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

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Part VI  Eyelid Surgery
It is possible to determine the amount of skin to be excised by using a forceps to
pinch the excess skin and muscle. However, it is not our practice to premark the
amount of skin to be removed by bunching. Functionally, the amount of skin that
is to be removed from the upper lid is not as important as the amount of skin that
is left behind after blepharoplasty. Four points, A through D, are important for the
upper blepharoplasty markings.
Markings
The patient’s eyelids are marked on the operating table after induction of anesthe-
sia. This permits more precise measurements using loupe magnification and calipers
to ensure symmetry of markings on both eyelids. Fine, wooden-tipped applicators
are used to mark the incisions with methylene blue.
The inferior excision line is drawn first. The initial mark indicates the upper eyelid
crease at the level of the midpupillary line (point A). In women this is usually 10 mm
above the lash margin and in men 7 mm above the lash margin. The markings are
tapered inferiorly at the medial and lateral lid margins following the gentle curve of
the upper lid crease. The lateral and medial marking should be 6 mm above the lash
line superior to the respective canthi (points B and C). The medial aspect of the mark-
ings should not extend nasal to the caruncle to avoid webbing or epicanthal folds
A
C
B
D

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Chapter 28  Upper Eyelid Blepharoplasty
above the medial canthus. The lateral extension should proceed in a crow’s-feet skin
line corresponding to the amount of redundant skin but should not extend past the
lateral orbital rim to prevent a prominent scar.
The superior marking of the skin incision is started at the level of the lateral limbus
(point D). At this point at least 10 mm of skin should be preserved between the su-
perior incision and the beginning of the thick eyebrow skin. The superior mark is
completed by following a gentle curve paralleling the contour of the lower marking
and tapering nasally to reduce the amount of skin and muscle that is removed along
the nasal half of the incision. No more than 5 mm of skin should be removed nasally;
overresection of skin and muscle is poorly tolerated nasally and often results in
lagophthalmos, which can cause corneal dryness. Because the cornea is much more
forgiving of lagophthalmos in the temporal half of the upper lid, more aggressive
skin removal can be performed laterally. Postoperative lagophthalmos in the nasal
half of the upper lid causes more symptoms of corneal exposure. Therefore efforts
to correct skin laxity in the nasal upper lid should be more conservative, relying on
brow repositioning if possible.
The skin-pinch technique for skin removal is used only in patients who need a
touchup after a previous blepharoplasty and in some primary patients who already
have a well-defined eyeshadow space and upper lid crease but have small redundant
skin folds.

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Part VI  Eyelid Surgery
During the process of marking, the surgeon should pay special attention to the pres-
ence of asymmetry of the eyebrow and eyelid fold. If the brows are asymmetrical
preoperatively, the upper eyelid markings should closely approximate one another,
but a concurrent procedure should be planned to correct brow position. However,
if the lid folds are asymmetrical, symmetry can be achieved by removing different
amounts of skin and muscle from each eyelid.
The complete upper eyelid marking is incised with a scalpel through the skin and
orbicularis oculi muscle. The upper edge of the incision is completed with needle-
tipped cautery, exposing the orbital septum.
The orbital septum is opened with Westcott scissors. This technique provides an open-
sky approach to the preaponeurotic space and exposes the orbital fat. The septum
should be opened along the upper incision to avoid injury to the aponeurosis, which
is present posterior to the orbicularis muscle at the lower incision in the lid crease.

Removal of fat from the central and nasal compartment can be performed conserva-
tively, carefully preserving the interpad septum between the central and nasal fat pads.
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Chapter 28  Upper Eyelid Blepharoplasty
A-frame deformity
Overresection of fat in this area will result in an A-frame or peaked-arch deformity of
the supratarsal crease. Preservation of fat at the interpad septum will maintain a sym-
metrical, gentle arch below the new upper lid fold. When fat excision is indicated,
it can be performed by direct sculpting with the needle-tipped cautery, which allows
greater precision and visualization of the medial palpebral artery. Clamping, resect-
ing, and cauterizing fat should be discouraged, because this can result in uncontrolled
bleeding. Inadequate cauterization can result in bleeding from the nasal fat pad. Poor
visualization and indiscriminate cauterization within the deep nasal orbit have been
reported to contribute to injury to the trochlea and superior oblique muscle. Patients
with injury to the superior oblique muscle will exhibit diplopia and head tilt toward
the side of the superior oblique injury after blepharoplasty. Preservation of fat should
be considered to prevent creation of a hollow, more aged-appearing orbit.

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Part VI  Eyelid Surgery
Excess skin, muscle, and septum are resected with scissors beveling away from the
levator insertion into the upper lid crease. This open-sky technique takes the same
amount of septum and orbicularis as it does skin, which reduces the risk of postop-
erative lagophthalmos by reducing subcutaneous bulk. If the edges of a large skin
resection are closed over large amounts of underlying orbicularis, a relative skin
shortage is produced, causing upper lid tightness and decreased lid closure velocity.
Surgical disinsertion of the levator aponeurosis af-
ter upper blepharoplasty is a well-recognized cause
of postoperative acquired ptosis. To minimize the
potential for this, supratarsal fixation of the pre-
tarsal skin muscle to the levator aponeurosis is per-
formed as a routine part of upper blepharoplasty
using a horizontal mattress suture of 6-0 Vicryl at
the midpupillary line.
Lateral brow fullness is caused by a prominent bony orbital rim or by excessive brow
fat (ROOF). The ROOF should be evaluated, and conservative resection of the brow
fat pad can then be performed by retracting the upper lid edge of the blepharoplasty
flap, exposing the superior orbital rim and ROOF. The redundant brow fat is marked
and resected away from the orbital rim with electrocautery. The underlying perios-
teum should be left intact to prevent the development of restrictive adhesions.

Ptosis of the orbital lobe of the lacrimal gland may be present and should be cor-
rected with suspension of the lacrimal gland into the lacrimal sac fossa. This is per-
formed by placing the lateral horn on traction and suturing the levator aponeuro-
sis to the arcus marginalis with a 6-0 Vicryl suture just at the level of the lacrimal
gland to prevent future lacrimal gland ptosis. The levator aponeurosis needs to be
placed on a downward stretch to eliminate the risk of postoperative lagophthalmos.
To avoid postoperative dry-eye syndrome, the lacrimal gland should not be resected.
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Chapter 28  Upper Eyelid Blepharoplasty
Internal brow fixation through the upper blepharoplasty incision can be performed
in patients who have mild laxity and require lateral brow support. After upper bleph -
aroplasty is completed, the superior lateral orbital rim and lateral brow area are ex-
posed by retracting the superior blepharoplasty incision. The orbicularis and ROOF
are dissected just superficial to the periosteum along the lateral third of the eyebrow.

