Operative Technique in Plastic Surgery – Kevin C.Chung

29
CHAPTER
Technique for Ptosis
Correction
Nuri A. Celik
DEFINITION
■ There have been many procedures advocated for the treatment of the upper
eyelid ptosis. Some of the techniques in the literature use incisional/excisional
methods to deal with the levator mechanism failures.1
■ The technique described in this chapter relies solely on the preservation of the
anatomical integrity of the levator system that is either stretched or detached
because of various reasons. The key to using this technique is the presence of a
good levator function. This is easily calculated by measuring the excursion of
the upper eyelid during extreme upper and downward gaze (FIG 1).
■ Practically, any measurement above 10 mm is proper to use this technique
efficiently. Iatrogenic or senile levator detachment patients are a different
group, because they present with decreased levator function; however, in most
cases, the system is intact to perform this type of correction. Fatty
degeneration of the levator muscle is also a possibility with aging.
ANATOMY
■ The upper eyelid is a complex structure that consists of multiple tissue layers
that seem to adhere to each other around the upper anterior tarsal surface.
When the skin and muscle layers are incised and a skin muscle flap is elevated
as a superiorly based flap, one notices a thin layer of adipose tissue on top of
the upper orbital septum that is more defined medially and somewhat less
laterally (FIG 2). The increased convexity of the globe is possibly responsible
from this uneven distribution of the fat layer. The underlying septum should
always be incised laterally and higher than the upper tarsal border in order not
to injure the levator mechanism inadvertently. There usually is a

preaponeurotic fat pad present, if not previously excised or developmentally
absent. Under the fat pad, toward the upper orbital rim, one can find the
vertically oriented fibers of the levator muscle. The surgeon should always
keep in mind that immediately under the levator aponeurosis, there is the
vertically oriented arterial loop of the supratarsal arch that might resemble the
fibers of the levator muscle, for untrained eyes, that might be difficult to
differentiate.
PATHOGENESIS
■ Periorbital aging is a very complex phenomenon. Twelve percent of the
patients in Dr. Lambros’ series had upper eyelid ptosis; however, there is no
reference to frontalis activity in his patient population.2 Increased frontal
muscle activity is a common finding in the elderly population and usually is a
compensation for a ptotic upper eyelid. The original percentages of upper
eyelid ptosis should be higher in the aging population due to the weakening of
the levator attachments or stretching of the aponeurosis.
FIG 1 • This young patient presents with bilateral ptotic
upper eyelids. A. He has empty upper sulci and an
increased supratarsal fold distance. B,C. The upper
eyelid excursion during the upper and lower gazes is 12

mm, and he has good levator function.
FIG 2 • Skin muscle flap elevated following upper
blepharoplasty incision. There is a thin layer of adipose
tissue medially and less laterally. This fatty layer is a
landmark to be able to distinguish the upper orbital
septum.
■ There are still some centers that use incisional and excisional surgical methods
on the levator mechanism. It is very important not to distort the anatomy of the
levator system.
■ The most frequent complications happen with resection of the levator
aponeurosis, because failure of the suture correction results in recurrence of
ptosis and loss of levator function (FIG 3).
■ Another possible mechanism is inadvertent surgical damage to the
aponeurosis (FIG 4).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ In younger patients, when present, ptosis is a significant complaint because a
higher upper eyelid arch is the norm in early decades of life.
■ In severe cases, there might be significant visual field obstruction (FIGS 5
and 6).
■ Asymmetric cases are easily diagnosed.
■ In senile ptosis, most of the time, the patient is not aware of the problem if it
is bilateral. Senile ptosis takes a long time to advance, and by that time,
compensatory mechanisms such as frontalis hyperactivity develop (FIG 7).

FIG 3 • This 28-year-old patient underwent two
unsuccessful left ptosis repair attempts in the previous
2 years. The second surgery consisted of resection and
shortening of the levator aponeurosis. The ptosis
recurred a week after surgery. He has the typical
symptoms of levator detachment with an increased
supratarsal distance, upper eyelid ptosis, and slight
elevation of the left eyebrow. The loss of the levator
aponeurosis contribution to the lateral canthus resulted
in relaxation of the lower eyelid on the left side causing
a scleral show and distortion of the proper cant of the
eye. Even the vertical orientation of the eyelashes is
affected due to loss of the levator aponeurosis pull on
the skin.
■ An occasional patient might complain about transverse wrinkles as a result
of the long-standing frontalis muscle contraction.
■ The anatomy of the brow-upper eyelid interface changes in ptosis patients. If
there is no skin excess to camouflage the superior sulcus, this area appears
hollow (FIG 8). The supratarsal crease-eyelash margin distance is increased,
and the upper eyelid covers more than 2 mm of the upper limbus. In elderly
cases, brow ptosis and skin excess disguise the deformity, and supratarsal
crease might appear to be of proper dimension. In these cases, elevating the
eyebrows will reveal the underlying pathology (FIG 9). A meticulous
preoperative assessment and planning ensure symmetric eyelid levels and

supratarsal crease distances.3 The superior sulcus fullness should also be
evaluated separately on both sides, and upper eyelid fat manipulation should be
taken into account in order to achieve a satisfactory outcome (FIG 10).
FIG 4 • A. A 64-year-old patient seen following a cyst
removal from the left upper eyelid. She has left frontalis
muscle hyperactivity due to left eyelid ptosis, an
increased supratarsal distance. B. Intraoperative
findings of the patient. The upper orbital septum is
opened, and the preaponeurotic fat pad is retracted to
expose the levator system. The right upper eyelid
shows a normal anatomy of levator muscle and
mechanism. C. The left upper eyelid levator
aponeurosis has a significant injury medially, which
possibly caused complete detachment of the system
resulting in upper eyelid ptosis. D. One year after
treatment with a levator advancement technique, she
had bilateral blepharoplasty to equalize the supratarsal
fold and correct the left ptosis. However, the frontalis
muscle hyperactivity is not completely resolved.

