The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

824
Part VI  Eyelid Surgery
The blood supply to the upper lid margin includes two arcades, the superior tarsal
arcade and the marginal arcade, which are branches of the medial palpebral and
lacrimal arteries. The superior tarsal arcade is located superior to the border of the
tarsal plate between Müller’s muscle and the levator aponeurosis. The lower eyelid
has a single inferior palpebral arcade along the lid margin just below the tarsal plate
supplied by the medial and lateral inferior palpebral arteries, and including an anas-
tomosis with the infraorbital artery from the external carotid system. Thus both lids
have a dual blood supply from the medial and lateral aspects, allowing safe lateral
canthotomy with preservation of the dominant blood supply from the medial infe-
rior palpebral artery.
An understanding of the arterial anatomy of the eyelid and orbit is particularly im-
portant because a rare cause of blindness after blepharoplasty is periorbital arterial
injection. Blindness can occur with inadvertent injections to the supraorbital or supra-
trochlear vessels, with retrograde flow into the ophthalmic artery causing central
retinal artery embolization; this includes periorbital injection of fillers. A second
cause of blindness is retrobulbar hematoma, which results in increased pressure be-
hind the globe, causing central retinal artery occlusion.
Supraorbital
artery
Central retinal
artery
Internal carotid
artery

Preauricular node
Submandibular node
Venous Drainage
825
Chapter 26  Applied Anatomy of the Eyelids and Orbit
Superior peripheral
venous arcade
Superior
palpebral vein
Nasofrontal vein
Supraorbital vein
Medial palpebral vein
Angular vein
Facial vein
Inferior peripheral
venous arcade
Lateral
palpebral vein
The lymphatic drainage of the upper and lower eyelids includes dual drainage to the
preauricular parotid nodes and the submandibular lymph nodes. The upper eyelid,
lateral canthus, and lateral half of the lower eyelid lymphatic vessels drain to the
preauricular lymph nodes. The nasal aspect of the upper and lower eyelids and the
Similar to the arterial system, venous drainage of the eyelid and periorbital region
includes a dual superficial and deep system. The external periorbital area is drained
by the internal jugular vein from branches including the anterior facial vein, super-
ficial temporal vein, and external jugular vein. The central orbital area is drained
into the cavernous sinus from branches including the superior ophthalmic vein, an-
terior ophthalmic vein, and pterygoid plexus.
Lymphatic Drainage

826
Part VI  Eyelid Surgery
medial canthus have lymphatic drainage along the facial vein, then inferiorly to the
submandibular lymph nodes. Lymphatic drainage is clinically relevant both as a con-
tributing factor to the formation of chemosis after blepharoplasty and for potential
meta static spread of malignant neoplasms or infection involving the periorbital region.
Midfacial Anatomy
The anatomic relationship between the lower eyelid and the midface must be ap-
preciated because changes in midface anatomy influence the appearance of the lower
eyelid. In addition to the periorbital fat compartments, two additional fatty layers
exist in the midface. Deep to the orbicularis oculi muscle is the suborbicularis oculi
fat (SOOF). This layer is readily appreciated after suborbicularis dissection below
the infraorbital rim. As the arcus marginalis is encountered and subsequently tra-
versed, the SOOF becomes apparent between the overlying orbital portion of the
orbicularis and the underlying soft tissue structures of the midface including facial
mimetic muscles. The SOOF may be compartmentalized by septa into vertical and
horizontal components, and the upper lid SOOF is divided into medial and lateral
compartments. These septa may have a role in the regional blood supply, as vascu-
lar supply to the skin of the face is thought toe be carried in the intercompartmental
septa. The SOOF’s greatest thickness and volume is lateral to the infraorbital fora-
men. The SOOF is deep to the superficial musculoaponeurotic system (SMAS) and
also envelops the zygomaticus major and minor muscles. In addition to the SOOF,
the malar fat pad is a triangular pad in the midface area, which is in the subcuta-
neous plane superficial to the SMAS. The midface presents with aging caused by the
descent of the malar fat pad, which often unmasks the orbital fat pads as a result of
inferior migration and thinning of the overlying tissue. The periorbital fat becomes
visible, with pseudoherniation of the orbital septum.
Orbital fat
SOOF
Malar fat pad

It is not only soft tissue changes that occur with age; assessment of the human skull
collection at the Smithsonian Institution suggests that progressive remodeling and
retrusion of the orbital rim occurs throughout life. Others have found that while
retrusion of the midface relative to the upper face does occur with age, this change
happens below the level of the infraorbital rim. The exact manner of age-related bone
change differs among patients, but overall, aging does remodel the orbital region and
seems to increase the negative vector in older patients.
827
Chapter 26  Applied Anatomy of the Eyelids and Orbit
This cross-section of the periorbital anatomy illustrates the fat compartments, sup-
porting ligaments, prezygomatic space, and subzygomatic space. In 1996 Kikkawa
et al described a major supporting structure of the midface, the orbitomalar liga-
ment, as the primary retaining ligament of the midface. It was thought to be an os-
seocutaneous ligament that originated at the inferior orbital rim just below the ar-
cus marginalis and to penetrate the orbicularis oculi muscle anteriorly, inserting into
the dermis. Muzaffar et al applied the more commonly used nomenclature, orbicu-
laris retaining ligament (ORL), in 2002. Mendelson and colleagues further delineated
this region in cadaver dissections and specified that there is a direct attachment of
orbicularis oculi muscle to the orbital rim inferomedially, from the anterior lacrimal
crest to about the level of the medial corneoscleral limbus. Farther laterally, the ORL
provides an indirect attachment from the undersurface of the orbicularis oculi mus-
cle to the orbital rim as far as the lateral canthal region, where it blends with the lat-
eral orbital thickening. In its lateral section, the ORL lies directly orbital to the zy-
gomaticofacial nerve, which is a reliable landmark for its location. The ORL is
similarly continuous in the upper eyelid, from the medial to the lateral orbit. The or-
bital septum inserts into the most marginal part of the orbital rim, with the ORL
inserting 2 to 3 mm outside this point. The merging of these two structures at their
insertion forms the arcus marginalis. The prezygomatic space is the soft tissue area
overlying the skeleton of the midface, namely the zygoma and maxilla. The infrazy-
gomatic space covers the vestibule of the oral cavity.
Zygomaticocutaneous ligament
SOOF
Septum
Orbitomalar ligament
Prezygomatic space
Zygomaticus major muscle
Subzygomatic space

828
Part VI  Eyelid Surgery
The orbitomalar ligament contributes to formation of the malar crescent and malar
bag, which are common findings with midface aging. Laxity of the ORL with age
allows descent of the central fat pad and the lid-cheek junction. Descent is more
prominent lateral than medially due to the direct attachment of the orbicularis oculi
muscle to the orbital rim medially. In addition, the orbitomalar ligament contributes
to the formation of the lid-cheek junction.
Lower eyelid bulge
Nasojugal groove
Malar mound
Levator labii superioris
alaeque nasi muscle
Levator labii
superioris muscle
Infraorbital nerve
Orbicularis oculi
muscle
Tear trough deformity
The orbitomalar ligament along with the origin of the levator labii superioris and
levator alaeque nasi muscles contribute to formation of the tear trough. The anatomy
of the tear trough is complex, with contributions from bone, muscle, and overlying
soft tissue. The concavity begins at the anterior nasal lacrimal crest and is formed
by the arcus marginalis, orbitomalar ligament, origin of the orbicularis oculi mus-
cle, levator labii superioris, and levator alaeque nasi muscles inferiorly. With aging
changes, descent of the SOOF contributes to attenuation of the overlying soft tissue,
thereby unmasking the nasojugal groove. As mentioned, the ORL attaches to the or-
bicularis oculi at the junction of the infraorbital rim, and the division of the orbi -
cularis retaining ligament provides mobilization of the SOOF and separates the prezy-
gomatic space from the preseptal space. Appreciation of the anatomy of the midface
is important when techniques are used to correct midfacial aging.

