Principles and
Techniques, ed 2. New York: Thieme Publishers, 2007.

Wilkins, 2007.
3. Siegel RJ. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 13:263, 1984.
4. Siegel RJ. Personal communication, 2008.
5. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the
temple and periorbital regions. Plast Reconstr Surg 105:1475, 2000.

the lower lid and lateral canthus. Plast Reconstr Surg 110:873, 2002.
7. Ghavami A, Pessa JE, Janis JE, et al. The orbicularis retaining ligament of the medial orbit: closing
the circle. Plast Reconstr Surg 121:994, 2008.

and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 12:77, 1996.
9. Pessa JE. The malar septum, the anatomical basis of malar mounds. Presented at the Annual


Corrugator topography. Plast Reconstr Surg 120:1647, 2007.
11. Guyuron B, Michelow BJ, Thomas T. Corrugator supercilii muscle resection through blepharo-
plasty incision. Plast Reconstr Surg 95:691, 1995.
12. Castanares S. Blepharoplasty for herniated intraorbital fat: anatomical basis for a new approach.
Plast Reconstr Surg 8:46, 1951.
13. Siegel RJ. Advanced upper lid blepharoplasty. Clin Plast Surg 19:319, 1992.
14. Fagien S. Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper
periorbita. Plast Reconstr Surg 110:278, 2002.
15. Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in aesthetic upper blepharoplasty.
Plast Reconstr Surg 113:32e, 2004.

1960.

Surg 116:1808, 2005.
18. Flowers RS. The art of eyelid and orbital aesthetics: multiracial surgical considerations. Clin
Plast Surg 14:703, 1987.
-
constr Surg 59:831, 1977.
20. Nahai F. Transconjunctival upper lid blepharoplasty. Aesthet Surg J 25:292, 2005.

Surg 117:1121, 2006.

dry-eye syndrome after blepharoplasty. Plast Reconstr Surg 82:619, 1988.
23. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome: guidelines for surgery? Plast
Reconstr Surg 68:249, 1981.

25. Fagien S. Reducing the incidence of dry eye symptoms after blepharoplasty. Aesthet Surg J
24:464, 2004.

8:803, 1981.

451
ANATOMY
Capsulopalpebral fascia

superioris muscle
Superior rectus muscle
Inferior rectus muscle
Inferior oblique muscle
Inferior tarsal muscle
Orbital septum
Arcus marginalis

Conjunctiva
Müller muscle
Superior tarsus
Inferior tarsus
Orbicularis oculi muscle
Orbital septum
Whitnall ligament

Cross section of the upper and lower eyelids.
TERMINOLOGY
Excess eyelid skin
Thin, excessive eyelid skin secondary to recurrent bouts of painless
lid edema
• 80% may have onset prior to age 20.
Drooping or ptosis of the upper eyelid
An outward turning of the eyelid margin
• Senile: Results from age-related laxity of lower lid
• Cicatricial: Results from scar-induced retraction of lower lid
Rolling of eyelid margin inward toward the sclera
• May result in irritation of the cornea or sclera by lashes

452
Part VII Facial Surgery
A downward displacement of the lid
margin resulting in inferior scleral show
Excess or protruding fat
through a lax septum
AESTHETIC EVALUATION OF THE
LOWER LID1,2

limbus without scleral show between the limbus
and lid margin.
Pretarsal orbicularis oculi
hypertrophy considered by many to be
aesthetic component of the youthful lower
lid.
• Often present in attractive eyes
• Results from pretarsal orbicularis muscle
fullness
Smooth, convex,
essentially imperceptible transition from lid to
cheek in youthful patients (Fig. 35-2)
• Stigmata of aging include:

intraorbital fat, malar pad descent,
nasojugal groove, visible inferior orbital
rim

CHARACTERISTICS OF THE AGING LOWER LID
Orbital rim
indentation
Malar
mound
Tear trough and
nasojugal fold
Medial fat
Brow ptosis

Youthful
Aged
Characteristics of aging periorbital region.