The dissection continues upward and laterally for 2 to 3 cm. Dissection cephalic to
the orbital rim should be performed bluntly with a cotton-tipped applicator to avoid
injury to the perforating zygomaticotemporal vein found in this area. Care should
be taken to completely release the lateral zone of fixation at the junction of the tem-
poral line of fusion and supraorbital rim. An internal browpexy is performed using
a 4-0 Prolene suture just deep to the dermis at the level of the inferior hair-bearing
brow and the underlying periosteum. The brow can be sutured 5 to 10 mm above
the orbital rim at the level of the lateral corneoscleral limbus to recreate the peak of
the brow. Only mild elevation can be obtained with an internal browpexy, but it
provides stabilization of the tail of the brow to prevent brow ptosis after the bleph -
aroplasty, which results in residual skin folds laterally.
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Part VI  Eyelid Surgery
After removal of excess skin, muscle, and fat, the upper lid incision is generously ir-
rigated with normal saline solution to remove any residual liquefied fat that can re-
sult in postoperative granuloma formation. The incision is closed with initial sutures
placed superior to the lateral canthus with interrupted 6-0 nylon that align the skin
and muscle. The incision lateral to the canthus is closed with interrupted 6-0 nylon
sutures and the incision medial to the lateral canthus with a running 6-0 nylon. Al-
though an intracuticular closure is commonly used, a running suture that encom-
passes both skin and muscle reduces tension on the dermis and leaves a better scar.
In addition, the interposed muscle prevents formation of adhesions from the dermis
to the aponeurosis, thereby minimizing contour irregularity and lagophthalmos.
Ancillary Techniques for Upper Lid Rejuvenation
Transblepharoplasty Excision of Corrugator
and Procerus Muscles
The upper eyelid, by providing limited access to the forehead, may be thought of as
a gateway to the medial and lateral brow. This gateway is limited by the supraor-
bital and supratrochlear nerves. Modification of the glabellar muscles through the

upper eyelid incision is effective in improving glabellar lines with minimal medial
brow elevation. The ideal candidates for this procedure are patients who are under-
going an upper blepharoplasty, have glabellar frown lines, minimal or no brow pto-
sis, and no excess skin above the nasal radix.
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Chapter 28  Upper Eyelid Blepharoplasty
After the upper lid blepharoplasty has been completed, the assistant retracts the su-
perior blepharoplasty incision, helping to expose the glabellar area. Dissection is
performed deep to the orbicularis toward the corrugator muscles with spreading
scissors or a cutting needle Bovie. As the superior orbital rim is approached, one can
identify the diagonal muscle fibers of the corrugator. Care should be taken to iden-
tify and preserve the supraorbital and supratrochlear nerve branches, which are vis-
ible at this stage. The supraorbital nerve is the larger and more lateral, and the supra-
trochlear branches are smaller, medial, and usually intertwined with the corrugator
muscle.
Supratrochlear nerve
Corrugator muscle
Supraorbital nerve
Once the corrugator is identified, a small mosquito clamp is used to dissect it and
bring it forward.

With the muscle isolated, coagulating current is used to resect a segment of the cor-
rugator muscle, producing a central gap. Injuries to the trochlea or superior oblique
muscle tendon are rare and are easily avoided by limiting any dissection behind the
origin of the corrugator.
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Part VI  Eyelid Surgery
The procerus muscle can also be divided through the upper blepharoplasty incision.
Patients with transverse glabellar or dorsal nasal skin lines from procerus muscle
activity benefit from this procedure. The orbicularis is elevated, and then a pair of
scissors are pushed blindly toward the nasal radix, cutting the fibers under the skin.
Postoperative swelling after these procedures is more prolonged than with standard
blepharoplasty. Head elevation and ice packs help with the swelling. The use of di-
uretics and a short course of methylprednisolone (Medrol Dosepak) can be consid-
ered in some patients.
Procerus muscle

Postoperative Care
The patient’s head should remain elevated to reduce edema and ophthalmic pres-
sure. Ice packs or cold compresses are applied to the eyelids for 48 hours. The eyes
should remain lubricated at all times with saline drops during the day and lubricat-
ing ointment at night. Lagophthalmos can be caused by periorbital edema; it resolves
spontaneously in 1 to 2 weeks. In these cases the eyedrops and ointment are essen-
tial to prevent corneal exposure and abrasions. Before discharge the patient’s vision
should be evaluated and documented. Any signs of corneal irritation or decreased
visual acuity require careful ophthalmologic evaluation including slit-lamp exami-
nation with the use of fluorescein eyedrops to evaluate the cornea. Patients are asked
to avoid the use of eyelid makeup on the suture lines and contact lenses for 2 weeks
after blepharoplasty. The sutures are removed 5 days postoperatively.
Complications
Vision Loss
Permanent vision loss is the most feared complication after blepharoplasty. If this
occurs, it is usually caused by retrobulbar hemorrhage. In an epidemiologic study
of more than 250,000 blepharoplasties, the incidence of retrobulbar hemorrhage
was 1 in 2000, with a 1 in 10,000 risk of permanent visual loss associated with it.
Acute retrobulbar hemorrhage may compress neurovascular structures, leading to
ischemia of the retina, central artery, and optic nerve. Most hemorrhages occur within
the first 24 hours after surgery (96%), and of these, more than half occur within the
first 6 hours postoperatively. The patient can present with severe pain and pressure
and visual changes that include hemianopsia, scotomas, or amaurosis fugax. Phys-
ical examination will reveal a tense and proptotic eye and loss of pupillary reflexes
with diminished or absent extraocular movements. Urgent treatment should be im-
plemented, because 90 to 120 minutes of ischemia can lead to irreversible blindness.
An ophthalmic consultation should be obtained immediately. If intraocular pressure
is elevated, topical and systemic glaucoma medications such as mannitol and acet -
azolamide (Diamox) are started. Systemic corticosteroids are needed to address sig-
nificant edema. The patient should be taken back to the operating room. The sutures
are removed and the surgical wound is reexplored to check for bleeding. If the con-
dition remains unresponsive, lateral canthotomy and cantholysis are performed to
relieve pressure. If these measures fail, a CT scan without contrast is warranted to
rule out a posterior hematoma. In these cases bony decompression may relieve or-
bital apex compression. The algorithm on p. 884 outlines the means for assessing and
treating retrobulbar hematomas.
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Chapter 28  Upper Eyelid Blepharoplasty

884
Part VI  Eyelid Surgery
Visual loss: Yes
Symptoms: Pain, visual changes
Signs: Proptosis, edema, decreased movement, reflexes
SUSPECTED RETROBULBAR HEMORRHAGE/HEMATOMA
Operative treatment:
Hemostasis
Canthotomy/orbitotomy
Delayed closure
Visual loss: No
Bedside suture removal
Ophthalmologic consultation
Administration of 95% oxygen/5% carbon dioxide
25% Mannitol (1.5-2 g/kg IV; 12.5 g over 3 min)
Acetazolamide (Diamox) 500 mg IV
Solu-Medrol 100 mg IV
Betaxolol (Betoptic) 1 drop, then BID
Operative treatment:
Hemostasis
Irrigation
Simple closure
Postoperative care:
Edema control/elevation
Frequent monitoring
Corticosteroids, IV/topical
Steps to Reduce the Risk of Retrobulbar Hemorrhage
 Maintain normal blood pressure.
 Inject anesthetic with care.
 Manipulate orbital fat gently during dissection.
 Ensure meticulous hemostasis.
 Place the patient in a head-up position postoperatively.
 Provide pain control measures.
 Instruct the patient to avoid strenuous activity.

Vision loss from perforation of the globe during the blepharoplasty can be prevented
with the use of corneal protectors. Diplopia may result from impaired ocular motil-
ity. In upper lid surgery it can be from edema or stretching of the vertical recti and su -
perior oblique muscles. Conservative management is recommended since the diplopia
will often resolve in the first few months as the edema and inflammation subside.
Hematoma
When a hematoma is seen intraoperatively, the wound should be explored, evacua-
tion performed, and proper hemostasis obtained. Small superficial postoperative
hematomas are treated conservatively with ice compresses and rarely need to be
drained by reopening the wound. If they persist, they can be evacuated with needle
aspiration or stab wound drainage after spontaneous clot dissolution 7 to 10 days
later. Large, expanding hematomas seen after surgery require immediate surgical ex-
ploration and evacuation. Residual areas of organized clotting can result in nodu-
lar irregularities or scarring of the middle lamella.
Lagophthalmos
Lagophthalmos may result from excessive skin resection or edema. It can lead to pa-
tient discomfort from exposed keratopathy and is worse in those with a preexisting
dry-eye condition. Lagophthalmos after blepharoplasty is usually temporary and
can be managed conservatively with patient reassurance, light massage, taping, and
application of lubricants day and night. If conservative therapy fails, surgical op-
tions include skin grafting, and release of orbital-septal adhesions. When placing a
full-thickness skin graft in the upper lid, it must not distort the upper lid crease. It is
placed in the pretarsal area not extending above the crease (over the eyeshadow space).
Dry-Eye Syndrome
Dry-eye syndrome is not an uncommon sequela after blepharoplasty. Even minimal
widening of the palpebral fissure with blepharoplasty can produce keratopathy in
patients with low tear production. Patients in their fifties or sixties (when tear pro-
duction is diminished), women receiving estrogen replacement therapy, patients who
cannot tolerate contact lenses, or those with a history of increased sensitivity and
dry-eye irritation are especially at risk for dry-eye syndrome. Performing Schirmer’s
test is important in the preoperative evaluation of these patients. Patients with a sig-
nificant decrease of tear production with an absent Bell’s phenomenon are not suit-
able candidates for aesthetic blepharoplasty. Initial treatment consists of ocular lu-
brication with artificial tears and ophthalmic ointment. Failure of this treatment
should prompt ophthalmologic examination and consideration of punctal occlusion
or additional antiinflammatory eyedrops such as topical cyclosporine.
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Chapter 28  Upper Eyelid Blepharoplasty