FIG 5 • A. A 52-year-old male patient with asymmetric
ptosis—right side more droopy than the left. He has
more frontalis muscle compensation on the right side
due to obliteration of the pupil. The laxity of the lateral
canthal tendon and the scleral show are possible signs
for the levator system detachment from its insertion on
the tarsus. The ptotic brows mask the supratarsal fold
deformity. B,C. The patient demonstrates good levator
muscle function that makes him an excellent candidate
for levator advancement correction.
FIG 6 • A 39-year-old patient with unilateral right ptosis
and the lack of frontalis muscle compensation. The
superior orbital sulcus fat volume is significantly
decreased. The left upper eyelid fat and excess skin are
camouflaging the real location of the supratarsal fold. In
these patients, skin excision should always be
accompanied with upper sulcus fat grafting.

FIG 7 • A 73-year-old female patient with a long-
standing upper eyelid ptosis due to complete
detachment of the levator aponeurosis from the upper
tarsus attachments. She has bilateral frontalis muscle
hyperactivity. Even this compensation has failed; she
has to hold her upper eyelids with her fingers in a
higher position to be able to see properly. The detached
edge of the levator mechanism is still pulling the skin
forming an unusually high supratarsal fold (arrows).
FIG 8 • A 49-year-old female with unusually high
supratarsal fold distance. She almost has no
preaponeurotic fat to fill the upper sulcus. Notice that
the upper orbital rim is clearly visible throughout its
course. The medial two-thirds of the brow is elevated to

compensate for the upper lid ptosis.
FIG 9 • A. A 60-year-old female presents with
asymmetric upper eyelid levels and levator function.
The supratarsal fold height is surprisingly symmetric
due to the presence of excess upper eyelid skin. Brow
ptosis masks the levator-upper tarsal border interface.
B. When the patient is asked to elevate the brows, the
deformity becomes visible. She has almost no upper
eyelid fat, and the levator is detached, pulling the skin
at a much higher level than normal. The normal level of
the supratarsal folds is completely deceiving. Skin
resection type of upper blepharoplasty will give her a
sunken eye appearance.

FIG 10 • A,B. A 39-year-old patient who had Fasanella-
Servat procedure for the treatment of her ptosis. She
also had resection of her upper eyelid medial fat pads
through a stab incision. She still has compensatory
frontalis muscle hyperactivity and residual ptosis. Notice
the high skin attachment of the levator system, more on
the left. Upper orbital sulcus appears relatively empty.
■ The unilateral ptosis cases are more difficult to assess preoperatively (FIG
11). The ptotic upper eyelid should be elevated to a normal position with the
finger, and the contralateral side should be watched carefully. If the normal
upper eyelid level drops as a result of this maneuver, this is a sure sign of an
occult ptosis. In this case, the surgical approach should involve both upper
eyelids to achieve symmetry postoperatively.
IMAGING

■ The assessment of the levator function is of utmost importance in surgical
candidates. The measurement of the upper eyelid excursion between extreme
upward and downward gaze gives the levator function, and a measurement
above 10 mm guarantees successful outcomes with levator advancement
technique.
FIG 11 • A 17-year-old male patient presents with left
upper eyelid ptosis. He has slight elevation of the left
medial eyebrow.
DIFFERENTIAL DIAGNOSIS
■ Congenital ptosis
■ Muscle disease
■ Fatty infiltration of the levator muscle
SURGICAL MANAGEMENT
Preoperative Planning
■ The patient should not take any blood thinning agents for 3 weeks
preoperatively. A bloodless field and loupe magnification are much needed for
proper dissection and recognition of the pertinent anatomy.
Positioning
■ The patient is placed on the surgical table in the supine position. A reverse
Trendelenburg positioning of the patient is best for a bloodless surgical field.
Approach

■ The supratarsal crease incision is used. It is not preferable to use the original
crease of the patient because it might be displaced higher due to the pull of the
levator muscle on the skin. I prefer to place my incision 8 mm from the upper
eyelid lash border. This unfortunately coincides with the junction of the levator
aponeurosis with the upper orbital septum and is a difficult area to delineate the
anatomy. This requires surgical expertise and the use of loupe magnification.
T E C H N I Q U E S
■ Levator Advancement Technique for the
Treatment of Upper Eyelid Ptosis
■ The patient is a 17-year-old who presents with left upper eyelid ptosis and
slight left eyebrow asymmetry. He has quite equal skin folds on both sides
and this ensures a good outcome. He has asymmetric levator function, 14 mm
on the right and 11 mm on the left (TECH FIG 1A,B). A surgical simulation
is performed by elevating the ptotic lid to a higher level with the index finger
while watching the normal side to detect a positional change. In his case, the
upper lid level drops on the normal side; hence, the surgery is performed on
both sides (TECH FIG 1C).
TECH FIG 1 • A,B. The patient has asymmetric

levator function, 14 mm on the right and 11 mm on the
left. C. Hering law in effect: if the left upper eyelid is
pulled to a higher level to simulate surgery, the right lid
drops. This shows the occult ptosis of the contralateral
side. In this case, a bilateral approach is mandatory.
■ Incision and Dissection
■ The upper eyelid incision is injected with local anesthetic and adrenaline
solution, and 7 to 10 minutes are allowed to pass before skin incision. The
surgical incision is placed at 8 mm from the eyelash margin in the middle and
both ends at 5 mm. Laterally, the lateral canthus is the outer limit, and
medially, the limit is the punctum (TECH FIG 2A).
■ The upper eyelid incision is performed very superficially, and then the
dermis is cut with the cautery to prevent bleeding. The dissection continues
with the muscle layer. There is uneven thickness of the orbicularis muscle in
the upper eyelid due to the convexity of the eye globe; the muscle is thicker
laterally and medially. It is advisable to advance along the medial incision
first, because there is a more significant adipose layer in between the muscle
and the upper orbital septum in this area. Once the dissection reaches this
layer, it is easier to extend toward the middle and then laterally, staying on
top of the orbital septum (TECH FIG 2B). Under loupe magnification, the
upper flap is dissected toward the upper orbital rim for another 10 mm,
staying immediately adjacent to the muscle layer (TECH FIG 2C). This
facilitates the closure at the end of the surgery.
■ The upper orbital septum is punctured, and 1 cc of saline is injected staying
close to the undersurface of the septum (TECH FIG 2D). This type of
hydrodissection facilitates the separation of the septum from the levator
aponeurosis. In most of the ptosis cases, there is not much of a tissue space in
between these layers, and this increases the risk for inadvertent levator
system surgical damage. If the patient has well-developed preaponeurotic fat
pads, these lie immediately under the septum (TECH FIG 2E). There are
fibrous connections in between the levator system and the fat pads; they are
released and the fat pad is retracted to visualize the levator muscle (TECH
FIG 2F).