Annotated Bibliography
Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane.
Plast Reconstr Surg 102:1646-1657, 1998.
Composite rhytidectomy adds repositioning of the orbicularis oculi muscle to the deep
plane face lift to achieve a more harmonious appearance of the face by adding perior-
bital rejuvenation. These two modifications allow a more predictable and impressive re-
sult. They reinforce the concept of periorbital rejuvenation as an integral part of facial
rejuvenation, which produces a more harmonious immediate result and prevents the
possible unfavorable sequelae of conventional rhytidectomy and lower blepharoplasty.
Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture.
Clin Plast Surg 18:183-195, 1991.
This article discusses the multitude of factors influencing the palpebral aperture. Unique
individual combinations of the orbital anatomic influences cause the variations in the
palpebral apertures.
Mendelson BC, Hartley W, Scott M, et al. Age-related changes of the orbit and midcheek
and the implications for facial rejuvenation. Aesthetic Plast Surg 31:419-423, 2007.
This paper describes the anatomy of the soft tissue and bony orbit. Changes that occur
during the aging process are discussed. CT imaging was performed in three groups of
patients of both sexes and different ages ranging from 21 to 70. Bony changes occurred
that demonstrated retrusion of the anterior maxillary wall, which may contribute to
midfacial aging.
Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar
mounds. Plast Reconstr Surg 110:885-896; discussion 897-911, 2002.
The authors describe the anatomy of the midcheek to explain midcheek aging and malar
mounds. A cadaver study located a glide plane space overlying the body of the zygoma.
Together the function of this space, as well as the anatomic boundaries and anatomic
features of this area, determine the characteristic aging changes that occur in this region
and explain malar mounds. The authors discuss the surgical implications resulting from
this anatomy.
Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the ligamentous attachments
of the lower lid and lateral canthus. Plast Reconstr Surg 110:873-884; discussion 897-
911, 2002.
The authors describe the surgical anatomy of the superficial fascia of the face, which
must include its deep attachments. Release of the deep ligamentous attachments (lateral
orbital thickening and orbicularis retaining ligament) of the orbicularis fascia is impor-
tant in some canthopexy and in rejuvenation procedures. The release allows effective
redraping and upward mobilization of the orbicularis of the lower lid and the premalar
soft tissues.
829
Chapter 26  Applied Anatomy of the Eyelids and Orbit

Suggested Readings
Darcy SJ, Hakimi M, Miller TA, et al. Magnetic resonance imaging characterization of or-
bital soft-tissue volume dynamics with age. Plast Reconstr Surg 124:1362-1364, 2009.
Ghavami A, Pessa JE, Janis J, et al. The orbicularis retaining ligament of the medial orbit:
closing the circle. Plast Reconstr Surg 121:994-1001, 2008.
Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation.
Plast Reconstr Surg 96:354-362, 1995.
Hass AN, Penne RB, Stefanyszyn MA, et al. Incidence of postblepharoplasty orbital hemor-
rhage and associated visual loss. Ophthal Plast Reconstr Surg 20:426-432, 2004.
Hirmand H, Codner MA, McCord CD, et al. Prominent eye: operative management in lower
lid and midface rejuvenation and the morphologic classification system. Plast Reconstr
Surg 110:620-628; discussion 629-634, 2002.
Hwang SH, Hwang K, Jin S, et al. Location and nature of retro-orbicularis oculus fat and
suborbicularis oculi fat. J Craniofac Surg 18:387-390, 2007.
Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: bypassing the pit-
falls. Clin Plast Surg 20:213-223; discussion 224, 1993.
Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic
system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Re-
constr Surg 12:77-88, 1996.
Knize DM. The superficial lateral canthal tendon: anatomic study and clinical application
to lateral canthopexy. Plast Reconstr Surg 109:1149-1157; discussion 1158-1163, 2002.
Pessa JE, Chen Y. Curve analysis of the aging orbital aperture. Plast Reconstr Surg 109:751-
755; discussion 756-760, 2002.
Pessa JE, Zadoo VP, Adrian EK, et al. Anatomy of a “black eye”: a newly described fascial
system of the lower eyelid. Clin Anat 11:157-161, 1998.
Ramirez OM, Santamarina R. Spatial orientation of motor innervation to the lower orbi -
cularis oculi muscle. Aesthetic Surg J 20:107-113, 2000.
Rees TD, LaTrenta GS. The role of Schirmer’s test and orbital morphology in predicting dry-
eye syndrome after blepharoplasty. Plast Reconstr Surg 82:619-625, 1988.
Rohrich RJ, Arbique GM, Wong C, et al. The anatomy of the suborbicularis oculi fat: im-
plications for periorbital rejuvenation. Plast Reconstr Surg 124:946-951, 2009.
Schaverien MV, Pessa JE, Rohrich RJ. Vascularized membranes determine the anatomical
boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 123:695-700,
2009.
Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven Press, 1985.
830
Part VI  Eyelid Surgery

Clinical Decision-Making
in Aesthetic Eyelid Surgery

FOAD NAHAI
CHAPTER 27

Evaluation
832
Part VI  Eyelid Surgery
The hallmark of youthful-appearing eyelids is a smooth contour that extends from the
brow to the upper lid and from the lower lid to the cheek and midface. The lid-cheek
junction lies over the infraorbital rim and is usually 5 to 12 mm below the lid mar-
gin. The skin is tight and the tissues are full. There is an upward slant from the me-
dial canthus to the lateral canthus, and eyelid tone is normal: a snapback test results
in rapid lid recovery, and lid distraction will be 6 mm or less.
Descent of brow
Nasojugal groove
Malar mound
Palpebromalar groove
Upper lid ptosis
Lower lid retraction
Lower lid bulge
Midcheek groove
Orbital fat atrophy
Tear trough deformity
In contrast, the aged eye appears hollow, with a definite demarcation from the brow
to the upper lid and the lower lid to the cheek and midface. In most individuals, the
eye fissure becomes smaller and rounder with age. The lid-cheek junction lies well
below the infraorbital rim, 15 to 18 mm from the lid margin. There is a downward
slant from the medial canthus to the lateral canthus and eyelid tone is significantly

reduced, with a very slow result to the lid snapback test and a lid distraction of
6 mm or greater. (See Chapter 28 for further discussion of evaluation of the aged eye.)
These aging changes, which develop gradually over time, are a combination of vol-
ume loss, loss of skin elasticity, and downward descent of the tissues. These changes
are classified into the following four types:
 Type I: Aging confined to the lower lid, with skin and muscle laxity and
pseudoherniation of the fat
 Type II: Aging no longer confined to the lower lid; in addition to skin and mus-
cle laxity, there is skin excess and minimal descent of the lid-cheek junction
 Type III: Lower lid aging with volume loss, descent of the lid-cheek junction
and malar eminence; skeletonization of the orbital rim and deepening of the
nasolabial fold, loss of skin elasticity and lid laxity are also common findings
 Type IV: Further volume loss and descent of the lid-cheek junction; deepening
of the nasojugal groove; presence of malar bags; further loss of skin elasticity,
lateral canthal descent and lid laxity with scleral show
833
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
TYPE I
Minimal
lower lid aging
TYPE II
Minimal descent
of lid-cheek
junction
TYPE III
Moderate upper
lid aging with
brow ptosis
Lid-cheek junction
below orbital rim
Nasolabial fold
TYPE IV
Upper lid aging
with mild ptosis
Lower lid laxity—
“round eye”
(scleral show)
Nasojugal groove
Malar bag
Tear trough