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Part VI  Eyelid Surgery
Blepharoptosis
Eyelid ptosis can be a common finding several hours after the procedure as a result
of the effects of local anesthesia on the levator muscle. Persistent ptosis can be caused
by edema or injury to the levator. Mild cases may resolve spontaneously and can be
managed expectantly for at least 3 months before surgery is considered. Severe pto-
sis with poor levator function requires reexploration and levator repair. If injury to
the levator is noticed at the time of surgery, it should be sutured back to the tarsus.
Overresection of Fat
Conservative blepharoplasty is the rule today, since overzealous fat resection can
lead to an unaesthetic, hollow, skeletonized appearance. Options for correction of
a sunken upper lid include fat transposition or grafting and the use of synthetic fillers.
Infection
Infection is very rare after blepharoplasty because it is a highly vascularized area. If
infection occurs, it can be treated with antibiotics and drainage if necessary.
Results
The following cases have been selected to represent a variety and continuum of pa-
tients who demonstrate age-related changes of the eyelids and periorbital region.
Patients with a heavy upper eyelid fold who did not have a visible significant pre-
tarsal space, even in youth, should undergo conservative resection to avoid a change
in the shape of the upper eyelid by creating a deep upper lid sulcus.

In men, removal of skin and muscle from the upper eyelid should be conservative
to preserve a low crease and avoid feminization of the upper eyelid.
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Chapter 28  Upper Eyelid Blepharoplasty
Floppy upper eyelid syndrome is common in large, burly men. This patient underwent
upper and lower blepharoplasties with canthoplasty of the upper and lower eyelids.
This patient had brow asymmetry and ptosis on the left side, with compensatory
frontalis activity. He is shown 6 months after bilateral upper and lower blepharo-
plasties and an endoscopic brow lift.

Concluding Thoughts
The upper lid and brow region is a very important determinant of facial aesthetics
and plays a vital role in facial rejuvenation. Although upper blepharoplasty is less
complex than lower blepharoplasty, judicious preoperative assessment and opera-
tive technique are essential to avoid possible complications such as lagophthalmos,
A-frame deformity, a shrunken-lid appearance, or eyelid ptosis. High-risk patients
have a lower tolerance to the anatomic and biomechanical changes that follow a
blepharoplasty; such individuals must be identified before the procedure. The tech-
nique described in this chapter represents the basic approach to upper lid blepharo-
plasty. The surgical outcomes have been carefully evaluated and are associated with
a low rate of complications and a high rate of patient satisfaction. The key princi-
ples for upper blepharoplasty include conservative removal of skin, muscle, and fat
to avoid a hollow upper lid sulcus or postoperative lagophthalmos. Adherence to
these basic principles significantly contributes to achieving the overall goal, which
is excellence in blepharoplasty results.
Clinical Caveats
 Upper lid blepharoplasty, although technically less challenging than lower lid bleph -
aroplasty, requires familiarity with periorbital anatomy.
 Individual goals in upper lid blepharoplasty vary and must be determined on an in-
dividual basis.
 Upper lid functionality is more important than aesthetics and should always be
maintained after upper lid blepharoplasty.
 High-risk patients can be recognized preoperatively with systematic clinical eval-
uation.
 Avoid placing the upper blepharoplasty incision more than 8 to 10 mm above the
lid margin.
 Fat preservation and conservative resection of skin and muscle during upper bleph -
aroplasty should be performed to reduce the appearance of a hollow orbit.
 The amount of skin that is left behind in the upper lid is more important than the
skin that is removed.
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Part VI  Eyelid Surgery

 Supratarsal fixation of the pretarsal skin and muscle to the levator aponeurosis
should be a routine part of upper blepharoplasty to minimize the development of
postblepharoplasty ptosis.
 Procedures like eyelid ptosis correction, lacrimal gland suspension, lateral brow-
pexy, and corrugator and procerus excision can be performed through the upper
blepharoplasty incision.
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Chapter 28  Upper Eyelid Blepharoplasty
Annotated Bibliography
Carraway JH, Miller JR, Lewis BK. Reoperative blepharoplasty. In Grotting JC, ed. Reopera-
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This chapter focuses on the most common and the most devastating complications
after upper lid blepharoplasty.
McCord CD, Codner MA, Nahai F. Upper lid blepharoplasty. In McCord CD Jr, Codner
MA, eds. Eyelid and Periorbital Surgery. St Louis: Quality Medical Publishing, 2008.
This chapter is a thorough updated review on upper eyelid blepharoplasty. It discusses
aesthetic considerations, preoperative evaluation, and operative technique. Ancillary pro-
cedures that are sometimes performed with upper blepharoplasty like transblepharo-
plasty excision of corrugator and procerus muscles are also discussed.
Pae J, Lisman RD, Lelli GJ. Upper eyelid blepharoplasty. Contemp Ophthalmol 8:1, 2009.
This article is a comprehensive review on upper lid blepharoplasty. It discusses preop-
erative evaluation, operative technique, and postoperative complications.
Sheen JH. A change in the technique of supratarsal fixation in upper blepharoplasty. Plast
Reconstr Surg 59:831-834, 1977.
The author discusses the refinement of his technique to eliminate postoperative morbidity.
Trussler AP, Rohrich RJ. MOC-PS CME article: blepharoplasty. Plast Reconstr Surg 121(1
Suppl): S1-S10, 2008.
Retrobulbar hematoma is the most feared complication after blepharoplasty. This arti-
cle provides a practical management algorithm on the topic. It also discusses prevention
and causes of postoperative blindness after eyelid surgery.