TECH FIG 2 • A. The surgical incision is planned 8
mm from the lash margin, and the corners have 5 mm
distance to maintain the natural curve of the
supratarsal crease. B,C. The upper eyelid skin and
muscle are incised, and the upper edge of the flap is
elevated off of the orbital septum. D,E. The injection of
saline into the upper orbital space helps with the
separation of the levator system from the septum. The
elevation of the upper orbital fat pad helps to visualize
the levator muscle. F. The levator muscle and the
aponeurosis are clearly visible immediately under the
preaponeurotic fat pad.
■ Suturing
■ There is a strong fibrous tissue layer along the anterior surface of the upper
tarsal plate immediately deep to the orbicularis muscle layer. A 6-0 nylon
suture is passed through this strong layer without penetrating the
cartilaginous tarsal plate. This prevents the unnecessary manipulation of the
upper eyelid tarsal plate (TECH FIG 3A).
■ The second suture is then passed through the aponeurosis close to the distal
edge of the levator muscle (TECH FIG 3B). The decision-making process
for the amount of aponeurosis shortening depends on the severity of the

ptosis and experience. The suture is then tied, which will effectively pull the
levator muscle closer to the upper tarsal edge (TECH FIG 3C).
■ The aponeurosis shortening sutures are placed on both eyes, and the patient
is asked to open the eyes and look forward (TECH FIG 3D). There should be
perfect symmetry of the upper eyelid levels. If not, the sutures are removed
and arranged accordingly. When equal upper eyelid levels are maintained,
two more additional sutures are placed on both sides of the midline suture to
reinforce the attachment of the system to the anterior tarsal plate.
■ The septum is closed with 6-0 poliglecaprone sutures, the upper flap is
pulled down, and the skin excess is measured. The orbicularis muscle is
never excised as the muscle fibers are more condensed close to the incision.
The skin is injected with a local anesthetic solution and de-epithelialized with
a surgical blade. Then the muscle is folded on itself and the skin is closed
with a 6-0 nylon continuous suture.
TECH FIG 3 • A. The 6-0 nylon suture is passed
through the strong fibrous tissues of the anterior
surface of the upper tarsal plate. The suture is then
grasped and pulled up to see if it will hold the repair.
B. The suture is then passed through the levator
aponeurosis at a level closer to the muscle. The
decision process for the placement of this suture is

obtained with practice and time. C. The suture is then
tied to pull the muscle closer to the upper tarsal
border, hence the name levator advancement repair.
D. After the levator is advanced on both sides, the
patient is asked to open the eyes to check for
symmetry. If this is not achieved, the levator system
suture is removed, and a new level is obtained to
provide equal upper eyelid levels.
PEARLS AND PITFALLS
Hemostasis
■ Instruct patient to stay away from blood thinning agents for at least 2
weeks.
■ Use freshly prepared local anesthetic and adrenaline solution.
■ Elevate the head of the bed.
■ Dissect with a Colorado tip cautery and obtain meticulous
hemostasis.
Orbital
septum
incision
■ Inject saline for hydrodissection to prevent injury to the levator.
Levator
muscle
■ The muscle is very fragile, and once it bleeds, its function is
temporarily lost—no touch technique is mandatory.
Symmetry
■ The patient is asked to open the eyes and look up and down to check
for function after placement of the aponeurosis shortening sutures.
POSTOPERATIVE CARE
■ Apply ice for 5 days.
■ Elevate the head of the bed.
■ Suture removal in 3 to 5 days
■ Ophthalmic antibiotic ointment application for the first 3 days
■ If the patient has compensatory frontalis muscle hyperactivity, he/she should
be informed that it would take up to 3 to 6 months for the muscle to relax. In

the early postoperative period, frontalis muscle activity might cause asymmetry
and overelevation.
■ The patient should understand that there is a period of 1 to 3 months of
refractory changes in the postoperative phase.
OUTCOMES
■ See FIG 12.
FIG 12 • The patient is seen 6 months after surgery with
symmetric upper eyelid levels. There is better match of
the left eyebrow position.
■ The most common complication is a slight asymmetry in the postoperative
period. This possibly is due to suture displacement in the healing phase. It is
more frequent in asymmetric ptosis cases, and a proper consent should be
obtained prior to initial surgery (FIG 13).
FIG 13 • A. A 37-year-old female presenting with right
upper eyelid ptosis and an occult ptosis on the left side.
She had levator advancement procedure on both sides
with medial fat pad excision and grafting of the middle
upper sulcus and 15-mm skin-only resection preserving
the orbicularis muscle mass. B. The patient has
asymmetric levels of the upper eyelids 4 months later.
There is inadequate correction of her occult ptosis on

the left side, even though the eyelid levels looked
perfectly symmetric on the operative table at the end of
the procedure.
REFERENCES
1. Carraway JH, Vincent MP. Levator advancement technique for upper eyelid
ptosis. Plast Reconstr Surg. 1986;77(3):394-403.
2. Lambros V. Observations on periorbital and midface aging. Plast Reconstr
Surg. 2007;120(5):1367-1376.
3. Faigen S. The role of the orbicularis oculi muscle ant the eyelid crease in
optimizing results in aesthetic upper blepharoplasty: a new look at the surgical
treatment of mild upper eyelid fissure and fold asymmetries. Plast Reconstr
Surg. 2010;125(2):653-666.