• Redundant with excessively thin and crêpey qualities

• Residual lines or wrinkles inevitable postoperatively
Comparison of lid-cheek
junction appearance in youth versus
aged.

453
Chapter 35
(blepharomelasma)
• Hyperpigmentation of the skin
Position of globe relative to the inferior orbital rim
• Useful for predicting postoperative tendencies of lid position
have poor lower lid suspension and are at risk for
postoperative ectropion and retraction.

is delayed return of the lid margin to native position when

is abnormal when the examiner grasps the lid margin between the

• Best corrected with supplemental canthal anchoring procedures (see Chapter 38)

Forced closure of eyelids improves festoon if secondary to
ptotic orbicularis oculi muscle
Shelving of orbicularis oculi muscle over orbital retaining ligament with
excess intraorbital fat

midface lift).
Weakening of the orbital septum may result in herniation of orbital
fat pads creating visible deformity of the lower lid.
• This may be corrected by fat removal, repair of septum without fat removal, and fat
relocation.
• Current techniques emphasize fat preservation.
(see Chapter 29)
• According to Barton et al,3 created by herniation of orbital fat, tight attachment of
the orbicularis along the arcus marginalis, and malar retrusion
• According to Codner et al,
4 created by herniation of fat over the orbitomalar
ligament, which arises from periosteum and attaches to skin

by the orbitomalar ligament, levator labii superioris, and levator alaeque nasi.
NOTE:

• Pronounced tear trough deformity may not be corrected with traditional
blepharoplasty techniques alone.

All patients should be questioned about dry eye symptoms.
• Blepharoplasty may contribute to or worsen dry eye symptoms in susceptible
patients.
• Ophthalmologic consultation may be warranted.


• Tarsal laxity, negative vector orbit, exophthalmos, or middle lamellar contracture of
lower lid can be present.

454
Part VII Facial Surgery
SURGICAL TECHNIQUES
NOTE:

SKIN RESURFACING

as chemical peel or laser resurfacing (see Chapters 16 through 18).
SKIN NLY BLEPHAROPLASTY INCH BLEPHAROPLASTY

• Patients with minimal redundant skin or fullness, usually isolated to the pretarsal

such as fat herniation, lid laxity or orbicularis ptosis
5
• Forceps are used to gently pinch the redundant skin over the pretarsal orbicularis
oculi to determine the width of skin to be resected.
• Appropriate width of skin to be resected is that which does not induce changes in
the position of the lower lid.

• Incision is performed with a No. 15 blade and excision of skin-only is performed with
cautery.

NOTE:

NOTE:

TRANSCONJUNCTIVAL FAT REMOVAL
Transconjunctival fat removal.

455
Chapter 35

• Young patients with excessive fat and no excess skin or orbicularis ptosis

• Incision made through conjunctiva to expose postseptal fat compartments
• Usually two separate incisions for access to three fat compartments
• Skin resurfacing may be performed as needed.
NOTE:

EXTERNAL LOWER BLEPHAROPLASTY AND ORBICULARIS SUSPENSION

Orbicularis suspension.
Browlift
dissection
Lateral orbit/temple elevated
using browlift procedure
Lower lid
suspended using
blepharoplasty
procedure
Trim overlap
Cut only as necessary to close gap
Suture to orbital rim

• Skin excess and orbicularis ptosis

• Subciliary skin incision


• Release of orbital retaining ligament and lateral orbital thickening
• Irrigation with Kenalog solution (2.5 mg in 0.5 ml saline solution)