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Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attach-
ments of the lower lid and lateral canthus. Plast Reconstr Surg 110:873-884; discussion
897-911, 2002.
Nahai F. Alternative approaches to brow lift. In Nahai F, ed. The Art of Aesthetic Surgery:
Principles & Techniques. St Louis: Quality Medical Publishing, 2005.
Pae J, Lisman RD, Lelli GJ. Upper eyelid blepharoplasty. Contemp Ophthalmol 8:1, 2009.
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 orbic-
ularis 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-
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Upper Blepharoplasty in the
Asian Patient

WILLIAM P. CHEN
CHAPTER 29

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Part VI  Eyelid Surgery
D
ouble eyelid surgery refers to the aesthetic procedure of creating an upper eye-
lid crease in an Asian patient who does not have a crease. It has evolved over
the last century from using buried suture ligatures into a more anatomically based
form of cosmetic blepharoplasty. In Asian countries, it is one of the most frequently
performed aesthetic surgeries. I coined the term Asian blepharoplasty in 1987 while
attempting to define the skills and pitfalls necessary for performing primary and re-
visional surgery in Asians.
The suture ligation methods are thought to be less invasive and easier to learn, but
they require tremendous practice to be adept. The external incision methods are eas-
ier to adapt by surgeons who have been exposed to the usual training in blepharo-
plasty. I think that the suture ligation method yields a relatively static crease, whereas
the incisional approach with crease construction yields a more dynamic crease that
mimics a natural crease on upgaze and downgaze.
In this chapter I will concentrate on the external incision method, because it yields
more predictable results.
Indications and Contraindications
Bearing in mind that Asian blepharoplasty is a form of aesthetic surgery, suitable
candidates include individuals who believe that adding a natural-appearing crease
to their eyelid fissure will enhance the shape and proportion of their eyelids. This
should certainly be performed within the anatomic parameters appropriate to Asians
and appropriate to the individual’s facial dimensions. Contraindications are the same
as those which apply to any prospective blepharoplasty patients, including individ-
uals who have unrealistic expectations of the changes that such a procedure can pro-
duce. Those who may not psychologically tolerate the significant change in look of
the eyelid fissure should not undergo such an aesthetic alteration. A patient must be
16 years of age or older before I perform this operation, since there is still a very
slight probability that a crease may be secondarily acquired around this age.
Anatomy of the Asian Eyelid, Incidence
of the Crease, and Crease Shape
On average within a family, there is approximately a 50% prevalence of an upper
eyelid crease, and this seems to generalize to Asian populations who are of Han back-
ground (Chinese, Koreans, and Japanese). There are geographic variations in inci-
dence of the crease, ranging from 25% to 80% or more, but the overall incidence

of 50% seems to hold true in my clinical experience. The vertical height of the upper
tarsus is typically between 6.5 and 7.5 mm, and on rare occasions 8.0 to 8.5 mm.
This is in contrast to the average dimension in non-Asians of 9.0 to 10.5 mm verti-
cal height.
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Chapter 29  Upper Blepharoplasty in the Asian Patient
The current consensus on the distinguishing features of a creased upper eyelid versus
one without a crease in Asians seems to be the presence or absence of terminal in-
terdigitations of levator aponeurotic fibers into the pretarsal orbicularis oculi fibers
and intermuscular septa, located in an area just slightly below or along the superior
tarsal border. The images above show an Asian upper eyelid in an open position
without any crease indentation (left) and with the presence of a crease (right).
Asians who have a natural crease tend to manifest either a nasally tapered crease
(left) or a parallel crease (right). The nasally tapered crease is low-set and runs par-
allel across the ciliary margin over the central and lateral portion of the upper lid,
while over the medial portion it converges inward toward the medial canthus, often
blending into a small ethnic medial canthal fold. The parallel crease runs parallel
across the ciliary border; over the medial portion, it simply runs independent of and
above any residual medial canthal fold.
Absence of a crease
Presence of a crease

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Part VI  Eyelid Surgery
Both these crease shapes are different from the semilunar crease typically seen in
non-Asians. The non-Asian upper eyelid typically shows a semilunar crease line on
the skin on downgaze, although this may manifest with either a parallel shape or
semilunar shape when viewed straight on.
Preoperative Assessment
It is common to see patients with asymmetry of the two upper lids as well as its
crease, asymmetry of fat and soft tissues (skin and orbicularis oculi muscle), asym-
metry in shape and height, and possibly latent ptosis.
A detailed history should be taken, outlining the goals of the procedure from the pa-
tient’s viewpoint, and an eye examination is done to document the various factors
mentioned previously. I note the shape of the face, its size, the position of the brow,
and its separation from the upper lid margin. These observations are combined into
a recommendation for the patient.
A surgically constructed crease that does not fold in well can result from borderline
levator contractility with no true anatomic ptosis. Patients are shown representative
before-and-after photos and photos of patients in various stages of the healing process
so their expectations will be realistic. Photos are taken in primary as well as revi-
sional cases.
Preoperative Planning and Anesthesia
Preoperative sedation and anesthetic include a combination of 10 mg of diazepam
(Valium) and 1 tablet of hydrocodone/acetaminophen (Vicodin) (or 1000 mg of acet-
aminophen) given orally an hour before the procedure. The local anesthetic is 2%
lidocaine with a 1:100,000 dilution of epinephrine. A 30-gauge needle is used, and
the volume injected is seldom more than 1 ml for each upper eyelid. A controlled
flow of room air is supplied through a nasal cannula. An intravenous line is inserted
in case further sedation is necessary.

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Chapter 29  Upper Blepharoplasty in the Asian Patient
Operative Technique
The surgical steps are as follows:
1. Marking the desired eyelid crease
2. Skin incision
3. Transection through the orbicularis oculi along the upper edge of the skin
incision
4. Approaching and opening the orbital septum
5. Handling the fat pads
6. Excision and debulking of the preaponeurotic platform
7. Resetting of tissue planes
8. Anastomosis of the levator aponeurosis to the skin: lid crease sutures and
wound closure
Marking the Desired Eyelid Crease
Marking involves precise measurement of the vertical height of the central portion of
the everted upper eyelid tarsus. This image shows the measurement of central height
of the tarsal plate on the right upper lid with a corneal protector in place. Typically
the central tarsal height is between 6.5 and 7.5 mm, with an occasional patient man-
ifesting 8.0 to 8.5 mm. The crease height is determined; typically 7 mm is chosen
based on patients’ stated preference during their initial consultations. A higher or
lower crease will be no more than 0.5 mm on either side of this average. This cen-
tral crease height is marked on the skin side and will determine the overall height of
the crease, whether one is planning a nasally tapered crease or a parallel crease. The
nasally tapered crease is chosen in more than two thirds of my patients and is eas-
ier to mark and execute in my hands. The crease shape is simply merged toward the
medial canthus when approaching nasally. For a parallel crease shape design, the
surgeon should try to stay parallel to the lash line while approaching the medial can-
thus. A segment of redundant skin and soft tissue is included in the line of excision—
typically a strip of skin measuring about 2 mm centrally, 2.5 mm laterally, and
1 mm medially. Most of the tissue swelling from the local anesthetic’s infiltration
should have subsided by this point of the initial marking.
2
29-1 Upper
blepharoplasty in
the Asian patient

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Part VI  Eyelid Surgery
Skin Incision
The skin is incised with a No. 15 surgical blade along the upper and lower lines of
marked skin. The photo shows the subcutaneous incisions made along the upper
and lower lines of skin marking. A dry 4  4 dressing is used to stabilize the skin
layer during this step. The blade tip cuts through the skin full thickness and stops
just when the fascial tissue overlying the orbicularis oculi is reached. The entire length
of the incision often requires several positioning and repositioning steps; this de-
mands utmost precision.
Transection Through the Orbicularis Oculi Along
the Upper Edge of the Skin Incision
I use a Colorado tip needle on a monopolar cautery (Bovie) with a low setting on
the cutting mode to make the transection through the orbicularis oculi muscle. The
tip is intentionally beveled upward along the orbicularis so that the orbital septum
is reached along a higher level than that of the superior tarsal border. Once transec-
tion through the preseptal orbicularis oculi has been completed, as shown above for
the right upper lid, a portion of the orbital septum is open and the preaponeurotic
fat pads can be seen. With this maneuver, the cautery tip is likely to reach the
preaponeurotic (postseptal) fat pad rather than injure the levator aponeurosis, and
it allows identification of the preaponeurotic space. This step of beveled transection