This classification is most useful in selecting appropriate procedures to address spe-
cific problems for each patient type. In addition to addressing the lower eyelid, it also
demonstrates that aging of the lower lid and midface are intertwined. Rejuvenation
of one without the other will lead to a suboptimal or patchwork result. Concomi-
tant with the aging changes of the lower lid and lid-cheek junction, there is a real or
apparent loss of volume that must be addressed.
A component evaluation of the eyelids to determine aesthetic options will also min-
imize complications. Components of eyelid evaluation are discussed next.
834
Part VI  Eyelid Surgery
Decision-Making Factors in Eyelid Surgery
Aesthetic Factors
Safety Factors
 Skin
 Upper lid ptosis
– Quality
 Lid tone
– Quantity
 Eye prominence
 Muscle
 Canthal position
 Fat
 Lid-cheek interface
 Scleral triangles
– Medial
– Lateral

Skin
As an individual ages, the elasticity of eyelid skin diminishes, causing the skin to ap-
pear loose and wrinkled. There is real or apparent skin excess. The physician evalu-
ates the quality and quantity of the skin. In assessing upper eyelid skin excess, the
brow should be held in its ideal position. The eyelids should always be evaluated with
the eyes open as well as shut.
Muscle
Muscle activity and morphology are noted. With aging, the orbicularis oculi muscle
may become lax and hypertrophic, especially in the pretarsal area. Infratarsal full-
ness may also be present. Although this fullness is often associated with a youthful
eye, some patients are concerned about infratarsal fullness.
Fat
Two pockets of periorbital fat are contained within the upper lid, with three in the
lower lid. The surgeon notes these and decides whether to preserve, redistribute, or
remove this fat. In addition, the retroorbicularis oculi fat (ROOF) lying along the
lateral orbital rim between the orbicularis oculi muscle and the periosteum is also
assessed. Under rare circumstances, some of this fat will need to be resected to im-
prove the contour of the lateral orbital rim.
Upper Lid Ptosis
The presence or absence of upper lid ptosis should always be recorded. If present, it
is pointed out to the patient and plans are discussed to correct it at the time of bleph-
aroplasty.
Lid Tone
Lower eyelid tone is evaluated with the lid distraction test and lid snapback test. Rou-
tine correction of lower lid laxity is essential to minimize complications.
835
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery

836
Part VI  Eyelid Surgery
Eye Prominence (Hertel Measurement)
Eye prominence is assessed by means of the Hertel ophthalmometer, which mea-
sures the distance between the cornea and the lateral orbital rim.
Normal eye prominence, which is seen in 65% of the population, ranges from 15 to
17 mm. Deep-set or anophthalmic eyes measure less than 15 mm, and any measure -
ment of 18 mm or greater indicates a prominent eye. These measurements play a sig-
nificant role in determining risk, procedure selection, and lid-anchoring techniques.
15 mm
15-17 mm
21 mm
Standard
measurement
15-17 mm
Prominent eyes
21 mm
Deepset eyes
15 mm
Prominent eye
Normal eye prominence
Deep-set eye

Canthal Position
837
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
The surgeon notes the position of the lateral canthus in relation to the medial can-
thus. The lateral canthus should normally be higher than the medial canthus. A lat-
eral canthus at the same level or lower than the medial canthus indicates significant
lid laxity, requiring horizontal lid shortening (canthoplasty).
Scleral Triangles
The triangle between the cornea and the medial canthus is called the medial scleral
triangle, and the triangle between the cornea and lateral canthus is called the lateral
scleral triangle. With increasing lid laxity and age, these triangles, especially the lat-
eral scleral triangle, are lost. Eye shape is judged by the shape and size of the lateral
scleral triangle. The tighter the triangle, the more almond-shaped the eye; conversely,
the looser the triangle, the rounder the shape of the eye.
Evaluation of skin, muscle, and fat plays a role in selecting the best treatment op-
tion. However, of more importance is evaluation of the lid-cheek interface and mid-
face aging for lower lid options. For the upper eyelid, the relationship between the
upper lid and the brow is an important determining factor.
YOUTHFUL EYE
Lid-cheek
junction
Lateral scleral
triangle
8-12 mm
Medial scleral
triangle
AGED EYE
Lid-cheek
junction
Lateral scleral
triangle
15-18 mm
Medial scleral
triangle
Medial
scleral
triangle
Lateral
scleral
triangle
YOUTHFUL EYE
Medial
scleral
triangle
Lateral
scleral
triangle
AGED EYE

838
Part VI  Eyelid Surgery
Evaluation of lid tone, eye prominence, and canthal position plays a pivotal role in de-
termining which lid-anchoring procedure is appropriate to minimize the potential
for complications.
Preoperative Planning
Treatment Options
A variety of surgical and nonsurgical options are available for treating upper and
lower eyelid aging. Fat grafting and injectables offer volume restoration of the upper
lid and the lid-cheek junction. Surgical options include transcutaneous and transcon-
junctival approaches. Procedures range from the simple transconjunctival removal
of fat from both upper and lower lids to complex procedures, including transpalpe-
bral procerus corrugator muscle modification and browpexy through the upper eye-
lid and transpalpebral midface lift through the lower eyelid.
Options for Fat Management
In recent years there has been a tremendous revolution in our thinking and approach
to facial rejuvenation. This is especially true in concepts of fat preservation and aug-
mentation, not only in face lifts but even more so in blepharoplasty. Gone is the stan-
dard skin, muscle, and fat excision blepharoplasty that I was taught many years ago.
Our current choices are to preserve or redistribute the periorbital fat and occasion-
ally remove or even augment the fat. For augmentation, options include autologous
fat, autologous dermis, fillers, and even alloplastic materials.
I base my options for fat management on evaluation of the lid-cheek junction and
choose a procedure to improve this area.
Although most surgeons continue to rejuvenate the lower lid surgically, injectable
fillers are being established as a safe and effective option for lower lid rejuvenation,
especially for correction of the tear-trough area.
1
27-1 Upper and
lower blepharoplasty
and midface
cheek lift

If the patient has an adequate volume of fat, my
preferred technique for improving the lid-cheek
junction is a combination of fat redraping and a
transpalpebral midface lift with orbicularis muscle
flap redraping. If the patient does not have fat her-
niation or enough fat for redraping, I plan no fat
manipulation, I do not open the periorbital septum,
and I rely on the transpalpebral midface lift and on
orbicularis muscle flap redraping.
839
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
Options for Fat Management
 Preserve
 Augment
 Redistribute
 Remove
If I think that these approaches are not adequate for correction of the lid-cheek junc-
tion, I consider autologous tissue augmentation. I have no experience with alloplas-
tic implants around the orbital rim, and I think that autologous tissue is as effective.
Occasionally, I do resect fat from the lower lid, most often from the lateral com-
partment when the fat bulges out. Both of the patients above have undergone peri-
orbital rejuvenation. The patient at the top of the page had no fat removal from
either lower eyelid. The patient immediately above had fat removed only from the
lower left eyelid.