456
Part VII Facial Surgery

• Canthal anchoring
• Redundant skin trimmed and incision closed
TIP: External skin–only techniques do not adequately address orbicularis ptosis and
in most cases do not adequately correct the lower lid deformity.
SENIOR AUTHOR TIP: A major consideration in lower eyelid blepharoplasty is when
to perform canthal anchoring and, if so, whether to do canthopexy or canthoplasty.
The decision to perform canthal anchoring is based upon the amount of horizontal
laxity (based on the “snap-back test” and the “pull-away test”), the prominence of the
globe (positive or negative vector), the amount of skin or skin/muscle resection planned
and other ancillary procedures performed (facial rhytidectomy, laser facial resurfacing,
chemical peel, etc.). In general, canthopexy, of which there are a multiplicity of
variations, is quicker and easier to perform and less likely to lead to postoperative
problems. It is therefore the treatment of choice for surgeons who may feel less than
completely comfortable in this region. It can correct mild degrees of lid laxity and
functions well as a “just in case” addition to the procedure.

must be performed. Canthoplast y is more complex and time-consuming and
more prone to postoperative problems such as dehiscence, conjunctival chemosis,
and lid asymmetry. Again, there are several variations on the theme but all can be
conceptualized as either resection of a redundant block of tarsal plate, formation of
a strip of tarsus from the redundant lid, or anchoring the tarsus via a drill hole in the
lateral orbital rim. Canthoplasty gives a greater degree of horizontal shortening with
increased stability of the lid margin.
Another consideration is when to add a spacer graft to the lower eyelid retractors to
counter the downward forces in a negative vector eye. Again, there are no hard and
fast rules but it should be considered when the exophthalmometry readings exceed

skin or skin/muscle resection planned by the surgeon. If the surgeon wishes to avoid
supporting grafts in the posterior lamella, one can purposely undercorrect the amount
of anterior lamella resected to compensate in a negative vector eye.
EXTERNAL LOWER BLEPHAROPLASTY WITH ORBICULARIS SUSPENSION
AND SEPTAL RESET
Capsulopalpebral
fascia
Septum orbitale
Orbicularis
oculi muscle
Orbicularis
retaining
ligament
Septal reset procedure.

457
Chapter 35
Repair septal hernia
Advance arcus marginalis
(septum plus fat)


• Skin excess and orbicularis oculi ptosis
• Visible nasojugal groove and fat herniation
• Tear trough triad

• Subciliary skin incision


• Release of orbital retaining ligament and lateral orbital thickening
• Release of arcus marginalis and extrusion of lower lid fat
• Suture reset of septum and orbital fat to anterior orbital rim periosteum
• Irrigation with Kenalog solution (2.5 mg in 0.5 ml saline solution)

• Canthal anchoring
• Redundant skin trimmed and incision closed
TIP: Septal reset procedures should be performed with the lower lid under tension (by
temporary Frost suture) to prevent excessive tightening of the septum and predisposing
patients to ectropion.
SENIOR AUTHOR TIP: I do not place a temporary tarsorrhaphy suture while
performing septal reset procedure as recommended here but completely agree that
a degree of caution is needed to reduce the risk of inducing postoperative lower
lid retraction. In general, if the orbital septum is widely opened and the orbital fat
prolapsed out and transposed over the inferior rim then the risk is relatively low. If the
actual septum itself is transposed then the risk is greater. This is because the septum

the same degree of transposition of the septum risks lid retraction more so than the
transposition of the orbital fat. When performing either procedure, I always look at the
tarsal plate to see if there is any inferior movement when suturing the transposed tissue.
I also feel the tension along the inferior border of the tarsal plate by pulling superiorly
with a forceps before and after suturing the tissue to be certain that the tension is not
excessive.

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Part VII Facial Surgery
OTHER CONSIDERATIONS
ORBICULARIS INCISION AND PARALYTIC ECTROPION
Whether orbicularis oculi muscle incision leads to paralytic ectropion after
blepharoplasty is controversial.
Pretarsal innervation is usually maintained through medial branches if the incision is
made only in the lateral portion of the muscle.
With any muscle splitting technique, proper preoperative risk assessment and
are requisite to a successful outcome.
POSTOPERATIVE CARE
All patients are advised to expect swelling, ecchymosis, and some restriction with
upward gaze.
Generally, most patients can expect to look “presentable” at 2-3 weeks.
Some use postoperative compressive bandages.