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Chapter 29  Upper Blepharoplasty in the Asian Patient
through the preseptal orbicularis oculi constitutes my first vector. The orbicularis
typically is the most vascular layer, and it is worthwhile to be meticulous in control-
ling any bleeding here with bipolar cautery.
Approaching and Opening the Orbital Septum
Preseptal fat is often seen commixed with orbicularis fibers plus fascial tissues and can
misdirect the surgeon into thinking that it is the deeper preaponeurotic fat, which
is distinctly globular, fluctuant, and easily prolapses through small rents in the or-
bital septum as one reaches it. The septum is opened horizontally with blunt spring
scissors; the surgeon must make certain to slant the septal cut upward to avoid cut-
ting blood vessels in the fat pads, not slanting downward toward vessels of the
aponeurosis or the aponeurosis itself. As shown, after the septum is opened, the
preaponeurotic space and levator aponeurosis can easily be seen.
Handling the Fat Pads
After the septum is opened horizontally, the fragment of tissues bounded by the up-
per skin incision and transorbicularis first vector can be rotated away from the un-
derlying levator to form a myocutaneous strip. A tissue retractor is applied on the
myocutaneous strip to explore the preaponeurotic space. Within the space one may
observe fluctuant preaponeurotic fat, or amorphous, bound-down fatty strands, or
Partial excision of the
preaponeurotic fat pad

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Part VI  Eyelid Surgery
smaller “islands” of fat. Depending on the preoperative evaluation of the sulcus and
the brow relationship to the upper lid margin, the surgeon may choose to do one of
the following:
1. Reposition all preaponeurotic fat.
2. Partially excise some preaponeurotic fat along the superior tarsal border, cre-
ating a clearance along the preaponeurotic platform.
3. When fat strands or islets of fat are observed, dissect this off and allow it to
retract upward to fill in the sulcus. This maneuver appears to greatly facili-
tate the glide mechanism (glide plane) of the levator relative to the anterior
skin lamella, allowing an eyelid crease to indent dynamically against a pas-
sively relaxed preseptal skin-muscle layer (the eyelid fold).
Excision and Debulking the Preaponeurotic Platform
The myocutaneous strip of tissue redundancy (2 mm of skin plus a slightly larger
fragment of preseptal orbicularis oculi just above the upper tarsus) can be excised
along the superior tarsal border using a Bovie cautery tip. This transection through
the lower edge of the orbicularis strip is called the second vector and completes the
trapezoidal debulking of the preaponeurotic platform. If there is some residual full-
ness along the lower edge of the skin incision, I may trim off some inferior orbicularis
fibers so that it will be less likely to interfere with the crease construction. The ex-
cision of an orbicularis strip along the inferior edge of the pretarsal skin is shown
above.
In summary, with skin incision and only two additional steps (the first vector through
the orbicularis and septum; the second vector through the orbicularis), one can com-
plete a beveled excision of these layers—skin and orbicularis oculi as a trapezoidal
fragment, and a fragment of orbital septum overlying the distal 4 to 5 mm of the le-
vator aponeurosis. Bleeding is controlled along the two planes that involved tran-
section through the vascular orbicularis.

Resetting the Tissue Plane
Resetting the tissue plane is an important step in primary as well as revisional Asian
blepharoplasty. After the redundant skin and muscle have been appropriately trimmed
and the preaponeurotic fat reduced or repositioned, it is essential to reset the tissue
planes by properly positioning the anterior skin-muscle layer in relation to the under-
lying aponeurosis. The surgical drapes are loosened to facilitate this resetting. This ma-
neuver avoids creating lagophthalmos or secondary ptosis. The original operative
field may have been isolated using surgical drapes, towels, and adhesive drapes; there-
fore the surgeon may inadvertently attach the skin edges at a higher point along the
aponeurosis rather than just along the superior tarsal border. This results in an overly
high crease and secondary ptosis; the frontalis muscles then become overactive, and
the eyebrows are unnaturally arched. In revisional cases, this resetting allows some
skin recruitment and brings in additional soft tissues to partially fill in any promi-
nent sulcus from fat excision associated with previous aggressive blepharoplasty.
Wound Closure and Crease Construction
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Chapter 29  Upper Blepharoplasty in the Asian Patient
The crease shape and height is controlled through accurate design as well as metic-
ulous application of crease-forming sutures; I prefer the soft texture of 6-0 silk sutures
for this purpose. They are applied from the lower skin edge, through the aponeuro-
sis along the superior tarsal border, through the upper skin edge, and then are tied
down, as shown above. Six to nine interrupted sutures are typically used. The rest
of the wound can be closed with 7-0 Prolene, nylon, or silk.
During wound closure, the crease height is repeatedly measured and compared with
the contralateral side to verify symmetry; adjustment is always made toward the
lower measurement of the two sides. It is not unusual to find that when one is fin-
ishing up on the second side, the crease height on the first side (which has been cov-
ered with ice or saline sponges) may measure half a millimeter lower. I do not use
any buried crease-fixation suture, even in revisional cases.

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Part VI  Eyelid Surgery
Postoperative Care
Topical antibiotic-steroid ointment may be applied for 1 week. The eyelids are rested
during the first 24 hours, with application of cold compresses. Sutures are usually
removed 1 week after the procedure.
Problems and Complications
Problems associated with Asian eyelid crease procedures often involve asymmetry
of the eyelid crease height, incomplete crease formation, or late obliteration of the
crease. The reasons may include poor execution, poor knowledge, inadequate de-
bulking of the soft tissues, marking the crease too high or low, or inadequate crease
indentation. Factors that are somewhat beyond the practitioner’s control include
poor levator function that was not noted during clinical examination, a bleeding
tendency, an allergy to medications, or infection.
Results
This 25-year-old Asian woman underwent primary Asian blepharoplasty. She is seen
2 months postoperatively.
This 35-year-old woman wanted a low-set parallel crease. She is seen 2 months post-
operatively.

This 30-year-old woman had undergone a crease procedure elsewhere. Her preop-
erative findings included an excessively high crease, a prominent sulcus, and crease
fold redundancy.
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Chapter 29  Upper Blepharoplasty in the Asian Patient
A beveled approach in a revisional upper blepharoplasty was done, with lysis of the
adhesions through the orbicularis oculi and fibrous scar.
The postoperative view at 2 months (right) shows improvement in the sulcus and
an overall lowering of the crease height. Skin shortage medially prevented a more
ambitious correction; however, this can be remedied in the future when skin in this
area develops more laxity.

Concluding Thoughts
Accurate definition of the crease height and shape determines the visible component
of the procedure, as well as outcome and measurable success rate. A layered and se-
lective debulking of the eyelid tissues makes the completion of these essential steps
more reliable and efficient. Less hemorrhage and injury of tissues are encountered. It
establishes the proper orientation and spatial geometry of the semirigid pretarsal
skin and tarsus (or posterior lamella, vectored by the levator muscle) relative to the
more passive preseptal and periorbital orbicularis (anterior lamella) when the eye-
lids are opened. Repositioning the preaponeurotic fat and resetting of the eyelid skin
and forehead structures relative to the posterior lamella are critical steps in prevent-
ing complications. These measures allow the proper height and crease shape to be
achieved as planned. It helps to soften the deepened sulcus appearance seen in revi-
sional cases. Exact anastomosis of the levator aponeurosis to the lid crease incision
along the superior tarsal border provides a higher probability for a successful out-
come. Proper execution of these steps allows one to create a natural-looking eyelid
crease without the use of permanent or buried static sutures.
The special niche of Asian eyelid crease procedures should progress from creating
an eyelid crease that appears static (with the crease very apparent on downgaze) to
a physiologically natural and dynamic crease (where it partially disappears on
downgaze). I hope that surgeons who perform these procedures can appreciate these
subtle goals to create a fluid crease for these special patients.
Clinical Caveats
 Accurate definition of the crease height and shape determines the visible compo-
nent of the procedure, as well as outcome and a measurable success rate.
 A layered and selective debulking of the eyelid tissues makes the completion of
these essential steps more efficient and reliable.
 Repositioning the preaponeurotic fat and resetting of the eyelid skin and forehead
structures relative to the posterior lamella are critical steps in preventing compli-
cations.
 Exact anastomosis of the levator aponeurosis to lid crease incision along the supe-
rior tarsal border provides a higher probability for a successful outcome.
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Part VI  Eyelid Surgery