30
CHAPTER
Asian Blepharoplasty
(“Double Eyelid” Surgery)
Clyde H. Ishii
DEFINITION
■ Asian blepharoplasty or “double eyelid” surgery is a procedure to create a
supratarsal fold.
■ The fusion level of the orbital septum–levator aponeurosis and dermal
insertions result in naturally occurring supratarsal folds.
■ The incision height, amount of remaining upper eyelid skin, height of fixation,
and levator function affect pretarsal exposure or “show.”
■ The shape of the desired fold varies according to patient preference.
ANATOMY
■ Tissue connections between the levator aponeurosis and pretarsal skin result in
the formation of the supratarsal fold1,2 (FIG 1).
■ Caucasians and Asians with naturally occurring supratarsal folds have a
relatively higher fusion level of the orbital septum and levator aponeurosis.3 In
contrast, these structures fuse at a lower level in Asians with low or absent
folds4 (FIG 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Ethnic differences must be considered when performing Asian blepharoplasty.
Asian blepharoplasty is not simply Caucasian blepharoplasty applied to Asians.
Asians undergoing this procedure want to enhance their appearance while
maintaining their ethnicity. Most Asians do not want to end up with deep-set
eyelids and tall supratarsal folds as seen in Caucasians.
■ Physical examination:
■ The upper eyelid is examined for asymmetry, ptosis, abundance of skin/fat,

and scarring or previous incision sites. The presence of brow ptosis should
also be noted because this will affect the final appearance.
■ The chosen height of the supratarsal fold is key to the final result and must be
discussed in detail with the patient. Patients are interested in the final amount
of pretarsal exposure or “show.” Most Asians prefer to end up with a pretarsal
exposure of 3 mm or slightly less. Older patients and males tend to prefer a
smaller amount of pretarsal exposure. Pressing a lacrimal probe or bent paper
clip against the eyelid may simulate the desired pretarsal exposure (FIG 3).
■ The shape of the desired fold is also very important and must be discussed
with the patient.
• Medially, the fold may taper toward the medial canthus resulting in an
“inside” fold5 (FIG 4).
• Folds that run outside the epicanthus (“outside” fold) will result in more of a
Western appearance5 (FIG 4). Some Asians prefer such an “outside” fold
because it gives the illusion of a narrower intercanthal distance.
• Most Asians prefer that the central third of the fold runs parallel to the lid
margin.
FIG 1 • Dermal attachments from the levator

aponeurosis result in the formation of the supratarsal
fold.
FIG 2 • Asians with short or absent folds have a lower
fusion level of the orbital septum and levator
aponeurosis.
• Laterally, the fold may run parallel to the lid margin or have a slight lateral
flare. This lateral flare produces an uplifted appearance and tends to mitigate
the natural bunching of skin in this area that occurs with aging.
SURGICAL MANAGEMENT
■ Surgical techniques to create a supratarsal fold include nonincisional methods
(sutures alone), partial incisional methods (one or more small incisions
combined with sutures), and incisional methods.
■ Nonincisional methods are mainly used for young patients who do not need
excision of skin or fat. Although these methods are associated with less
postoperative edema than partial incision or incisional methods, the fixation is
not as durable and loss of the fold is well-documented.
■ Partial incisional methods allow for excision of excess fat and better fixation

than nonincisional methods but any excess skin cannot be addressed.
■ My preferred technique is the incisional method because it allows the surgeon
to address redundancy of skin/fat and correct any accompanying
blepharoptosis while providing secure fixation. These incisions heal well, and
unsightly scars are rare. In my experience, the advantages of this technique far
outweigh any disadvantages.
FIG 3 • Simulation of a supratarsal fold using a lacrimal
probe or bent paper clip.
Preoperative Planning
■ The desired height and shape of the fold are once again discussed with the
patient.
■ Marking of the eyelid is performed with the patient in the supine or
semirecumbent position. Needed materials include vernier caliper, toothed
forceps, and marking pen (FIG 5). An alcohol swab is used to clean the eyelid
of makeup or oil film.
■ The caliper is set to the desired fold height, and ink is applied to the distal tip
of the caliper. With the eyelids closed, the surgeon gently lifts the superior
lid/brow skin until slight eversion of the upper lid lashes is noted. The
proximal tip of the caliper is placed at the lid margin and a marking is laid
down in line with the midpupil. A similar marking is made laterally if a slight
lateral flare of the fold shape is desired. If an “inside” fold is desired, the
markings can taper toward the medial canthus. For an “outside” fold, the
medial markings run several millimeters above the epicanthus.

FIG 4 • Medially, the fold may taper toward the medial
canthus (“inside” fold) or run outside the epicanthus
(“outside” fold).
FIG 5 • Vernier caliper, toothed forceps, and marking
pen.
■ Markings for skin excision depend on the amount of skin excess in a given
patient. Younger patients usually need only 0 to 2 mm skin excision. In older
patients, the amount of skin excess is determined by gently grasping the eyelid

skin with toothed forceps. One tip of the forceps is placed on the fold height
marking above while gathering the excess skin with the other tip. Mild
eversion of the lid lashes is used as an end point. A third to half of the
measured skin excess is marked centrally, and the markings taper medially and
laterally to complete the elliptical marking. One should err on the more
conservative side of skin excision in patients who desire a more subtle
pretarsal exposure.
Positioning
■ The patient is positioned supine on the operating table.
Anesthesia
■ The procedure is performed under local anesthesia with mild sedation.
■ The sedation must be mild so patients can open/close their eyelids on
command after the fixation sutures are placed. This allows the surgeon to
check for symmetry regarding fold height and shape.
Approach
■ An incisional approach is used because of its versatility while providing very
secure fixation.
T E C H N I Q U E S
■ With the eyelid under stretch, the elliptical skin incisions are made and a
strip of skin is excised. A strip of orbicularis is also removed along with any
excess submuscular fat. The fusion of the orbital septum and levator
aponeurosis is thus exposed as it approaches the tarsal plate (TECH FIG 1).
The orbital septum may be entered to address any excess retroseptal fat. Care
should be taken to leave some fat behind to avoid unnatural accessory folds
from forming above the fixation line.

