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

Late Complications
Most if not all late complications are related to lid retraction, its consequences, and
alterations in eyelid closure mechanics. A brief review of eyelid mechanics and in-
nervation follows to identify the anatomic causes of these problems.
Eyelid Mechanics and Innervation
Eyelids have multipart mechanics contributing to orbicularis muscle function. Con-
tracture occurs in different parts of the muscle, depending on the function needed.
There is interplay between orbicularis contracture and counter pull at the eyelid at-
tachment at the lateral canthus. This interplay affects eyelid blinking and eye fissure
shape.
Eyelid Movement: Division of Labor in the Orbicularis
In previous studies involving segmental surgical removal of the orbicularis oculi mus-
cle in large series of patients with blepharospasm, it was shown that only the orbi-
cularis muscle in the inner canthus is responsible for everyday eyelid tone, move-
ments associated with blinking, and normal eyelid closure. This section of the
orbicularis also provides the “motor” for the lacrimal pump mechanism for the
drainage of tears. The rest of the orbicularis, the extracanthal orbicularis, is respon-
sible only for emergency and emotional eyelid closure, such as squeezing, squinting,
and animations of expression.
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Part VI  Eyelid Surgery
CHEMOSIS TREATMENT
Administer lubricant drops
and ointment
No resolution
Instill Neo-Synephrine drops 2.5%
Steroid drops
Resolution
Resolution
No resolution
Patch eyes
No resolution
Incise and resect
Resolution

Anatomic classification of the orbicularis into the orbital, preseptal, and pretarsal
orbicularis is convenient for surgical labeling, but a functional classification of the
orbicularis into an inner canthal orbicularis and an extracanthal orbicularis should
be adopted for better understanding of eyelid function.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
These illustrations show the division of function (division of labor) seen in the or-
bicularis muscle. The extracanthal orbicularis is primarily responsible only for ac-
cessory squeezing movements and expression of the eyelid. The inner canthal orbi-
cularis, as shown in the upper illustration (purple-shaded area), is responsible for
normal blinking movements, eyelid tone, and the lacrimal pump mechanism. The
larger areas shown at the lower left demonstrate the vector of pull of the intercanthal
orbicularis toward the nose and the counterpull on the eyelids by fixation of the lat-
eral canthal tendon.
Eyelid Innervation: Division of Innervation of the Orbicularis
It follows that because there is a division of labor in orbicularis muscle function,
there is also a duality of innervation of the orbicularis. Electromyographic (EMG)
studies, clinical observations, and anatomic studies have shown this to be the case.
The extracanthal orbicularis is supplied by the zygomatic branch of the facial nerve,
whereas the inner canthal orbicularis is supplied by a vertical extension of the buc-
cal branch of the facial nerve.
Extracanthal orbicularis
Inner canthal orbicularis
Responsible for:
Eyelid closure/blinking
Lower lid tone for position
Tear pump
Responsible for:
Squeezing
Animation
Expression
Protection from flying objects

The dual innervation of the orbicularis muscles is illustrated. Branches of the zygo-
matic portion of the facial nerve supply the extracanthal orbicularis, and vertical
branches of the buccal branch of the facial nerve supply the canthal orbicularis and
corrugator muscles.
Loss of innervation from the zygomatic branch of the facial nerve to the extracanthal
orbicularis can occur, but in the absence of lower lid laxity it will produce little
change in eyelid position or tone as long as the buccal branch innervation to the in-
ner canthus remains intact. Standard surgical incisions in the pretarsal or preseptal
orbicularis external to the inner canthus cause no abnormalities in lower eyelid po-
sition or tone. With regard to the effect of subciliary incisions, recent EMG studies
show that microdenervation of the pretarsal orbicularis muscle does not occur, even
if the recording electrode is placed directly into the surgical incision line. However,
loss of eyelid innervation from the buccal branch of the facial nerve to the inner can-
thal area will cause profound changes in eyelid function, with reduction or absence
of eyelid blinking, poor lower lid tone and position, and a weakening of the lacrimal
pump mechanism, causing tearing.
Lateral Canthal Anchoring
The mechanics of eyelid closure, the normal blinking movements of the upper and
lower lid, require firm attachment at the insertion of the lateral tendon for counter-
pull. Because contracture of the orbicularis in the inner canthus is responsible for
blinking of the eyelids, if it is unopposed, an abnormal nasally directed eyelid move-
ment occurs with each blink. Firm anchoring laterally is needed for counterpull
against canthal contracture to convert the vector of the blink movement into a ver-
tical one for proper eyelid closure. Patients who lack lateral canthal anchoring suf-
fer from faulty eye-blinking mechanics. The nasal movement of the eyelids that oc-
curs with each blink results in “fish-mouthing” of the eyelids when the individual
attempts eyelid closure. This situation can cause lagophthalmos and eye exposure
of varying degrees.
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Part VI  Eyelid Surgery
EXTRACANTHAL ORBICULARIS
CANTHAL ORBICULARIS
Zygomatic branches VII
Buccal branches VII

The structures in the eyelids that are responsible for blinking movements are shown.
The inner canthal orbicularis, with its contracture, provides the motor for the eye-
lid blink but can only be effective if there is firm counterpull of the eyelids laterally
at the outer canthus. The top illustration shows normal closure with firm lateral can-
thal anchoring. The bottom illustration shows reduced closure, to the point of fish-
mouthing, with weak or dehisced lateral canthal attachments.
AESTHETIC GOALS IN THE LOWER LID:
A MIDFACE AESTHETIC UNIT
Normally the inferior arc of the orbicularis oculi muscle and the underlying subor-
bicularis oculi fat (SOOF) span the eyelid and orbital rim area in the midface. With
aging there is sagging or ptosis of the orbicularis muscle, accompanied by loosening
of the orbitomalar ligament, which causes a downward descent of the SOOF and
malar fat. This facial descent results in a loss of padding over the inferior orbital rim
and a loss of cheek fullness, characteristics that are inconsistent with a youthful ap-
pearance. This descent is usually accompanied by herniation of fat as well as skin
laxity in the eyelid.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
Counterpull of
lateral canthal
attachment
Loosening of
lateral canthal
attachment