840
Part VI  Eyelid Surgery
A review of a personal series of 100 consecutive blepharoplasties revealed 49% with
fat redraping, 38% with no fat manipulation, 9% with fat excision, and 4% with
autologous grafting in the lower lid. In the upper eyelid in the same series, I resected
fat from the medial nasal pocket in 76% and from the lateral pocket in only 24%
of cases. These numbers are indicative of my current practice and the continuing
trend toward fat preservation and fat augmentation in the periorbital area.
Resection of the ROOF was very popular several years ago and was part of my ap-
proach to the upper eyelid and lateral brow in selected patients. Today, with a bet-
ter understanding of the aging process and the role of volume, I do not resect the
ROOF. Patients with a full subcutaneous pocket deep to the lateral hair-bearing brow
who would benefit from ROOF resection are few and far between.
UPPER LID BLEPHAROPLASTY
Fat
excision
No fat
manipulation
Fat
grafting
Fat
redraping
49%
38%
9%
4%
Lateral
pocket
Medial/nasal
pocket
76%
24%
LOWER LID BLEPHAROPLASTY
LOWER LID FAT MANAGEMENT
LID-CHEEK
JUNCTION
Periorbital fat
Normal/youthful
Plan: Lower lid blepharoplasty
Fat management
Without midface lift
Aged/descending
Plan: Lower lid blepharoplasty
Fat management
Transpalpebral midface lift
Augment
Excise
No fat manipulation
Insufficient
Normal or sufficient
Excess
Periorbital fat
Augment
Redrape and resect if needed
Redrape
Insufficient
Normal or sufficient
Excess

With the current interest in fat preservation and adding volume to the lower eyelid,
it is possible that the surgeon may injudiciously inject excessive amounts of autolo-
gous fat into the periorbital area, as is demonstrated in this patient. Given the un-
predictability of the survival of the grafted fat, this is not an uncommon finding.
Transconjunctival and transcutaneous fat removal has proved to be a relatively
straightforward and effective procedure for correction of this problem. The injected
fat bears little resemblance to the periorbital fat and maintains the appearance and
morphologic character of the area from which it was harvested.
841
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
The transcutaneous approach was chosen for this patient so that her lid retraction
and skin excess could be addressed, along with removal of excess injected fat.
10 mm
10 mm
10 mm
Autologous fat grafts

842
Part VI  Eyelid Surgery
Transconjunctival fat removal is shown in
another patient.
Options for rejuvenating the upper eyelid include transconjunctival and transcuta-
neous approaches. The transconjunctival approach has a limited role, confined to
excision of fat from the medial or nasal fat pocket. The most versatile approach to
the upper lid is excision of skin and muscle (the open-sky approach), which allows
access to the periorbital fat, ROOF, lateral brow, glabellar muscles, and levator mus-
cle. Recently the skin excision with muscle preservation approach to the upper eye-
lid has been popularized. With this volume-preserving procedure, the orbicularis is
preserved to increase the volume of the upper eyelid. Access deep to the orbicularis
is possible by merely dividing the muscle rather than resecting it.
Options for Upper Eyelid Rejuvenation
 Transconjunctival fat removal from the medial pocket
 Skin and muscle excision
– Gateway to the lateral brow
– Gateway to the glabellar muscles
– Ptosis repair
 Skin excision with muscle and fat preservation
Upper Eyelid
Options for upper eyelid rejuvenation are fewer than those for the lower eyelid. Most
upper eyelids are approached through a standard skin-muscle incision. Rarely, the
transconjunctival approach is an option to resect excess fat in the medial pocket. A
skin excision with muscle preservation may sometimes be the best option to preserve
orbicularis muscle to maintain volume in the upper eyelid.

Transconjunctival Approach
The transconjunctival approach has limited application for removal of the medial
or nasal fat pocket only. I have found this to be a safe, efficacious technique in pri-
mary as well as secondary fat removal from the medial pocket. Ideal candidates have
a bulging medial fat pocket of the upper eyelid with no excess upper eyelid skin.
The lateral fat pocket, preaponeurotic fat, in the upper eyelid lies anterior to the le-
vator aponeurosis, whereas the medial or nasal fat pocket lies medial to the aponeu-
rosis.
843
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
Options for Upper Eyelid Rejuvenation
Trans-
Skin and
Components
conjunctival
Muscle Excision
Skin Excision
Skin
—


Muscle
—

—
Fat


—
(medial pocket only)
Lateral brow
—

—
Glabellar muscles
NA

—
Ptosis repair
NA

—
Degree of effectiveness indicated by the number of pluses.
NA, Not applicable.
The insertion of the levator aponeurosis into the tarsal plate prevents herniation of
the lateral fat pocket; however, the medial horn of the levator aponeurosis is much
higher than the lateral horn. This allows herniation of the medial fat and access to
the medial fat through the conjunctiva. The incision is made in the conjunctiva me-
dial to the medial border of the tarsal plate.
Superior tarsus
Lateral horn of
levator aponeurosis
Levator
Levator aponeurosis
Medial horn of
levator aponeurosis

The advantage of this transconjunctival approach is that it eliminates the need for
an incision in the upper eyelid skin. This approach has been free of complications in
my hands, and I have not seen any ptosis. The limitation of this approach is that only
one aspect of upper eyelid aging—medial fat herniation—is addressed.
Skin-Muscle Excision
Skin-muscle excision is the most versatile approach to the upper eyelid, allowing ma-
nipulation and excision of fat from both periorbital fat pockets, excision of ROOF,
if indicated, access to the lateral brow, and access to the glabellar muscles. The skin-
muscle excision approach also affords exposure of the levator and its aponeurosis
for ptosis repair. It is a proven approach with minimal morbidity. Potential problems
include inadvertent disruption of the levator aponeurosis, leading to postoperative
ptosis, and misplaced scars.
Skin Excision
In keeping with recent trends to preserve and restore volume in facial rejuvenation,
a volume-preserving upper lid skin excision has been described (Fagien). If access
deep to the orbicularis is needed, the orbicularis is divided rather than resected. It is
thought that the small amount of orbicularis that is spared with this approach adds
volume to the upper lid.
Lower Eyelid
My approach to the lower eyelid is based on management of fat, skin, muscle, and the
lid-cheek junction. Options include the transconjunctival and transcutaneous ap-
proaches. A detailed evaluation of the eyelid and periorbital area helps to determine
the appropriate selection of surgical technique. A variety of procedures are available
to manage the skin laxity and excess, periorbital fat, muscle, and the lid-cheek in-
terface and lid laxity. Some are relatively straightforward with minimal if any mor-
bidity (for example, skin-pinch blepharoplasty and transconjunctival fat removal),
whereas others, especially those designed to improve on the lid-cheek junction, are
not only complex and technically demanding but also may lead to lid retraction and
exposure. Correction of lid laxity and routine lid anchoring at the time of the pri-
mary procedure are prerequisites to minimize these potential complications.
844
Part VI  Eyelid Surgery

Fillers
Autologous fat as a filler in the periorbital area is increasing in popularity and ef-
fectiveness (see Chapter 13). A variety of fillers, including nonanimal stabilized
hyaluronic acid fillers (NASHAs), porcine collagen, and the semipermanent Radiesse
are available for volume restoration of the lower lid, especially the nasojugal groove
(see Chapter 12).
Pinch Blepharoplasty
The pinch technique is safe and effective for removal of excess, inelastic eyelid skin
without disturbing the underlying orbicularis muscle. Although it has a role as a
stand-alone procedure, a pinch blepharoplasty may be combined with transcon-
junctival fat removal from the lower lid. It may also be used as an adjunct to face-
lift procedures such as the extended MACS-lift, which elevates the midface, result-
ing in excess lower lid skin. Although a canthopexy can be performed with a
skin-pinch blepharoplasty, it is not imperative.
845
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
Options for Lower Eyelid Rejuvenation
 Fillers
 Pinch blepharoplasty
 Transconjunctival fat removal
 Transconjunctival fat redistribution
 Transcutaneous
– Skin flap
– Skin-muscle flap
– Fat management
– Orbicularis redraping
 Midface Lift
– Full open approach
– Limited or endoscopic approach
 Certain face-lift techniques
The lid-cheek junction can be improved and the lower lid rejuvenated through ma-
nipulation of the SMAS with open face-lift procedures, such as the high SMAS tech-
nique, SMASectomy, and the extended MACS-lift technique with a skin-pinch bleph -
aroplasty. Although all of these will improve on the lower lid, in my experience the
results do not match those of a skin-muscle flap blepharoplasty approach.