TECH FIG 1 • Exposure of fusion involving orbital the
septum and levator aponeurosis.
■ Skin-Aponeurosis Fixation Technique
■ Three or four 7-0 nylon sutures are placed to secure the levator aponeurosis
to the muscle-dermis of the pretarsal skin edge (TECH FIG 2).
■ The sutures may be either of the buried internal variety or external in nature.
■ I prefer buried internal sutures because I like to remove all external sutures
on postoperative days 4 to 5.

TECH FIG 2 • Skin fixation to the levator aponeurosis.
■ Skin-Tarsus Fixation Technique
■ The caliper is used to place markings on the tarsus in the mid pupil line and
laterally according to the patient’s desired fold height. Medially, the markings
parallel the pretarsal skin edge.
■ 7-0 nylon sutures are placed to secure the markings on the tarsus to the
muscle-dermis of the pretarsal skin edge (TECH FIG 3).
■ At the medial and lateral extremes where the tarsus tapers narrowly, the
sutures fix the aponeurosis to the muscle-dermis of the skin edge. As noted
above, the sutures in this technique may be of the buried internal variety or
external in nature.
■ The skin-tarsus fixation technique results in a more static and well-defined
fold when compared to the skin-aponeurosis fixation technique described
above.
■ Closure: Skin closure is performed using a 7-0 nylon running suture for
both techniques.

TECH FIG 3 • Skin fixation to the tarsal plate.
PEARLS AND PITFALLS
Planning
■ Most Asians prefer only a modest amount of pretarsal exposure (3
mm or less) compared to their Western counterparts.
■ Creating an “outside” fold or eyelids with significant pretarsal
exposure will tend to Westernize the eye, and many patients will
find this distressing.
■ The desired fold height, shape, and pretarsal exposure should be
carefully discussed with the patient preoperatively.
■ Reviewing preoperative and postoperative images of other patients
or models may be helpful.
Technique
■ The leading edge of the levator aponeurosis must be carefully
identified when using the skin-aponeurosis fixation technique.
Failure to identify and secure the proper anatomic structures will

lead to incomplete/lack of folds.
Postoperative
care
■ Patients desiring a taller supratarsal fold with more pretarsal
exposure will show more pretarsal edema postoperatively, and this
will persist for several months. Accordingly, patients should be
informed of this preoperatively.
POSTOPERATIVE CARE
■ Apply cold compresses during the first 24 hours.
■ Cleanse the suture line with water and apply a light coat of antibiotic ointment
two to three times a day.
■ Avoid use of cosmetics to the upper eyelid for 10 days.
■ Avoid bending, straining, or strenuous activities for 1 week.
OUTCOMES
■ A highly satisfactory outcome is likely if the patient’s desired final appearance
is properly understood and the procedure is performed with the above
guidelines in mind.
■ Pre-existing asymmetry involving a patient’s brow or lid level may affect the
final result. Such asymmetry must be discussed with the patient prior to
surgery.
COMPLICATIONS
■ Bleeding/hematoma
■ Excessive swelling
■ Asymmetry in fold height/shape
■ Dehiscence
■ Infection
■ Incomplete/loss of folds
■ Multiple folds
■ Milia
■ Suture granuloma
■ Hypertrophic scarring
REFERENCES
1. Sayoc BT. Anatomic considerations in the plastic construction of a palpebral
fold in the full upper eyelid. Am J Ophthalmol. 1967;63(1):155-158.
2. Cheng J, Xu FZ. Anatomic microstructure of the upper eyelid in the oriental

double eyelid. Plast Reconstr Surg. 2001;107:1665-1668.
3. Yoon KC, Park S. Systemic approach and selective tissue removal in
blepharoplasty for young Asians. Plast Reconstr Surg. 1998;102(2):502-508.
4. Siegel R. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg.
1984;13(4):263-273.
5. Zubiri JS. Correction of the oriental eyelid. Clin Plast Surg. 1981;8(4):725-
737.

31
CHAPTER
Section IX: Lower
Blepharoplasty
Transconjunctival Approach
to Resection and/or
Repositioning of Lower
Eyelid Herniated Orbital Fat
Allen Putterman
DEFINITION
■ This procedure is undertaken to treat baggy lower eyelids and inferior orbital
rim hollowing.
ANATOMY
■ Pertinent anatomic structures are the lower eyelid conjunctiva, Müller muscle,
capsulopalpebral fascia, orbital fat, and orbital septum (FIG 1).
■ There are three distinct lower eyelid orbital fat pads (nasally, centrally, and
temporally).
■ The nasal and central fat pads are divided by the inferior oblique muscle, and
the central and temporal fat pads are separated by the temporozygomatic
ligament.
■ There may be a second temporal fat pad.1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients note fullness and bagginess of their lower eyelids. Some patients also
notice a hollowing appearance in the inferior orbital rim area.
■ This technique is also especially advantageous for:

■ Younger patients with large amounts of herniated orbital fat
■ Patients who have had previous blepharoplasties and for whom an external
approach might lead to eyelid retraction or ectropion
■ Fat repositioning is advocated for patients with inferior orbital rim
hollowness.
SURGICAL MANAGEMENT
■ The transconjunctival approach to removal of herniated orbital fat is the
preferred method of treatment in patients who have only herniated orbital fat
with minimal or no evidence of dermatochalasis (excess skin) and no
hypertrophic orbicularis oculi muscle.
FIG 1 • Eyelid anatomy.