postoperative edema.
Moisturizing eyedrops and/or ophthalmic lubricating ointment should be provided to
prevent dry eye symptoms and desiccation of the sclera.
If no canthopexy is performed, a Frost suture should be placed to prevent lid retraction.
Patients should be counseled to refrain from using contact lenses in the postoperative
phase.
COMPLICATIONS
PERIBULBAR HEMATOMA
Usually results from bleeding of the orbicularis oculi muscle
Vision is usually not threatened.
If seen intraoperatively, they should be evacuated.
Small hematomas seen in the postoperative phase can be watched.

liquefaction.
Prevention is aimed at meticulous perioperative blood pressure control; postoperative
ice packs and elevation of the head are essential.6
RETROBULBAR HEMATOMA
Rare but serious complication (0.04% incidence)7
Can compress neurovascular structures and cause retinal ischemia and optic nerve
compression
Symptoms include severe pain, visual changes, proptosis, and ecchymosis.
CAUTION:

Medical treatment of retrobulbar hematomas includes mannitol, acetazolamide, and
systemic and topical steroids.

459
Chapter 35
DRY EYE SYNDROME
Symptoms include itching, foreign body sensation, burning, secretions, and frequent
blinking.
Documented dry eyes, history of dry eyes, and abnormal orbital and periorbital
anatomy such as lower lid laxity are predictors of postoperative dry eye complications.
Blepharoplasty should be delayed for in patients who previously

Prevention is largely related to proper patient screening.

proceed with blepharoplasty.8
Treatment includes lubricating drops and ointment.
Eye patch or Frost suture can also be used if lubricating measures do not improve
symptoms.

production.8
SENIOR AUTHOR TIP: Dry eye syndrome in the postoperative period can also be
treated by temporary or permanent punctal plugs which partially block the lacrimal

Also keep in mind that ocular rosacea can mimic all of the symptoms of dry eye. This
can activate in the eyelids in individuals so predisposed after eyelid surgery. A history
compatible with rosacea may suggest that a trial of low-dose tetracycline is in order.
CHEMOSIS
Can be caused by manipulation of the conjunctiva or prolonged scleral exposure
leading to desiccation
Frequent moisturizing with wetting drops, ophthalmic lubricating ointments, and
intermittent forced lid closure prevents exposure-related desiccation.
Most cases will resolve spontaneously.

Steroid drops can be used under careful surveillance in refractory cases.10
Physicians can also give 2.5% Neo-Synephrine eyedrops, because they suppress

SENIOR AUTHOR TIP: The treatment of conjunctival chemosis has probably generated
more arcane solutions than anything else that I can imagine. I have seen cases where
the edema persisted over 6 months from the time of the surgery. The conjunctiva is well
supplied with lymphatic vessels that drain into the preauricular node (from the upper
eyelid) and to the submandibular node (from the lower eyelid). Surgical procedures
on the lids disrupt the normal lymphatic drainage. This seems to be especially true
when a canthotomy and cantholysis is performed in the lower eyelid. In time, the
lymphatic channels recanalize and the chemosis resolves. In addition to the treatments
suggested here are massage, hypertonic saline drops and ointments, diuretics, and
pressure patches. I have on occasion actually cut into the swollen conjunctiva with sharp
scissors and found immediate and permanent resolution of the problem. I have also
found instances in which cutting into the conjunctiva was not at all helpful. My feeling
is that we tend to believe that whatever treatment we rendered immediately before
the spontaneous resolution of the problem is what worked.