846
Part VI  Eyelid Surgery
The excess eyelid skin is pinched with one pair of pickups in the left hand while the
second pair of pickups in the right hand progressively pinches and squeezes the ex-
tra skin, proceeding from lateral to medial.
This “pinched” skin is then trimmed with a pair of scissors.
The skin excision is completed.

Because the skin has been pinched, there is very little bleeding after the skin excision.
By spreading the skin, the extent of the resection can be seen, and bleeding points
can be cauterized with bipolar cautery.
Transconjunctival Approach
The transconjunctival approach offers two treatment options: preseptal and post-
septal. The postseptal approach is the most popular as well as the safest and easiest
route to accessing the periorbital fat compartments. This approach only allows fat
excision. The incision is made 4 to 5 mm below the tarsal border at the level of the
vascular arcade. The conjunctiva and lid retractors are incised together, and the fat
pockets are immediately identified and excised as needed.
847
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
Options for Lower Eyelid Rejuvenation
Transconjunctival
Trans-
Trans-
and Laser
Skin-Muscle
Trans-
conjunctival
conjunctival
Resurfacing or
Skin-
and
palpebral
Components
Preseptal
Postseptal
Skin Pinch
Muscle
Orbicularis Flap
Midface Lift
Skin






Muscle






Fat






Lid-cheek

—
—
—


interface
Degree of effectiveness indicated by the number of pluses.
The preseptal approach affords the opportunity to resect fat as well as the option to
redrape the fat; it also provides access to the midface region. The incision is made
along the tarsal border through the conjunctiva and lid retractors, then over the peri-
orbital septum toward the orbital rim.

These transconjunctival approaches obviously will not allow excision of skin or mus-
cle. Some have advocated approaching the fat and the midface through the transcon-
junctival approach and adding a simple skin-pinch excision to deal with the excess
lower eyelid skin. Laser resurfacing with transconjunctival blepharoplasty is another
option. The major advantage of the transconjunctival approach is the fact that no
incisions are made in the orbicularis, thus minimizing, if not totally eliminating, the
risk of lid retraction. I have found the transconjunctival approach for fat excision to
be safe and effective with minimal if any risk of lid retraction. I have also found that
it is much more difficult to manipulate fat and to access the midface through a pre-
septal transconjunctival approach. I prefer to manipulate the fat and approach the
midface through a transcutaneous muscle-skin flap. (See Chapter 33 for more de-
tailed information on transconjunctival blepharoplasty.)
Transcutaneous Approach
The traditional transcutaneous skin-muscle flap is still my preferred approach to the
lower eyelid in a patient who requires more than simple fat excision. This approach,
especially any incision in the orbicularis, has come under considerable attack and
scrutiny over the past few years. Some believe that any incision within the orbicu-
laris will lead to its denervation and result in lid retraction. However, the cause of
lid retraction is multifactorial, with orbicularis denervation merely one of the many
potential causes.
848
Part VI  Eyelid Surgery
Causes of Lid Retraction
 Anterior lamellar insufficiency
 Middle lamellar scarring
 Lid laxity
 High-risk patient
 Orbicularis muscle excision/denervation
The anterior lamella is composed of skin and the orbicularis muscle. Overresection
of skin and muscle will lead to lid retraction. This is easily avoided through judicious
skin excision. The middle lamella is composed of the periorbital septum and peri-
orbital fat. Without doubt, scarring of the middle lamella is a major cause of lid re-
traction, and any procedure requiring manipulation within the middle lamella will
increase the risk of lid retraction. This risk is minimized through meticulous dissec-
tion and hemostasis in the middle lamella and aggressive treatment of any postop-
erative bleeding or hematoma.

Unrecognized or untreated lid laxity is also a major cause of lid retraction. The rou-
tine application of lid-anchoring techniques in patients undergoing the transcuta-
neous skin-muscle flap approach and middle lamellar manipulations significantly re-
duces the risk of lid retraction. Horizontal lid shortening, if indicated, is also my
routine. This is particularly appropriate for high-risk patients, including those with
prominent or enophthalmic eyes and for anyone undergoing a secondary blepharo-
plasty. There is no question that true and complete denervation of the orbicularis,
especially the pretarsal portion, will lead to lid retraction. Similarly, there is no ques-
tion that a 5 mm rim of innervated orbicularis should remain on the tarsal plate.
The question of denervation is currently a topic of much debate. The orbicularis is
innervated by the zygomatic and buccal branches of the facial nerve. The bulk of the
orbicularis muscle, the extracanthal orbicularis, is innervated by the zygomatic
branches; classically, these branches run from below upward almost perpendicular
to the tarsal plate, and there is no question that division of the orbicularis as in the
skin-muscle flap approach, will divide these branches. The extracanthal orbicularis
is responsible for squeezing the eyelid, whereas the inner canthal orbicularis (that
part of the orbicularis within 5 to 10 mm of the medial canthus) is responsible for
eyelid closure, blinking, lower lid tone, and the tear pump.
849
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
This extracanthal portion of the muscle is innervated by the buccal branches and is
usually preserved with the standard skin-muscle incision unless the incision in the
muscle is continued all the way to the medial canthus. Leaving a 5 mm segment of
pretarsal muscle on the tarsal plate and limiting the incision in the orbicularis to
within 10 to 15 mm of the medial canthus will preserve a functioning, fully inner-
vated portion of the orbicularis with adequate lid tone and closure.
Zygomatic nerve
branches
Buccal nerve
branches
Frontal nerve
branches
MOTOR INNERVATION—PERIORBITAL REGION

850
Part VI  Eyelid Surgery
I individualize the extent of the incision in the orbicularis muscle. I approach the
lower eyelid through the skin incision and elevate a small skin flap; the orbicularis
muscle is then divided separately and elevated as a combined skin-muscle flap. The
extent of the incision I make in the orbicularis depends on my plans for the middle
lamella.
If I do not plan any middle lamellar manipulations, such as fat excision or redrap-
ing, I make a limited-access incision in the orbicularis starting 10 mm lateral to the
lateral canthus and extending up to 10 mm medial to the lateral canthus. This short
incision allows access to the entire midface complex. It also enables release of the ar-
cus marginalis all the way to the medial canthus, identification and preservation of
the infraorbital nerve, and full subperiosteal dissection of the midface. I prefer to do
the dissection with a headlight and a slim retractor, although others have advocated
the use of the endoscope.
If fat redraping or dermis fat augmentation is planned, then the orbicularis incision
is extended to within 10 to 15 mm of the medial canthus with a full-access incision.
Both of these incisions allow me to excise as much skin as needed, elevate and fix
the midface, redrape the orbicularis, and resect any orbicularis excess. Occasionally,
in a patient who has excess periorbital fat, the limited-access incision may be com-
bined with transconjunctival fat removal.

Orbicularis Flap
851
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
All of the transcutaneous skin–muscle flap procedures on the lower lid include or-
bicularis muscle flap redraping. This serves two purposes: functional and aesthetic.
The orbicularis is redraped so that it sits snugly against the lower lid tarsus and adds
extra support to the lower lid. Redraping with a vertical or combined diagonal and
vertical vector will elevate the midface complex, especially the diagonal vector, and
will further enhance the youthful appearance of the lower lid.
Transpalpebral Midface Lift
Many approaches are available to rejuvenate the midface area. I prefer this combined
approach, because it allows the lower lid and midface to be treated as a single unit.
I make a limited-access or full-access incision, depending on the need for middle
lamella manipulation. Through either approach, a full subperiosteal dissection and
elevation of the midface are performed. I include some subperiosteal dissection be-
low the infraorbital rim on all blepharoplasties in type II, III, and IV patients.
Regional Procedures
Blepharoplasty is one component of periorbital rejuvenation. Often upper lid bleph-
aroplasty is combined with some type of brow or forehead rejuvenation. The lower
lid is so intimately involved with the midface complex that I think of the lower lid
and cheek as one entity. Therefore, in almost all blepharoplasties for type II, III, and
IV patients, I perform a midface lift; the extent, of course, is individualized, depending
on the degree of aging and our goals for the patient. These regional procedures re-
flect the approach to facial rejuvenation, addressing facial zones or the entire face
rather than individual components, such as the eyelids, brow, or midface.