Suggested Readings
Chen WP. Aesthetic eyelid surgery on Asians: an east-west view. Hong Kong J Ophthalmol
3:27-31, 2000.
Chen WP. Asian blepharoplasty. Update on anatomy and techniques. Ophthal Plast Reconstr
Surg 3:135-140, 1987.
Chen WP. Beveled approach for revisional surgery in Asian blepharoplasty. Plast Reconstr
Surg 120:545-552; discussion 553-555, 2007.
Chen WP. The concept of a glide zone as it relates to upper lid crease, lid fold, and applica-
tion in upper blepharoplasty. Plast Reconstr Surg 119:379-386, 2007.
Chen WP. Concept of triangular, trapezoidal, and rectangular debulking of eyelid tissues:
application in Asian blepharoplasty. Plast Reconstr Surg 97:212-218, 1996.
Chen WP. Expert commentary on blepharoplasty and blepharoptosis surgery in Asians.
In Mauriello JA Jr, ed. Unfavorable Results of Eyelid and Lacrimal Surgery. London:
Butterworth-Heinemann, 2000.
Chen WP. Upper blepharoplasty in the Asian patient. In Putterman AM, ed. Cosmetic Oculo -
plastic Surgery, 3rd ed. Philadelphia: WB Saunders, 1998.
Chen WPD. Asian Blepharoplasty and the Eyelid Crease: A Color Atlas With DVD. London:
Butterworth-Heinemann/Elsevier Science, 2006.
Chen WPD. Asian blepharoplasty—finesse and pitfalls. In Chen WPD, ed. Oculoplastic
Surgery—The Essentials. New York: Thieme, 2001.
Chen WPD, Khan JA, McCord CD Jr, eds. Color Atlas of Cosmetic Oculofacial Surgery.
London: Butterworth-Heinemann/Elsevier Science, 2004.
Chuangsuwanich A. Short incisional double-eyelid blepharoplasty for Asian patients. Aes-
thet Surg J 26:280-286, 2006.
Collin JR, Beard C, Wood I. Experimental and clinical data on the insertion of the levator
palpebrae superioris muscle. Am J Ophthalmol 85:792-801, 1978.
Kruavit A. Asian blepharoplasty: an 18-year experience in 6215 patients. Aesthet Surg J
29:272-283, 2010.
Ma FY, Cheng MS. Mini-incision double eyelidplasty. Aesthet Surg J 30:329-344, 2010.
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Lower Eyelid Blepharoplasty

MARK A. CODNER, JUAN DIEGO MEJIA
CHAPTER 30

D
espite the frequency with which lower blepharoplasty is performed, the pro-
cedure remains a complex, challenging, and technically demanding one that
should not be considered routine. Minimizing complications and maximizing post-
operative results depend on careful preoperative planning and meticulous intraop-
erative technique. In addition to evaluating the eyelids, the surgeon must carefully
assess the periorbital anatomy, including the midface, because midfacial aging can
have a profound effect on the appearance of the lower lid. The lower lid and mid-
face compose an aesthetic unit that is best treated together, and the standard lower
lid approach provides an easy entry for midface rejuvenation. However, it is impor-
tant to individualize the operative plan to address individual patient needs.
It is essential to identify risk factors and concomitant medical conditions that could
contribute to postoperative complications. Excellent blepharoplasty results can be
achieved through the combination of careful preoperative assessment and meticu-
lous surgical technique using an anatomic approach to the aesthetic correction of
aging changes of the eyelids and periorbital region. Traditional blepharoplasty tech-
niques placed little emphasis on lower lid support or the correction of acquired
anatomic changes of the surrounding periorbital region. Newer techniques emphasize
lower lid support, such as routine canthopexy or canthoplasty, as well as transpalpe-
bral elevation of the midface and fat preservation and repositioning. In our patients,
routine canthal anchoring has been the key to achieving good, predictable results
and avoiding complications.
Indications
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Part VI  Eyelid Surgery
Candidates for lower blepharoplasty are individuals with valid complaints in con-
junction with physical findings that are amenable to surgical improvement. Typical
complaints include a tired look, puffy lower eyelids, malar bags, wrinkled skin, an
AGING CHANGES
Lower lid bulge
Palpebromalar groove
Malar bag
Midcheek groove
Nasojugal groove

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Chapter 30  Lower Eyelid Blepharoplasty
Medical Conditions That Might Increase the Risk of Complications
 Blepharochalasis
 Benign essential blepharospasm
 Rosacea
 Dry-eye syndrome
 Pemphigus
 Sarcoidosis
 Graves’ disease
 Menopause
Physical Examination
To produce a result that will be aesthetically pleasing to the patient, the surgeon must
take time to understand his or her complaints and concerns, and these should be
confirmed by the physical examination. For example, patients complaining of lower
eyelid bags may actually have midfacial aging or malar bags, which would not be
improved with standard lower blepharoplasty techniques. Therefore the surgeon must
be diligent in evaluating both the patient’s complaints and the underlying anatomic
findings to improve the aesthetic appearance of the periorbital region and provide
the best possible outcome. The physical examination should proceed sequentially to
ensure complete assessment of the periorbital anatomy. A Snellen eye chart is used
to document preoperative visual acuity in all patients before blepharoplasty.
accentuated lid-cheek junction, and a deep nasojugal groove. Patients must under-
stand the importance of treating the lower lid–midface as an aesthetic unit. In most
cases, treatment of one area without the other will produce unsatisfactory results.
Preoperative Assessment
Medical History and Evaluation
The first step in a thorough evaluation includes taking a history to identify specific
conditions, including inflammatory eyelid disorders, Graves’ disease, benign essen-
tial blepharospasm, and dry-eye syndrome. All of these increase the risk of compli-
cations after blepharoplasty and should be screened before surgery. These conditions
are discussed in Chapter 28.

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Part VI  Eyelid Surgery
Eye Protection Mechanisms
Patients should be evaluated for the presence of Bell’s phenomenon, since the com-
bination of dry eyes with a poor Bell’s phenomenon may lead to significant postop-
erative corneal dryness (left).
These patients should be further evaluated with Schirmer’s test. The conjunctiva is
anesthetized in the inferior lateral fornix with tetracaine eyedrops. Then 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 (right). Decreased tear
production is present when less than 10 mm of the Schirmer’s strip is wet after
5 minutes.
Eye Prominence
The globe should be examined to evaluate its position relative to the bony orbit. Pa-
tients with prominent eyes have a negative vector, which is visible on the lateral view
of the orbit when the anterior aspect of the globe is anterior to the underlying soft
tissue of the infraorbital rim. Patients with deep-set eyes have a positive vector, where
the globe is posterior to the infraorbital rim and overlying soft tissues.
Deep-set eye
Prominent eye

A more detailed analysis can be performed with a Hertel exophthalmometer, which
measures the position of the globe relative to the lateral orbital rim. Normal globe
prominence is in the range of 16 to 18 mm; patients with enophthalmos have mea -
surements less than 16 mm, and those with exophthalmos have measurements greater
than 18 mm. Patients with deep-set eyes or prominent eyes are at increased risk for
complications, and the degree of prominence influences the level at which the lateral
canthus will be anchored during lateral canthoplasty.
In patients with a standard eye position (16 to 18 mm), the lateral canthal fixation
should be in line with the inferior edge of the pupil to produce a normal eye fissure.
Patients with prominent eyes (19 mm or more) exhibit a tendency for downward mi-
gration of the eyelid margin with lateral tightening, which will produce postopera-
tive scleral show. Canthal anchoring in a standard position will “clothesline” the lid
margin underneath the eye. In patients with mild prominence, supraplacement of the
lateral canthal tendon is needed at the level of the midpupil. However, canthal an-
choring in a higher position will impair upper lid closure. Therefore, with increas-
ingly prominent eyes (as in patients with Graves’ disease), canthal anchoring should
not surpass the midpupillary line; other techniques are needed, such as recession of
the inferior retractors, insertion of primary spacers, or crisscross anchoring of the
upper and lower lids. Patients with deep-set eyes (15 mm or less) need lower and
deeper lateral canthal anchoring, because a standard canthal position can cause up-
ward clotheslining of the lower lid, narrowing the eye fissure and reducing the size
of the lateral scleral triangle.
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Chapter 30  Lower Eyelid Blepharoplasty