460
Part VII Facial Surgery
INFECTION
Rare complication of blepharoplasty
Dry eye is a predisposing factor.
Can be treated with
LOWER LID MALPOSITION
The after lower lid blepharoplasty
May range from mild inferior scleral show to severe ectropion
Can be caused by cicatricial and/or gravitational forces overcoming the support
mechanisms of the lower eyelid11

and dynamic elasticity of the lower lid.9

patients with proptosis, malar hypoplasia, and high myopia.
Mild lid malposition can be managed with eyelid massage.
If needed, operative intervention is delayed until the late postoperative period.
LAGOPHTHALMOS
Occurs from lid edema, excessive skin resection trauma to the orbicularis oculi, and
iatrogenic orbital septal shortening
Typically resolves as muscles relax and edema subsides
Treatment includes light massage and nocturnal lubrication.
If conservative measures fail, surgery may be necessary.
TOP TAKEAWAYS

Accurate, individualized assessment of each patient’s orbital morphology and lid
deformity is central to the proper approach to lower lid blepharoplasty.

A graduated treatment plan is developed for each patient depending on the
presence of skin laxity, orbicularis oculi ptosis, fat herniation, and tear trough
deformities.

Canthal anchoring techniques should be considered a routine aspect of lower lid
blepharoplasty.
REFERENCES
1. Flowers RS, DuVal C. Blepharoplasty and periorbital aesthetic surgery. In Aston SJ, Beasley RW,


2. Guyuron B. Blepharoplasty and ancillary procedures. In Achauer BH, Eriksson E, Guyuron B, et

2000.
3. Barton FE, Ha R, Awada M. Fat extrusion and septal reset in patients with the tear trough triad:
a critical appraisal. Plast Reconstr Surg 13:2115, 2004.
4. Codner MA, Kikkawa DO, Korn BS, et al. Blepharoplasty and brow lift. Plast Reconstr Surg
126:1e, 2010.

461
Chapter 35

2008.
6. Trussler AP, Rohrich RJ. MOC-PSSM CME article: blepharoplasty. Plast Reconstr Surg 121
(1 Suppl):S1, 2008.
7. Wolfort FG, Vaughan TE, Wolfort SF, et al. Retrobulbar hematoma and blepharoplasty. Plast
Reconstr Surg 104:2154, 1999.
8. Pacella SJ, Codner MA. Minor complications after blepharoplasty: dry eyes, chemosis, granu-
lomas, ptosis, and scleral show. Plast Reconstr Surg 125:709, 2010.

10. Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following
cosmetic lower blepharoplasty. Plast Reconstr Surg 122:579, 2008.
11. McCord CD Jr. The correction of lower lid malposition following lower lid blepharoplasty. Plast
Reconstr Surg 103:1036, 1999.

462
BACKGROUND
1
• Nonincision method using three sutures of silk thread removed postoperatively
Sayoc,2 Millard,3 and Fernandez4

• Upper lid blepharoplasty is now the most common plastic surgery procedure in Asia.
Approximately 30%-50% of Asians have a natural supratarsal crease.5
Not a “Westernizing” of the eyelid
• Patients typically request a natural look that opens the eye, while respecting their
Asian identity.
6
DIFFERENCES BETWEEN WHITE AND ASIAN EYELIDS
(Fig. 36-1)
• Absent or short superior palpebral crease



• Inferior descent of preaponeurotic (prelevator) fat
• Short tarsal height (Asians 6.5 ± 8.0 mm; whites 11.3 ± 1.7 mm)
8
• Medial epicanthal fold
A
B
Corresponding cross sectional fascial anatomy of A, an Asian eyelid and B, a white eyelid.

Jerome H. Liu, Richard Y. Ha, Lily Daniali, William Pai-Dei Chen

463
Chapter 36 Asian Blepharoplasty
Preseptal fat
Orbital septum
Levator aponeurosis
Orbital septum
Levator aponeurosis
Tendrils from levator
aponeurosis to skin
White
Asian
C
D
Note the low fusion of the septum and levator in the C, Asian eyelid versus the
high fusion in the D, white eyelid. Also note the presence of abundant preseptal fat and the lack
of fascial attachments from the levator to the orbicularis and skin.

2,9-13

dermis to create the palpebral crease in whites.

subcutaneous tissue of pretarsal skin.

because the levator does not penetrate the

subcutaneous tissue.
SENIOR AUTHOR TIP: I support the view of Since Collins’


wraparound intermuscular fascia of the orbicularis oculi.