852
Part VI  Eyelid Surgery
Ancillary Procedures
The surgical procedures described will rejuvenate the upper and lower eyelids and
improve the relationship of the upper lid and brow, and the lower lid–cheek junc-
tion and midface. Frequently, additional ancillary procedures are performed to en-
hance the result. These include peels, laser resurfacing, alloplastic implants, and fat
grafting or fillers as an adjunct.
Laser resurfacing or peeling of sun-damaged, wrinkled skin at the time of bleph-
aroplasty is a safe procedure, because the skin has been elevated as a reliable mus-
culocutaneous flap with a full blood supply.
Fat is the filler material of choice around the eyelids and cheek. Although autologous
fat injections are frequently the primary treatment for aging in the periorbital area,
they also have a significant role as an adjunct to lower lid blepharoplasty and mid-
face lift. As discussed previously, dermis fat is placed along the orbital rim to enhance
the results in patients who have a deficiency in this area. Alloplastic materials, espe-
cially cheek implants, may also enhance the results.
Results
This woman in her midforties exhibited type II aging of the lower lid–cheek junc-
tion. She also had lid laxity, a round eye, and scleral show bilaterally. She underwent
upper and lower lid blepharoplasties with a transpalpebral midface lift and lid
anchoring to correct the lid laxity and scleral show. She also had a face and neck lift.
Her postoperative result shows correction of the aging changes of the lower lid and
correction of the lid laxity and round eye.

This middle-aged woman had type II aging of the lower lids, brow ptosis, grade IV
glabellar and forehead lines, and grade III aging of the lower lid–cheek junction and
nasolabial folds. She was treated with an endoscopic brow lift, upper and lower lid
blepharoplasties with a transpalpebral midface lift, and erbium laser resurfacing of
the forehead and glabella. Postoperative views show an improved brow position, lid-
cheek junction, midface, and nasolabial folds. The split-face view more dramatically
demonstrates the rejuvenative effect of these procedures.
853
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery

This woman, who is in her sixties, had type III aging of the lower lids, as well as lid
laxity, tear-trough deformity, nasojugal grooves, and early development of malar
bags. Upper and lower lid blepharoplasties with a transpalpebral midface lift, or-
bicularis redraping, and canthopexy were performed. She also underwent concomi-
This woman in her late forties had type II aging changes of the lower lids, midface,
and jowls. She underwent a short-scar face lift, rhinoplasty, and lower lid blepharo-
plasty, with fat redistribution and orbicularis redraping. She was very pleased with the
improvement in the lower lid–cheek junction, nasolabial folds, and perioral area.
854
Part VI  Eyelid Surgery

855
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
tant erbium laser resurfacing of the periorbital area. The postoperative result shows
improvement in the lid-cheek junction, with amelioration of the malar mound and
early festoons.
More severe aging changes are evident in this 60-year-old woman, who had type IV
aging of the lower eyelids. She had lid laxity; the lateral canthus was significantly
lower than the medial canthus. She also had malar mounds and festoons. To address
these problems, she underwent lower lid blepharoplasty with a transpalpebral mid-
face lift, horizontal lid shortening with cantholysis and canthoplasty, and a face and
neck lift. Her postoperative result shows significant improvement in the lower lid–
cheek junction, amelioration of the festoons, and improved eyelid position.
This 40-year-old woman had prominent eyes with a Hertel measurement of 23, thus
making her a high-risk blepharoplasty patient. She underwent lower lid blepharo-
plasty with fat redistribution and placement of a primary spacer graft with Allo-
Derm and canthopexy and a short-scar face lift.

856
Part VI  Eyelid Surgery
Release of the lower lid retractors is shown (left). The primary AlloDerm spacer is
placed (middle), and the fat is redistributed (right).
This split-face view demonstrates the postoperative improvement in the lower lid–
cheek junction, with normal lid position.

Long-Term Results
857
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
This type II patient is shown 9 years after an endoscopic brow lift, upper and lower
blepharoplasty with fat redistribution, orbicularis redraping, and canthopexy.

858
Part VI  Eyelid Surgery
Another type II patient demonstrates a typical result; she is shown 3 months,
5 months, and 5 years after a skin–muscle flap blepharoplasty with fat redistribution,
orbicularis redraping, and canthal anchoring.
Preoperative
3 months postoperatively

859
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
5 months postoperatively
5 years postoperatively

Choosing the Best Option
860
Part VI  Eyelid Surgery
OPTIONS FOR UPPER EYELID BLEPHAROPLASTY
FAT
SKIN
MUSCLE
Augment
Skin-muscle incision and fat excision
Skin excision only
Insufficient
Sufficient
Excess
BROW ACCESS
PROCERUS
CORRUGATOR
MUSCLE
EXCISION
Lateral pocket
Medial pocket
Both pockets
Skin-muscle flap and fat excision
Open skin incision and muscle preservation
Skin-muscle excision
Skin-muscle incision and fat removal
Transcutaneous fat removal
Transconjunctival fat removal
Skin removal
Sufficient
Excess
Skin-muscle removal
Skin-muscle excision
Eyelid volume sufficient
Eyelid volume insufficient
Skin excision
Skin-muscle excision
Skin excision only with muscle incision and preservation
Skin-muscle excision
Skin excision only with muscle incision and preservation

861
Chapter 27  Clinical Decision-Making in Aesthetic Eyelid Surgery
OPTIONS FOR LOWER EYELID BLEPHAROPLASTY
FAT
SKIN
MUSCLE
Augment with fat
or fillers
Transcutaneous approach
with pinch-skin or laser excision
No manipulation
Insufficient
Sufficient
Excess
LID-CHEEK
JUNCTION
MIDFACE LIFT
Transcutaneous
Transcutaneous:
limited access
Redrape
Resect
Transconjunctival
approach
Transconjunctival
approach
Transcutaneous:
limited or full access
No excess
Excess
No excess
Excess
Transcutaneous:
full access
Transcutaneous:
limited access
Transconjunctival
Transcutaneous:
full access
Transconjunctival
preseptal
Transconjunctival
postseptal
Transconjunctival
preseptal
Transcutaneous
Transcutaneous:
full access
Transcutaneous:
limited access
Transcutaneous:
limited access
Transcutaneous
approach
Transcutaneous:
full access
Youthful
Aged
Transconjunctival
approach
OR
OR
OR
OR
OR
OR
OR
OR
OR