T E C H N I Q U E S
Video p1-c031
■ Anesthesia and Eye Preparation
00:00 / 00:00

■ Two percent lidocaine (Xylocaine) with 1:100 000 epinephrine is injected
subcutaneously at the center of the lower eyelid just beneath the lashes.
■ An additional anesthetic agent is injected into each fat pad.
■ To inject the anesthetic into the nasal, central, or temporal fat pad, the
surgeon inserts a 25-gauge, 0.8-cm needle just above the inferior orbital
rim and directs it downward slightly until it penetrates its entire length (0.8
cm).
■ The barrel of the syringe is withdrawn to make sure that no blood vessel
has been entered and approximately 0.5 mL of the agent is injected into
each of the three fat pads.
■ Topical tetracaine is instilled over the eye, and a scleral lens is placed over
the eye to protect it.
■ A 4-0 black silk traction suture is placed through the skin, orbicularis
muscle, and superficial fascia at the center of the eyelid. The surgeon pulls
the eyelid downward with a traction suture as the assistant everts the lower
eyelid over a small Desmarres retractor to expose the inferior palpebral
conjunctiva.
■ Additional anesthetic is injected subconjunctivally over the inferior
palpebral conjunctiva across the eyelid.
■ Isolating the Eyelid Retractors
■ A Colorado needle is used to cut the conjunctiva from the medial to temporal
end of the eyelid halfway between the inferior palpebral fornix and the
inferior tarsal border (TECH FIG 1A).
■ The surgeon grasps the inferior edge of the severed palpebral conjunctiva,
while the assistants grasps the adjacent, more superior edge with forceps, and
the assistant pulls the Desmarres retractors downward (TECH FIG 1B).
■ The two forceps are pulled apart.
■ Further dissection with the Colorado needle is carried out through the
Müller muscle, and capsulopalpebral fascia until fat is seen.
■ A 4-0 black silk double-armed suture is passed through the inferior edge of
the conjunctiva, the Müller muscle, and the capsulopalpebral fascia, and the
suture arms are pulled upward and clamped to the drape (TECH FIG 1C).

TECH FIG 1 • A. A Colorado needle is applied to the
inferior palpebral conjunctiva halfway between the
fornix and the inferior tarsal border and is used to
sever the conjunctiva from medial to temporal end of
the eyelid. B. With forceps, the surgeon and surgeon’s
assistant grasp the inferior and superior edges,
respectively, of the severed palpebral conjunctiva to
facilitate dissection of the Müller muscle and
capsulopalpebral fascia with the Colorado needle. C.
A 4-0 double-armed black silk suture is placed through

the inferior edge of the conjunctiva, Müller muscle,
and capsulopalpebral fascia and is pulled upward and
clamped and taped to the drapes.
■ Excision of Orbital Fat
■ A small Desmarres retractor is placed over the lower eyelid and is pulled
downward and outward to expose the orbital fat.
■ With the use of a disposable cautery and Westcott scissors, blunt dissection
is carried out to isolate the three orbital fat pads.
■ The temporal herniated orbital fat is isolated, and the fat that prolapses with
gentle pressure on the eye is clamped with a hemostat and cut along the
hemostat blade with a no. 15 Bard-Parker blade (TECH FIG 2A).
■ Cotton-tip applicators are placed underneath the hemostat as a Bovie cautery
is applied over the fat stump.
■ The surgeon grasps the fat with forceps before it is allowed to slide back into
the orbit to make sure that there is no residual bleeding that might cause a
retrobulbar hemorrhage.2
■ After the first temporal fat pad is removed, the surgeon applies additional
pressure to the eye to determine whether there is a second temporal fat pad:1
■ If a second temporal fat pad is found, it is also removed. The central and
nasal fat pads are then removed in a similar manner.
■ The retractor suture is removed, and then the conjunctiva is reapproximated
with three 6-0 plain catgut buried sutures (TECH FIG 2B).

TECH FIG 2 • A. The surgeon removes the temporal,
central, and nasal fat orbital fat pads by cutting along
the hemostat blade with a no. 15 Bard-Parker blade
and then applying a Bovie cautery to the fat stump. B.

The conjunctiva is reapproximated with three 6-0 plain
catgut buried sutures.
■ Orbital Fat Repositioning
■ If there is both herniated orbital fat and inferior orbital rim hollowing, fat
repositioning is performed.
■ After the isolation of the orbital fat pads, an incision is made over the nasal
inferior orbital rim, and periosteum is dissected for approximately 1 cm
inferior to the orbital rim from the orbital bone (TECH FIG 3A).
■ A 4-0 Prolene double-armed suture is threaded through the distal end of the
nasal orbital fat pad, and then each arm of the suture passes subperiosteally 1
cm beneath the inferior orbital rim and exits through the skin (TECH FIG
3B).
■ The central fat pad at times will also be repositioned in a similar manner.
TECH FIG 3 • A. Orbital fat repositioning. Periosteum
is dissected from orbital bone over the nasal half of
the lower eyelid for approximately 1 cm. B. A 4-0
Prolene double-armed suture is threaded through the
nasal lower eyelid distal fat stump. Each arm of the
suture is passed subperiosteally approximately 1 cm
beneath the inferior orbital rim and exits through skin
inferior to the hollowed areas. C. If there is excessive
lower eyelid fat, the nasal and or central fat pads are
divided into pedicles and parts of the fat pads are
excised and parts repositioned. D. The 4-0 Prolene

sutures are tied over cotton pledgets to allow the
nasal and central fat to be repositioned into the nasal
inferior orbital rim hollowed areas.
■ The arms of the suture are tied over cotton pledgets to allow the nasal and
central fat pads to be repositioned into the inferior orbital rim hollowed area
and to fill this area as well as to decrease the bagginess of the lower lid.
■ At times, if there is too much nasal or central fad, pedicles are used to divide
the nasal and/or central fat, parts of the nasal and central fat pads are excised,
and parts are repositioned (TECH FIG 3C).3
■ The cotton pledgets and 4-0 Prolene sutures are removed approximately 1
week postoperatively (TECH FIG 3D).
PEARLS AND PITFALLS
Inferior
oblique
muscle
■ Identify inferior oblique muscle to avoid injury with secondary
diplopia.
Temporal fat
■ Check for the second or deeper temporal fat pad after initial
temporal fat pad is removed to avoid residual temporal lower lid
postoperative fullness.1
Fat
transposition
■ Perform fat pedicles with fat repositioning if there is a large
amount of fat to avoid inferior orbital rim overfill and bulging.3
Selective fat
removal
■ Only remove the fat that flows forward when gentle pressure is
applied to the eye through the eyelids to avoid overcorrection with
secondary inferior orbital rim hollowing.
Excess
swelling
■ Apply pressure to closed eyelids over areas of postoperative
conjunctival chalasis to speed resolution of conjunctival chalasis.4
■ If there is a retrobulbar hemorrhage, remove the conjunctival
sutures and do a lateral canthotomy.2
POSTOPERATIVE CARE
■ No dressings are used after surgery.