Lower Lid Evaluation
The lower eyelid should be evaluated for lateral canthal descent, lower lid laxity, and
the presence of scleral show, as well as excess skin and muscle, orbital fat, and malar
bags. The presence of scleral show should be a red flag to the surgeon; this is often
caused by a combination of a prominent eye, lower lid laxity, and poor infraorbital
support. Adjunctive procedures should be considered, such as lateral canthal sup-
port, a possible midface lift, or orbital rim augmentation.
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Part VI  Eyelid Surgery
A positive lateral canthal tilt is present when the lateral canthus is superior to the
medial canthus; a negative lateral canthal tilt is present when the lateral canthus is
inferior to the horizontal position of the medial canthus. A negative canthal tilt may
indicate descent of the lateral canthus from disinsertion, laxity, or the presence of a
prominent eye. These last patients are at increased risk for lid malposition and re-
quire lateral canthal support during blepharoplasty procedures.
Lower lid crease
Lid-cheek junction
Medial canthus
Nasojugal groove
Upper lid crease
Upper lid fold
Canthal tilt
Lateral canthus
Upper lid sulcus
Positive lateral canthal tilt
Negative lateral canthal tilt
The eyelid should be evaluated for both shape and function. The lateral canthal posi-
tion is normally 2 mm superior to the medial canthal position, and an imaginary line
should be drawn from the medial to the lateral canthus indicating the canthal tilt.

The lid snapback test may indicate the presence of lower lid laxity; however, this is
a fairly subjective test, and conclusions drawn from it may be inaccurate (left). More
precise evaluation can be obtained by lid distraction. Anterior lid distraction should
be less than 3 mm from the globe. Anything greater indicates lid laxity and postop-
erative risk for scleral show, ectropion, or corneal exposure. Appropriate lateral can-
thal anchoring can help reduce the risk in these cases (right).
Herniated Fat Pads
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Chapter 30  Lower Eyelid Blepharoplasty
Lateral fat pocket
Arcuate expansion
Central pocket
Inferior oblique muscle
Medial (nasal) fat pocket
Usual areas of fat herniation and protuberance
Progressive weakening of the overlying septum as individuals age has been an ac-
cepted theory for the protrusion of the fat pads. Descent of the midface with aging
also contributes to the unmasking of the lower eyelid bags as the interface between
the lid and cheek becomes more apparent, leading to a “double-bubble” appearance.
The lower lid has medial, central, and lateral fat prominences. The volume of these
fat pads varies among patients. The surgeon should mark and document the most
prominent fat pads preoperatively, because this can be difficult to do when the pa-
tient is on the operating table. The lateral fat pad is the most commonly overlooked
pad in lower lid blepharoplasty, yet it generally contains the greatest volume and
contributes most significantly to the lower lid bags. The options for managing the
fat of the lower lid depend mostly on the amount of fat and on the characteristics
of the lid-cheek junction. With this in mind, the fat pads can be preserved, removed,
redistributed, or even augmented with autologous fat grafting.

Tear-Trough Deformity
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Part VI  Eyelid Surgery
The tear trough is a midfacial hollow that begins at the inner canthus and travels
obliquely toward the lid-cheek junction. The orbitomalar ligament, along with the
origin of the levator labii superioris and levator labii alaeque nasi muscles, contributes
to its formation. Release of the orbitomalar ligament in the preperiosteal plane and
fat transpositioning or grafting are effective for adding volume and improving this
concavity.
Skin Pigmentation
Sometimes dark circles around the eyes are shadows produced by the convexity of
the herniated fat, and these can be improved with blepharoplasty. However, many
patients have pigmentation of the skin that will remain even after surgery, and it is
important that the patient be told this. Use of hydroquinone may be effective to
lighten dark circles caused by hyperpigmentation.
Midface
Aging changes in the midface are characterized by descent of the tissues, exposing
the inferior orbital rim and allowing the postseptal fat to become more visible. Recog-
nition of these changes is essential as the surgeon chooses the proper procedure.
Transconjunctival fat removal alone without correction of vertical midface descent
in these patients will lead to a skeletonized appearance of the lid-cheek junction. Pa-
tients with mild midface descent can benefit from extended blepharoplasty with re-
lease of the orbitomalar ligament with fat repositioning to produce a smoother lid-
cheek junction. Those with more advanced aging changes and midface descent require
a lower lid blepharoplasty combined with a midface lift.
Tear trough
deformity
Levator labii
superioris muscle
Orbital rim
Levator labii superioris
alaeque nasi muscle

Malar Eminence
Fat should be removed conservatively in patients with prominent cheekbones, be-
cause excessive resection will create a sunken lower lid appearance, accentuate the
malar eminence, and disturb the balance of the lid-cheek junction. Patients with a
lack of projection of the malar eminence are at greater risk for lower lid malposi-
tion after blepharoplasty. These patients can present with preexisting scleral show
and prominent eyes. Canthal anchoring and lower lid release procedures are espe-
cially important in these cases to decrease the risk of complications.
Patient Education
All of the potential risks of surgery should be discussed with patients before bleph -
aroplasty surgery. Common complications may include swelling, ecchymosis, chemo-
sis, and lagophthalmos. Other possible complications include infection, hematoma,
hypertrophic scarring, dry eye, epiphora, asymmetry, lid malposition, ectropion, en-
tropion, and the rare risk of vision loss. Informed consent should include a detailed
preoperative discussion of these risks with the patient.
Preoperative Planning
Classification of Periorbital Aging
A classification system of periorbital aging may aid in selecting the appropriate sur-
gical procedure for correction. The classification is based on the anatomic findings
associated with aging of the eyelids as well as midface descent, including the pres-
ence of tear-trough deformity, nasolabial folds, and bags under the lower lids. This
classification system focuses on the relationship between the lower lid and the mid-
face using an anatomic approach to develop a specific surgical plan.
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Chapter 30  Lower Eyelid Blepharoplasty
Classification of Periorbital Aging
Type
Age-Related Changes
Appropriate Procedure
I
Excess fat, no skin excess
Transconjunctival blepharoplasty
II
Excess skin, muscle, and fat
Transcutaneous blepharoplasty
Changes above intraorbital rim
Preperiosteal cheek lift
Minimal lower lid laxity
Lateral canthopexy
III
Excess skin, muscle, and fat
Transcutaneous blepharoplasty
Descent of malar fat pad
Subperiosteal cheek lift
IV
Malar bags
Subperiosteal cheek lift
Significant lower lid laxity
Lateral canthoplasty

Minimal
descent of
lid-cheek
junction
TYPE II
Minimal
lower lid aging
TYPE I
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Part VI  Eyelid Surgery
Type II patients have a combination of lower lid aging and early evidence of midfa-
cial descent. As the malar fat pad descends, the lid-cheek junction is more evident,
with the inferior orbital rim becoming visible through attenuated soft tissue. Midfa-
cial descent is often associated with loss of upper malar fullness, which contributes
Type I patients demonstrate the earliest changes of periorbital aging, with findings
confined to the lower eyelid. The presence of dermatochalasis includes acquired age-
related excess folds of skin and muscle, along with apparent fat excess. However, the
volume of orbital fat remains relatively unchanged from youth to middle age and is
even resistant to volume loss in cachectic patients. In contrast, facial fat, including
the malar fat pad and jowl, undergoes redistribution with age; that is, deflation and
descent. The perception of increased orbital fat volume is often affected by the pres-
ence of edema. In type I patients, the focus is to improve the appearance of the eye-
lids by means of upper and lower blepharoplasty, including fat resection by a
transconjunctival or transcutaneous approach and possible skin resection or resur-
facing. Alternative procedures are also appropriate, including resetting or tightening
the orbital septum and repositioning and retaining intraorbital fat.