13-17

expansions from the levator to the orbicularis muscle.14

aponeurosis and orbital septum, creating a

adherence of the orbicularis muscle and the overlying skin.

464
Part VII Facial Surgery



below the superior border of the tarsal plate.

levator and the septum to extend inferiorly.

between levator-septal complex and orbicularis muscle.

the eyelid margin.
7,13,18
• Asian skin has with higher collagen content.
• Asian upper lid has more prominent




• Asians have

• Asians have


• Appears as a skin web that overlies portion of the medial canthus and obscures the
lacrimal caruncle, and possibly the medial portion of the sclera.
SENIOR AUTHOR TIP: The term epicanthal fold has been overapplied even to normal

patients with congenital syndromes like Down syndrome and blepharophimosis
syndrome). The treatment, epicanthoplasty, has been overprescribed as a surgical


lid fold is common and easily corrected as part of tissue removal in a double-eyelid
crease procedure through incisional approach, the myriad methods of epicanthoplasty

be called a true epicanthal fold.19
• Johnson20
were described as pathological entities, although the epicanthus tarsalis in its

Asians who have no upper lid crease, or even in those who are born with a natural
crease.

465
Chapter 36 Asian Blepharoplasty
A
B
C
D
Types of epicanthus. A, Tarsalis. B, Superciliaris. C, Palpebralis. D, Inversus.
: Fold is seen along medial upper eyelid, and covers
part of the medial pretarsal region. May block view of the dermal portion of the
caruncle, which is normally seen as opposed to the deeper conjunctival portion
at its base.
SENIOR AUTHOR TIP: Many Asians have a medial upper lid fold without it blocking
any of the medial portion of the pretarsal region, and the caruncle can still be seen. I
do not consider these patients as having epicanthus tarsalis.
Fold originates from the brow and follows down
to the lacrimal sac in an inferonasal oblique fashion, may block portion of the
superonasal iris, and covers caruncle from view.
Bridges both upper and lower eyelids; covers the
caruncle from view.
Main portion of this fold sits along medial portion of
lower eyelid, and arches up superonasally to cover medial canthal angle as well as
caruncle view.
• Epicanthal folds, especially the last three types, are usually seen associated with
rare conditions like blepharophimosis, congenital ptosis, Down syndrome, or as an

466
Part VII Facial Surgery
SENIOR AUTHOR TIP: In patients being considered for Asian upper blepharoplasty
(with construction of upper lid crease), the reduction or excision of any medial upper
lid fold should be considered as part of the upper blepharoplasty, rather than labeled
as a mild form of pathological epicanthus tarsalis necessitating the creation of a special
“epicanthoplasty” to be added to the surgical procedure.
AESTHETICS

• Thickness


• Need accurate evaluation of brow position



• Evaluation of crease/brow ratio

Crease and pretarsal show tapers from lateral to medial.

Crease is parallel to the lid margin along its entire course; no tapering
occurs down into an epicanthal fold.


• Patient decision
• Based on aesthetics
• Ideally, approximately of pretarsal show
13,21,22

• Upper eyelid margin is normally 1-1.5 mm below superior corneal limbus.

distance (MRD).
• Ptosis is present when MRD <3 mm.

eyelids.

PREOPERATIVE EVALUATION AND SURGICAL PLANNING
STANDARD HISTORY AND PHYSICAL EXAMINATION
Blepharoplasty workup
History of dry eyes
MARKINGS

Determine degree of pretarsal show and thus amount of skin resection (if needed).
Determine need for debulking of preaponeurotic fat.
A