This page intentionally left blank
This page intentionally left blank

Upper Eyelid Blepharoplasty

MARK A. CODNER, JUAN DIEGO MEJIA
CHAPTER 28

864
Part VI  Eyelid Surgery
B
lepharoplasty is one of the most commonly performed surgical procedures in the
United States. Blepharoplasty in the upper lid is generally less surgically de-
manding than in the lower lid. However, serious complications such as lagophthal-
mos and corneal exposure can occur unless the surgeon uses sound judgment. The
procedure must be safe, with conservative skin removal, while preserving function
and ensuring upper lid closure. The amount of skin left behind in the upper lid is
more important than the skin that is removed. Careful assessment of the eyebrow
position is essential, because brow ptosis can be a substantial contributing factor to
dermatochalasis. It is important to identify risk factors that could increase the po-
tential for complications after blepharoplasty. Once assessment and planning are
complete, the blepharoplasty procedure must be performed with precision to achieve
the desired goal.
Evolution of Technique
One of the earliest reports of surgery of the eyelids was during the tenth century,
when Avicenna (980-1037) noted that excess upper eyelid skin caused visual impair-
ment. Techniques were developed to excise these folds to improve vision. In 1792,
in the European literature, Beer first described the excess upper eyelid skin that is
now known as dermatochalasis. The term blepharoplasty was used by Von Graefe in
1818; however, the term was actually applied to reconstructive procedures that were
used to correct defects of the upper eyelid caused by excision of carcinoma. Although
blepharoplasty was initially used to describe any reconstructive surgical procedure
that corrected or shaped the eyelids, the term was later applied to cosmetic proce-
dures, which were developed in the mid-nineteenth century. Descriptions of bleph -
aroplasty techniques were published by a number of authors, including MacKenzie
(1830), Alibert (1832), Graf (1836), and Dupuytren (1839), all of whom recom-
mended skin excision only. The presence of pseudoherniation of orbital fat was first
described by Sichel (1844), and Bourguet (1929) was the first to propose that fat be
removed in addition to skin during blepharoplasty. Bourguet also described two sep-
arate fat compartments in the upper eyelid. He was reportedly the first to describe
removal of lower eyelid fat through a transconjunctival approach. Joseph (1931) re-
ported on surgical markings for upper and lower eyelid blepharoplasty incisions;
these markings are still being used today. Castanares (1951) published one of the
initial comprehensive reports of eyelid fat compartments of the upper and lower eye-
lid. Modern blepharoplasty techniques continued to evolve after World War II through
the contributions of many excellent surgeons. Some of the notable surgeons who
contributed to the evolution of blepharoplasty include Sheen (1974), who reported
the technique of levator fixation for the creation of a supratarsal fold as well as ex-
cision of upper lid orbicularis oculi muscle in addition to skin excision, and Baker
and Gordon (1977), who refined the technique of upper lid blepharoplasty.

Indications and Contraindications
Candidates for upper blepharoplasty are those with valid physical findings that are
amenable to surgical improvement. Typical complaints include excess upper eyelid
skin and upper eyelid folds. Candidates should demonstrate complete upper lid clo-
sure, as well as normal velocity of closure movement; this is necessary to provide
adequate protection of the cornea, thereby preventing exposure. After a normal up-
per lid blepharoplasty, a small amount of lid closure velocity can occur. Patients who
have normal precorneal tear film, ocular motility, Bell’s phenomenon, and corneal
sensation can usually tolerate this transient event.
Patients with certain preexisting conditions may be at risk of complications after
blepharoplasty.
865
Chapter 28  Upper Eyelid Blepharoplasty
Blepharochalasis, or chronic puffy eyelids, is caused by repeated episodes of extreme
eyelid edema, erythema, and thin excess skin resulting from a histamine response
and is related to increased levels of immunoglobulin E. This rare condition also seems
to be exacerbated during menstrual cycles. Unlike dermatochalasis (excess upper
eyelid skin), it is difficult to correct and likely to recur.
Patients with rosacea are predisposed to corneal dryness and possible ulceration
from exposure of the cornea after blepharoplasty. Patients with a known history of
sarcoidosis should be considered at increased risk for healing complications. Non-
caseating granuloma formation in blepharoplasty incisions has been reported; this
occurs as a result of sarcoidosis of the surgical scar.
Pemphigus is an autoimmune disorder that leads to chronic inflammatory changes
of the conjunctiva and ocular adnexa. Scar contracture of the conjunctival fornix
may occur, causing foreshortening and lid malposition. Another periorbital disor-
der associated with increased risk of complications is benign essential blepharospasm,
an involuntary disorder of spastic orbicularis oculi muscle, which often contributes
to redundant upper eyelid skin. Blepharoplasty should be avoided, because improve-

866
Part VI  Eyelid Surgery
ment in symptoms is unlikely. Current management includes a nonoperative ap-
proach that involves periorbital injection of the orbicularis oculi muscle with botu-
linum toxin.
Aesthetic Considerations
Concepts of beauty vary, and there are also significant differences among individu-
als in upper lid anatomy. When looking at different images of women considered
beautiful, we see that beautiful eyelids can differ in regard to the amount of visible
skin above the lashes, accentuation of the upper lid, and fullness of the area above the
brow. The first step in planning upper lid blepharoplasty is to define specific aes-
thetic goals for each patient. Patients commonly have their own personal goals, and
these should be defined and clarified before surgery. They usually desire a crease-
fold relationship similar to their appearance in their youth. Dramatic changes caused
by overresection of upper lid tissue can create a hollowed or operated appearance
that may be unnatural for the patient.
In general, most women want a more visible eyeshadow space with a high upper lid
crease and an arched brow. A lower crease, narrower eyeshadow space, and a flat-
ter brow are the standards in men. Commonly, men need brow stabilization during
surgery to avoid postoperative brow drop and narrowing of the brow-lash distance
after upper lid blepharoplasty.
Medical Conditions That Could Increase the Risk of Complications
 Blepharochalasis
 Rosacea
 Sarcoidosis
 Pemphigus
 Benign essential blepharospasm
 Graves’ disease
 Dry-eye syndrome
 Menopause

Pertinent Anatomy
Key landmarks and danger zones to consider when performing blepharoplasty are
discussed in detail in Chapter 26.
867
Chapter 28  Upper Eyelid Blepharoplasty
The muscular anatomy of the periorbital region is shown. The orbicularis muscle is
divided into three separate components: the orbital, preseptal, and pretarsal divisions.
The orbicularis muscle is innervated by branches of the facial nerve. Diffuse inner-
vation is supplied by the frontal, zygomatic, and buccal branches. Recent electromyo-
graphic studies and cadaver dissections showed evidence of significant innervation
of the medial orbicularis muscle of the upper and lower lid from the buccal branch.
Lateral raphe
Zygomaticus minor
muscle
Frontalis muscle
Orbital orbicularis muscle
Preseptal orbicularis muscle
Pretarsal orbicularis muscle
Anterior reflection,
medial canthal tendon
Transverse part,
nasalis muscle
Levator labii superioris
alaeque nasi muscle
Levator labii superioris
muscle
Zygomaticus major
muscle
Infraorbital nerve
Zygomatic nerve
branches
Buccal nerve
branches
Frontal nerve
branches

Cross-sectional anatomy demonstrates the anterior and posterior lamella as well as
the layers of muscle, fat, and ligaments that contribute to the periorbital contour.
Preoperative Assessment
Medical History and Evaluation
The first step in a thorough evaluation includes a history directed toward identifi-
cation of specific medical conditions that can increase the risk of complications.
These conditions include blepharochalasis, rosacea, pemphigus, Graves’ disease, and
benign essential blepharospasm. Blepharoplasty may be contraindicated in these in-
dividuals. If the surgeon decides to proceed with the surgery, the blepharoplasty
should be conservative to minimize the risk of corneal dryness or lid malposition.
868
Part VI  Eyelid Surgery
Patients with puffy eyelids are often seen by the plastic surgeon with undiagnosed
hyperthyroid or euthyroid Graves’ disease. Preoperative evaluation should take into
account the results of laboratory testing, including free T4 levels, and an endocrine
SOOF
Müller’s muscle
Levator palpebrae superioris muscle
Superior rectus muscle
Inferior rectus muscle
Inferior oblique muscle
Inferior orbital rim
Arcus marginalis
Superior orbital rim
Eyebrow
Brow fat pad (ROOF)
Postseptal fat
Orbital septum
Levator aponeurosis
Dermal insertions
Conjunctiva
Superior tarsal plate
Pretarsal orbicularis muscle
Inferior tarsal plate
Inferior pretarsal muscle
Capsulopalpebral fascia lid retractors
Postseptal fat
Inferior septum
Orbitomalar ligament