significantly to the loss of lower lid support. These patients require augmentation of
the infraorbital rim, either through arcus marginalis release and fat repositioning or
elevation of the suborbicularis oculi fat (SOOF) to camouflage the infraorbital rim.
Modified superficial midface-lift techniques with dissection in the supraperiosteal
plane may be considered.
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Chapter 30  Lower Eyelid Blepharoplasty
Lid-cheek
junction below
orbital rim
TYPE III
Nasolabial
groove
Malar bag
TYPE IV
Nasojugal
groove
Type III patients display more advanced midfacial aging, with further descent of the
lid-cheek junction and deepening of the nasolabial folds. Descent of the malar fat
pad contributes to the formation of the nasolabial fold and requires elevation, either
with a subperiosteal midface lift or combined face-lift procedures that elevate the
malar fat pad.
Type IV patients have extensive midfacial aging changes, including malar bags, and
often demonstrate lower lid malposition with lid laxity. Subperiosteal dissection is
required, with release of the orbitomalar ligament, orbital retaining ligaments, and the
subzygomatic space to elevate the midface, along with lateral canthal support to cor-
rect lower lid laxity.

Patient Preparation
Preoperatively the patient is instructed to stop taking all medications that increase
the risk of bruising and swelling, including aspirin, ibuprofen, and vitamin E. Home-
opathic herbs such as Arnica montana and bromelain may reduce postoperative
edema and ecchymosis and have been used routinely for surgery patients for more
than 15 years. Patients are instructed to carefully remove all makeup, particularly
mascara residue, and to wash the face the morning of surgery. Lower blepharoplasty
can be performed with a general anesthetic or with intravenous conscious sedation.
The patient should be placed in a reverse Trendelenburg position to decrease venous
pressure. Surgical preparation includes application of a dilute povidone-iodine (Be-
tadine) solution to the eyelids and face, taking care to avoid exposure of the con-
junctiva; the eyes are irrigated with balanced saline solution before corneal protec-
tors are placed.
Operative Technique
Anesthesia
Adequate intravenous or general anesthesia is obtained; preoperative antibiotic ad-
ministration is recommended. Local anesthetic, consisting of lidocaine 1% with epi -
nephrine 1:100,000, is injected with a 27-gauge needle into the lateral canthus, lower
eyelid, and inferior orbital rim, avoiding the marginal arcades and the deep orbital
structures to reduce the risk of eyelid or retrobulbar hematoma.
Markings
The lower lid incision is initially marked with a
single point at the level of the lateral canthus.
Markings should extend approximately 6 to
10 mm inferolaterally in a prominent crow’s-feet
skin line. Approximately 10 mm of skin should
be preserved between the lateral extension of the
upper and lower blepharoplasty incisions. Post-
operative webbing or distortion can occur if
these incisions are placed too close together. The
remainder of the marking parallels the lid mar-
gin approximately 1 mm below the eyelashes.
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Part VI  Eyelid Surgery

Lower Lid Blepharoplasty
919
Chapter 30  Lower Eyelid Blepharoplasty
The lower lid skin is incised with a scalpel lateral to the canthus, exposing the un-
derlying orbicularis oculi muscle, which is then divided with electrocautery into the
submuscular space.
With the lower lid on stretch, scissors are used to dissect a subcutaneous tunnel over
the pretarsal muscle just below the lashes, and with the same instrument the skin is
incised, stopping 4 mm inferior to the punctum.

Through the lateral incision, the scissors are used once again to dissect a submus-
cular tunnel, and a second parallel incision is made through the orbicularis, pre-
serving a 5 mm strip of pretarsal orbicularis muscle. Electromyographic analysis has
revealed normal function to the pretarsal muscle strip with minimal risk of dener-
vation. The skin-muscle flap is then dissected anterior to the septum with a Bovie
cutting needle to the level of the infraorbital rim. Dissection continues past the in-
fraorbital rim just superficial to the periosteum, releasing the orbitomalar ligament
to improve the appearance of the lid-cheek junction.
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Part VI  Eyelid Surgery
Submuscular dissection continues over the septum down to the orbital rim. The or-
bitomalar ligament is divided along the entire infraorbital rim. A tear-trough defor-
mity requires release of the medial origins of the orbicularis oculi, levator labii su-
perioris, and levator alaeque nasi muscles from the inferior orbital rim. Once the
orbitomalar ligament is released, the SOOF becomes visible, and dissection superfi-
cial to the periosteum is continued approximately 10 mm below the orbital rim, pre-
serving the zygomaticofacial and zygomaticotemporal nerves. Release of the orbit-
omalar ligament allows elevation of the SOOF with the skin-muscle flap. Elevation
of the SOOF with orbicularis muscle redraping camouflages the inferior orbital rim,
giving the lid-cheek junction a smoother appearance.

Fat can be removed conservatively with the Bovie from all three lower lid compart-
ments, and the orbital septum is resected along with excess fat (left). Removal of the
septum may reduce the risk of subsequent septal scar formation. If fat resection is
planned, the arcuate expansion of Lockwood’s ligament between the central and lat-
eral fat pad should be preserved for additional support to prevent further herniation
of periorbital fat. When fat transposition is the objective, Lockwood’s ligament should
be divided to allow adequate release and redraping of the fat pads.
921
Chapter 30  Lower Eyelid Blepharoplasty
Alternative procedures might also be considered: arcus marginalis release, septal re-
set, or septal tightening. Septal reset, as described by Hamra, involves suturing the
septum orbitale over the inferior orbital rim to produce a youthful convex contour to
the lower eyelid–cheek complex. Septal tightening, described by de la Plaza and
Mendelson, encompasses suture tightening of the septum after partial resection or
septal plication without resection. These procedures are designed to improve the
pseudoherniation of the orbital fat through the septum. As in an upper blepharo-
plasty, the lower lid should be irrigated with normal saline solution after resection
of the orbital fat pads.
Care should be taken to avoid injury to the inferior oblique
muscle between the nasal and central fat pads. The inferior
oblique muscle is reportedly the most common extraocu-
lar muscle injured during blepharoplasty, usually from in-
discriminate cauterization. The lateral fat pocket should be
reevaluated after lateral canthopexy, because lateral tension
will cause additional herniation.

Lateral Canthal Support
922
Part VI  Eyelid Surgery
Canthal
tendon
vector
Muscle
suspension
vector
The degree of lower lid laxity should be evaluated intraoperatively by placing ante-
rior traction on the lower eyelid away from the globe and measuring the amount of lid
distraction with calipers. Lid distraction of 1 to 2 mm indicates minimal lid laxity;
3 to 6 mm indicates moderate laxity; more than 6 mm indicates significant lid laxity.
Routine lateral canthal anchoring is performed as part of all of our lower bleph-
aroplasties. A lateral canthopexy is indicated in patients with minimal or moderate
lid laxity. When lid distraction is more than 6 mm from the globe or when persis-
tent intraoperative lid laxity is seen after a routine canthopexy, horizontal shorten-
ing of the lid is performed with a lateral canthotomy and canthoplasty. Regardless
of the type of anchoring used (canthopexy or canthoplasty), the internal vector of
fixation is essential. The canthus should be anchored inside the orbital rim to enable
the lid to conform to the globe.