■ The patient is instructed to apply ice cold compresses on the eyelids, and pads
(4 × 4 in.) soaked in a bucket of saline and ice are applied with slight general
pressure to the eyelids:
■ When the pads become warm, they are dipped again into the saline and ice
and reapplied.
■ This process is repeated for 24 hours but is not necessary during sleep.
■ The application should be fairly constant, especially for the first
postoperative hours. After that, the compresses are applied for about 15
minutes with a 15-minute rest period in between until bedtime. The
applications are resumed on awakening.
■ To reduce edema postoperatively, the patient lies in a bed with the head
approximately 45 degrees higher than the rest of the body:
■ Nurses should check for bleeding associated with proptosis, pain, or loss of
vision every 15 minutes for the first 2 to 3 hours postoperatively or until the
patient leaves the surgical facility.
■ Every hour thereafter until bedtime, the family or patient should monitor the
patient’s ability to count fingers and should check the residual proptosis and
pain.
■ If the patient cannot count fingers or has marked proptosis or pain, the family
should take him or her to the emergency room.
■ If loss of vision occurs secondary to retrobulbar hemorrhage, it could be
treated by opening the incision involved and doing a lateral canthotomy.2
■ Neomycin ointment is applied to the eyes twice a day for the first 2 weeks.
FIG 2 • A. A patient with lower eyelid herniated orbital
fat preoperatively. B. Postoperative appearance after

removal of herniated fat with a transconjunctival
approach. C. A patient with lower eyelid herniated
orbital fat and inferior orbital rim hollowing areas. D.
Postoperative photograph showing resolution of the
baggy lower lids and filling in of the inferior orbital rim
hollowed areas.
OUTCOMES
■ I have performed the transconjunctival approach in more than 1000 patients
(FIG 2A–D).
■ The procedure has the advantages of causing less eyelid retraction and
ectropion than with the skin flap or skin muscle flap approaches because the
external lamellae are not manipulated.
■ I believe there is less ecchymosis because the orbicularis muscle and skin are
not severed.
■ There tends to be more conjunctival chemosis immediately postoperatively
with this procedure than with the external technique. If it occurs, it is treated
with pressure applied over the closed eyelids.4
■ With the fat repositioning, there is always the concern of overfill of the
inferior orbital rim hollowed areas. I have performed fat repositioning for the
last 25 years and so far have not had to repeat the procedure or to remove
overfill of herniated orbital fat. Titrating the amount of fat reposition, I believe,
has been the secret to that success.3
■ I have had several patients who initially postoperatively had diplopia, but this
has resolved in all patients, and I have not had any permanent diplopia from fat
repositioning.
COMPLICATIONS
■ Several patients in whom I have performed a transconjunctival approach had
postoperative residual dermatochalasis, which needed to be removed through
an external approach.
■ Better patient selection or combined initial procedure with a skin flap
excision or orbicularis muscle plication could have presented this problem.
REFERENCES
1. Putterman AM. The mysterious second temporal fat pad. Ophthalmic Plast

Reconstr Surg. 1985;1:83-86.
2. Putterman AM. Temporary blindness after cosmetic blepharoplasty. Am J
Ophthalmol. 1975;80:1081-1083.
3. Aakalu VK, Putterman AM. Fat repositioning in lower lid blepharoplasty: the
role of titrated excision. Ophthal Plast Reconstr Surg. 2011;27:462.
4. Putterman AM. Treatment of conjunctival prolapse. Arch Ophthalmol.
1995;113:553-554.

32
CHAPTER
Indications and Technique
for Skin Pinch Skin Excision
in the Lower Eyelids
Charles H. Thorne and Sammy Sinno
DEFINITION
■ Skin pinch skin excision is a technique in which excess lower eyelid skin is
simply grasped and excised without performing any subcutaneous dissection.
■ Dermatochalasis is the condition of excess and loose eyelid skin. It is
important to distinguish this condition from blepharochalasis.
■ Blepharochalasis is a syndrome of recurrent eyelid edema that causes thinning
and fine wrinkling of eyelid skin.
ANATOMY
■ The skin of the eyelid is the thinnest of the body at less than 1 mm and has a
high concentration of sebaceous glands.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ All patient undergoing eyelid surgery should have a detailed ophthalmologic
history. History of previous periorbital surgery, visual disturbances, and
relevant medications are noted.
■ Patients who are candidates for skin pinch lower eyelid blepharoplasty have
redundant and lax skin and often complain of a “tired” look. The stimulated
effect of surgery can be reproduced preoperatively by providing gentle lateral
traction on the lower eyelids.
■ Patients who undergo this procedure may undergo additional procedures to
correct other periorbital deformities, ie, transconjunctival lower eyelid fat
removal for “puffy eyelids.”
IMAGING

■ No imaging is needed for this procedure.
SURGICAL MANAGEMENT
■ The procedure is relatively simple and straightforward if carefully planned.
Preoperative Planning
■ Skin pinch lower blepharoplasty can be performed under general anesthesia or
local anesthesia. If local infiltration is used, the surgeon must be aware that
skin excision may be less precise because the field has been distorted.
Positioning
■ The patient is positioned supine. Corneal protectors can be used but are
associated with increased risk of corneal abrasion.
Approach
■ The removal is performed just under the ciliary margin.
T E C H N I Q U E
■ Excess Eyelid Skin Removal
■ Using two Adson-Brown forceps, the skin of the lower eyelid near the
ciliary margin is grasped and moved cephalically.
■ The skin is then tented up sequentially from lateral to medial and crushed
with a fine hemostat for hemostasis and to precisely outline the amount of
skin to be removed (TECH FIG 1A–C).
■ Using a Stevens scissors, the tented skin only is excised. The skin is trimmed
from medial to most commonly just lateral to the lateral canthus (TECH FIG
2A–C).
■ Closure is performed using a running 6-0 silk suture (TECH FIG 3A,B).