consultation may be appropriate. Ocular manifestations of Graves’ disease often
include upper and lower lid retraction, increased orbital volume, exophthalmos, and
puffy eyelids. Standard blepharoplasty techniques should be modified to correct lid
position because of the increased risk of corneal exposure and keratitis.
869
Chapter 28  Upper Eyelid Blepharoplasty
Patients with an underlying history of dry eyes, which is often associated with in-
tolerance to contact lenses, require preoperative tear film evaluation, including
Schirmer’s test. Schirmer’s test is performed by anesthetizing the conjunctiva in the
inferior lateral fornix with tetracaine eyedrops. The excess tear film is blotted with
a cotton-tipped applicator, and a Schirmer’s strip is placed in the lateral fornix while
the patient maintains a forward gaze. Tear production is considered decreased when
less than 10 mm of the Schirmer’s strip is wet after 5 minutes.
The combination of decreased tear production with increased operative tear film
loss from lagophthalmos after blepharoplasty may contribute to significant corneal
exposure, including the potential for keratoconjunctivitis or corneal ulceration. Pa-
tients with a history of dry eyes who have an abnormal Bell’s phenomenon on phys-
ical examination are at particular risk for corneal exposure. To minimize complica-
tions in this group of patients, blepharoplasty should be approached with caution
and performed conservatively. In addition, patients who have had recent LASIK sur-
gery for vision enhancement should not undergo blepharoplasty for at least 6 months
to allow adequate corneal sensation to return and to give the corneal incision ade-
quate time to heal, minimizing the risk of superinfection.
In addition to patients with underlying medical conditions, patients with unrealis-
tic expectations may be at risk for dissatisfaction and should be identified before
surgery. This group of patients is quite varied and most commonly includes younger
patients who demonstrate minimal anatomic findings that are out of proportion to
their complaints. Patients who have had previous surgery performed by another sur-
geon and who are inordinately upset despite minimal imperfections also require care-
ful evaluation and possible psychiatric screening. These patients should be asked to
demonstrate the precise nature of their concerns, along with preoperative photo-
graphs of their eye appearance. If a valid complaint cannot be substantiated by care-
ful evaluation, surgery should be deferred.

Physical Examination
The physical examination of patients who present for blepharoplasty should pro-
ceed sequentially to ensure complete assessment of the periorbital anatomy. Visual
acuity is tested with a Snellen eye chart. Bell’s phenomenon should be documented.
If a patient has dry eyes or a history of dry eyes, a Schirmer’s test is performed, and
referral to an ophthalmologist should be considered.
Upper Lid
The upper eyelids should be evaluated for excess skin (dermatochalasis), excess or-
bital fat, eyelid ptosis, levator function, prolapse of the lacrimal glands, excess retroor-
bicularis oculi fat (ROOF) or brow fat pads, prominent supraorbital rims, and floppy
upper lid syndrome. Asymmetrical upper eyelid folds may be caused by upper lid pto-
sis, brow asymmetry, upper lid retraction, or asymmetrical amounts of excess tissue.
Blepharoptosis is the abnormally low position of the upper eyelid on normal gaze. It
is important to differentiate simple dermatochalasis from upper lid ptosis to ensure
optimal results. Clinical measures that should be taken are the position of the up-
per lid margin, the levator function and the lid crease height. The upper lid margins
should be symmetrical and should not be lower than 2 mm from the superior cor-
neoscleral limbus. Levator function is assessed by measuring the upper eyelid excur-
sion from extreme downgaze to extreme upgaze and should be more than 10 mm.
This should be measured by stabilizing the eyebrow to limit contribution from the
compensating frontalis muscle. The normal upper lid crease is 7 to 10 mm above
the lid margin and is usually higher in women than in men. In simple dermatochala-
sis these measurements are normal. The type of blepharoptosis most commonly seen
in an aesthetic patient is involutional ptosis, which may be seen in conjunction with
dermatochalasis or brow ptosis. In this type, the patient will notice gradual descent
of the upper eyelid, an elevated lid crease height, and normal levator function. These
patients’ ptosis can easily be corrected with tarsolevator advancement during the
upper blepharoplasty procedure.
870
Part VI  Eyelid Surgery
Common Causes of Upper Lid Ptosis
 Congenital ptosis
 Involutional ptosis
 Aponeurotic dehiscence
 Myogenic ptosis—myasthenia gravis
 Chronic progressive external ophthalmoplegia
 Neurogenic ptosis—Horner’s syndrome
 Mechanical ptosis—tumor, trauma

Patients who are thought to have upper lid ptosis should also be carefully evaluated
for a history of congenital ptosis; aponeurotic dehiscence; myogenic ptosis, includ-
ing myasthenia gravis; chronic progressive external ophthalmoplegia; neurogenic
ptosis, including Horner’s syndrome; and mechanical ptosis from tumor or trauma.
871
Chapter 28  Upper Eyelid Blepharoplasty
Patients with minimal unilateral acquired ptosis should undergo the cover test, which
is performed by placing an eye patch over the ptotic eyelid for 5 minutes, after which
the contralateral eyelid is evaluated. This often reveals an underlying ptosis in the
contralateral eyelid, since there is decreased visual input from the ptotic eye. Her-
ing’s law of equal innervation states that decreased visual input from one eye with
ptosis will result in increased and equal neural output to both eyelids to raise the
level of the eyelids, resulting in an equal increase in activity of both levator muscles.
The cover test is required to isolate and objectively evaluate the contralateral non -
ptotic eyelid.

Preoperative evaluation also includes examination of the superior lateral orbit for
prolapse of the lacrimal gland. Excess ROOF requires conservative removal of the
brow fat pad lateral to the supraorbital nerve. This may be combined with an inter-
nal browpexy of the lateral brow. Extreme fullness of the superolateral orbital rim
may be addressed with an osteoplasty using a burr to reduce the bony prominence.
872
Part VI  Eyelid Surgery
The upper eyelid should be evaluated for floppy eyelid syndrome, which is common
in large, burly men. The upper eyelid everts during forced closure; correction re-
quires resection of a portion of the lateral tarsal plate with canthoplasty of the up-
per lid. Failure to correct this can result in postblepharoplasty closure problems: an
overriding upper eyelid, chemosis, or separation from the globe.
Brow
The eyelid must always be considered in conjunction with the eyebrow. The eyebrow
should be evaluated for ptosis and symmetry in addition to the aesthetic relation-
ship between the height of the nasal and lateral portions of the brow. In men, the
brow should be at the superior orbital rim, whereas in women, the brow should be
above the rim, with the arch apex in line with the lateral limbus. Signs of brow pto-
sis include lateral upper eyelid hooding and a narrowed brow-lash distance. The de-
scent of eyebrow fat and the excess upper lid skin that develops with age may ob-
struct vision. Compensation by frontalis contraction keeps the eyebrow above the
orbital rim, clearing the visual field. Once the upper lid skin is removed, frontalis
compensation is no longer necessary, and underlying brow ptosis becomes appar-
ent. Concomitant brow lift or internal brow fixation through the blepharoplasty in-
cision can help to stabilize the eyebrow in the proper position. Lack of brow stabil-
ity will predispose the patient to descent of the brow after an upper blepharoplasty
if the brow laxity is not corrected. Furthermore, patients with underlying unilateral
upper lid ptosis may present with eyebrow asymmetry, which is apparent to the pa-
tient, even though the ptosis may not be.