467
Chapter 36 Asian Blepharoplasty
A
z
y
x
Measure how much skin overhang to
remove to obtain the desired amount of visible
pretarsal skin . Double the length of and add
1.5 mm for the caudal bend, depending on skin
thickness, to calculate the amount of skin to be
removed at that point on the lid. This exercise
may be repeated at two or more points along the
lid. Pretarsal height is shown If a frontal lift
will be performed, assess the skin in this same
way, but with the measured lid’s corresponding
eyebrow held at the level of “best guess” esti-
mate of where the “postlift” brow will reside in
6 months.
BROWLIFT OPTIONS
Endobrow
Temporal brow
Coronal brow
INCISIONAL VERSUS NONINCISIONAL
suture, minimal incision, closed
• Higher incidence of relapse
• Best reserved for eyelids requiring








• More common technique

468
Part VII Facial Surgery
SENIOR AUTHOR TIP:
twentieth century when understanding of anatomy was rudimentary. During the period
from 1930-1960 there was greater integration of awareness of anatomy of the face
and eyelids with advances in techniques that are selectively targeted. External incision
methods and suture methods became more common. The great rivalry between the
proponents of the two schools of Asian eyelid crease surgery fueled greater evolution
of simple and complex methods in each school.
Eventually, every practitioner needs a greater understanding of the physiology and
biodynamic of the complex layers of the upper lid, as well as techniques that suit his
or her technical capability. It would be simplistic and foolhardy to think that the upper

incision and excision in external incision methods, along with multiple needle passes
in buried suture methods in which permanent sutures are placed at various distances
above
function of the levator muscle and Müller muscle.

nondissolvable suture material was placed within their upper eyelid layers, or that
opening or closing their eyelids does not occur quite as naturally. They often describe
a strained feeling or tightness.
EPICANTHOPLASTY

Fold is present without local distortion.
Fold extends to level of lower limbus.



• Epicanthoplasty is considered for moderate or severe epicanthal folds.
21
• Patient preference

• Prominent folds that give appearance of telecanthus or strabismus
• Epicanthus inversus with fold turning laterally onto lower eyelid

TECHNIQUE
INCISIONAL TECHNIQUES WITH LEVATOR ERMAL FIXATION
Many authors have described the levator release technique.2,17,23-25

• Supratarsal incision with excision of a strip of orbicularis muscle

469
Chapter 36 Asian Blepharoplasty
• Removal of excessive fat and soft tissue


through D)


A
B
C
D
In the operating room, the lid is turned over and the tarsus measured. B, With the
skin under uniform traction, the incision or the lower margin of the skin excision is marked with a
Jameson caliper 8-9 mm above the lashes for a 4 mm tall pretarsal segment, 8 mm for a 2.5-3 mm
segment, and 7 mm for a 1.5-2 mm pretarsal segment. The 2 mm added by including the lashes
and lid margin compensate for the tightly stretched skin and the inward curvature necessary to
reach the anterior tarsus. The skin excision rarely extends beyond the orbital rim and the actual lid
creasing. C and D,
this during excision to prevent transecting aponeurosis.
• Skin and muscle resection



excision.

• Remove sliver of conjoined fascia (Fig. 36-5, and B).

470
Part VII Facial Surgery


Conjoined fascia
grasped and
tented
A
Narrow sliver of
fascia excised
B

adherent conjoined fascia. B, A narrow sliver of conjoined fascia is resected.
• Incise remainder of the septal levator junction.



• Smooth and redrape pretarsal tissues.
• Reattach levator (Fig. 36-6, and B).



Orbital septum incised
Levator aponeurosis
(retracted)
Orbital fat “wedge”
A
incised
um
s
osis
osis
”
ge”
re purcha
Sutu
mis, creating
derm
fat “sling”
a f
g
ase
ting
es
g
B
The forceps hold the two components of the fat sling. The upper forceps is on
the edge of the orbital septum, while the lower places have the medial free edge of the levator

vascularized fat wedge separates the two layers. B, After the pretarsal tissues are smoothed and
advanced nasally, sutures approximate the free edge of the levator aponeurosis to the pretarsal
tissue. In this case, the aponeurosis is sutured to both the anterior tarsus and the dermis at the
margin of the lower incision.