TECH FIG 1 • A–C. A hemostat is used to precisely
and sequentially outline the planned skin resection.
TECH FIG 2 • A–C. The skin is excised using Steven
scissors.

TECH FIG 3 • A,B. Closure with 6-0 silk suture.
PEARLS AND PITFALLS
Preoperative
counseling
■ Patients must be counseled that all lower eyelid laxity cannot be
removed to avoid lower eyelid malposition.
■ This procedure should be avoided with patients who exhibit
lower eyelid malposition and/or poor lower eyelid tone.
Local
anesthesia
■ Injected volume can reduce precision of the procedure.
Lateral
extension of
excision
■ If excision is not carried out lateral to the lateral canthus,
bunching and incomplete correction can result.
POSTOPERATIVE CARE
■ Patients are instructed to apply cold compresses to the eyes continuously for
12 hours after surgery.
■ Sutures are removed at 3 days.
■ Alcohol should be avoided for 2 to 3 days and heavy exercise avoided for 2
weeks.
■ Patients are encouraged to sleep on their backs.
OUTCOMES
■ Excellent contour is restored to the lower periorbita following excess skin
excision.

■ This technique does not require any dissection, so complications such as
excess bruising, swelling, and eyelid malposition are nonexistent.
COMPLICATIONS
■ If too much skin is excised, there is a possibility for excess tension on the
incision at closure. Typically, delayed healing will occur spontaneously.

33
CHAPTER
Indications and Technique
for Transconjunctival Fat
Removal and Redraping in
the Lower Eyelids
Francisco G. Bravo
DEFINITION
■ Patients with good skin quality who present with prominent lower eyelid bags
and evident nasojugal and palpebromalar grooves may benefit from
transconjunctival fat removal and redraping of excess fat over the inferior
orbital rim.1–4
■ This procedure avoids the need for external incisions, which may be visible in
younger patients and may be associated with a higher incidence of
complications such as lower lid retraction, scleral show, and prolonged
swelling.
■ The need for routine use of canthal support techniques is also generally
avoided through this approach.
■ A recessed lower orbital rim and an evident tear trough deformity may be
augmented and attenuated, respectively, with the patient’s own prominent
lower eyelid bags without the need for fat grafting or synthetic filler injections.
ANATOMY
■ The lower eyelid consists of an anterior, middle, and posterior lamella5 (FIG
1A).
■ Skin and the orbicularis oculi muscle form the anterior lamella.
■ The orbital septum, orbital fat, and suborbicularis adipose tissue form the
middle lamella.
■ The tarsal plate, lower eyelid retractors (capsulopalpebral head and fascia),

and the conjunctiva form the posterior lamella.
■ The orbicularis oculi muscle is subdivided into the pretarsal, preseptal, and
orbital components.
■ There are three postseptal fat compartments in the lower eyelid (FIG 1B).
■ Nasal and central fat pads are separated by the inferior oblique muscle.
■ Central and lateral fat pads are separated by the arcuate expansion of the
Lockwood ligament (FIG 1C).
■ The orbicularis retaining ligament or orbitomalar ligament attaches the
palpebral orbicularis oculi muscle to the underlying maxilla (FIG 2A).
■ The tear trough or nasojugal groove and the lid-cheek junction or
palpebromalar groove extend below the orbital rim and are explained by
anatomical features in the subcutaneous plane6 (FIG 2B).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation for patients seeking lower eyelid surgery includes
a detailed assessment of the patient’s medical history and a thorough physical
examination.7
■ Medical history
■ Special attention should be paid to risk factors that may predispose to
postoperative complications.
■ Thyroid pathology, diabetes, hypertension, heart disease, coagulopathy, and
any previous periorbital surgery or trauma should be documented.
■ Vision disorders such as impaired visual acuity or the need to use corrective
glasses or contact lenses should be noted before surgery.
■ The use of medications such as aspirin and other nonsteroidal anti-
inflammatory drugs, anticoagulants, and certain vitamins and herbal
supplements such as vitamin E and ginkgo should be recorded and suspended
2 weeks prior to surgery.

FIG 1 • A. The lower eyelid consists of an anterior,
middle, and posterior lamella. B. There are three
postseptal fat compartments in the lower eyelid. C.
Central and lateral fat pads are separated by the
arcuate expansion of the Lockwood ligament.

FIG 2 • A. The orbicularis retaining ligament or
orbitomalar ligament attaches the palpebral orbicularis
oculi muscle to the underlying maxilla. B. The tear
trough or nasojugal groove and the lid-cheek junction or
palpebromalar groove extend below the orbital rim and
are explained by anatomical features in the
subcutaneous plane.
■ Smoking history should also be documented and interrupted preferably for 4
weeks prior and 2 weeks after surgery.
■ A history suggestive of dry eye syndrome should be clarified, and if present,
the decision to proceed should be discussed carefully with the patient.
■ Physical examination
■ Evaluation should be performed with three goals in mind:
• To document preoperative eye function
• To identify anatomical features that may predispose patients to developing
postoperative complications
• To identify the specific anatomical features that are causing the patient’s
concern in order to customize the procedure
■ Functional evaluation should include an examination and documentation of
visual acuity, extraocular muscular movements, Bell phenomenon, pupillary