The skeletonization of the orbital rim area associated with age is a major contribu-
tor to the aging appearance in the midface area. Surgery that fails to address the eye-
lid and cheek area as an aesthetic unit falls short of producing a true reversal of ag-
ing changes in this area. Techniques that use supraplacement of the inferior arc of
the orbicularis muscle to reposition the midcheek upward correct the underlying
problem of ptosis of the orbicularis. In patients undergoing primary cosmetic sur-
gery, as the skin of the lower lid and midface is recruited upward, the resulting skin
redundancy can be excised. In patients undergoing reoperation with lower lid re-
traction caused by excessive skin removal, the additional skin recruited by upward
movement of the orbicularis introduces needed skin into the lower lid. In corrective
surgery, the technique of orbicularis redraping is a valuable tool that allows the sur-
geon to avoid skin grafts in patients with a shortage of skin in the lower lid.
Eye Fissure Shape
In patients undergoing aesthetic eyelid surgery, a youthful configuration of the eye-
lid fissure is needed to reduce the perception of aging in the eyelids. The elements
that define eye fissure shape are the position of the eyelid margins and the shape of
the exposed scleral triangles on either side of the cornea. The size of the cornea is
uniform in all persons, but the shape of the scleral triangles may vary. Generally, the
nasal scleral triangle is smaller, and the lateral scleral triangle is larger and more
pointed. In most individuals, the position of the lateral canthus is slightly higher than
the inner canthus and is at the level of the inferior edge of the pupil.
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Part VI  Eyelid Surgery

The youthful eye fissure shape shown above is defined by the position of the eyelids
and the exposed sclera on either side of the iris, the nasal (medial) scleral triangle,
and the lateral scleral triangle. The standard position of the lateral canthus is in line
with the inferior edge of the pupil and is slightly higher than the inner canthus. Eye
fissure changes that occur with age are shown in the eyes at right. In a deep-set eye,
the eye fissure becomes smaller, with a reduction in the size of the lateral scleral tri-
angle. In a prominent eye, downward bowing of the lower lid is evident.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
The shape of the scleral triangles and eye fissures is seen in the eyes of these young
women. With aging there is relaxation of lateral canthal attachments, which may
cause the eye fissure to change in shape according to eye prominence. In persons
with normal or deep-set eyes, the fissure tends to become rounder and smaller. In
persons with prominent eyes, a downsliding of the lower lid, scleral show, and en-
largement of the lateral scleral triangle may occur. Proper canthal anchoring restores
a more youthful look to the eye fissure by changing the shape of the fissure and the
shape of the lateral scleral triangle.
Deep-set eye
Prominent eye
Lateral scleral
triangle
Nasal scleral
triangle
YOUTH
AGE

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Part VI  Eyelid Surgery
This woman is shown before and after lateral canthopexy and a midface lift. The
eye fissure has been corrected from rounded and small with age (left) to a more open,
elliptical, youthful shape (right).
A change in eye fissure shape is demonstrated in this man. After canthal anchoring,
the shape of his eye fissure changed from rounded (left) to a more youthful, ellipti-
cal shape (right).
It has been shown mathematically that protrusion of the eye against the eyelid af-
fects the shape of the eye fissure. Upper lid curvature is determined almost exclu-
sively by indentation of the globe on the eyelid. Lower lid curvature is determined
by a combination of globe indentation and the position and tone of the lateral can-
thal tendons. Lateral canthal anchoring has a powerful influence on lower lid posi-
tion and curvature.
Techniques of Lateral Canthal Anchoring
Strengthening the eyelid attachments at the lateral canthus can take the form of a
pexy procedure, with plication of the canthal tendons or canthoplasty, cantholysis, and
shortening of the lower lid with reattachment to the lateral periosteum. In patients
with lower lid laxity, reinforcement with shortening of the lower lid is necessary.

The two common methods of lateral canthal anchoring are illustrated. With can-
thopexy, a mattresslike suture attaches both the upper and lower tendons to the peri-
osteum inside the orbital rim. With canthoplasty, the lower lid is shortened to com-
pensate for laxity. In both cases the upper lid is included in the anchoring to the
orbital periosteum. Whichever procedure is used, the axial vector of lid anchoring
must travel inside the lateral orbital rim so that the lower lid will be flush with the
curvature of the globe.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
The normal vectors of attachment of the lateral canthal tendons and the orbicularis
muscle are shown. The lateral canthal extension of the tarsoligamentous sling in-
serts well inside the orbital rim, whereas the orbicularis muscle inserts externally on
the orbital rim.
Indications for Canthoplasty Versus Canthopexy
Significant laxity of the tarsoligamentous sling must be addressed surgically by tight-
ening or shortening the lower lid to stabilize it and prevent postoperative ectropion
or buckling when a blepharoplasty is performed.
CANTHOPEXY
CANTHOPLASTY
Muscle
suspension
vector
Lateral
canthal
tendon
Pretarsal orbicularis
Orbital septum
Eisler’s pocket
Canthal
tendon
vector

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Part VI  Eyelid Surgery
This patient, who had lower lid laxity after blepharoplasty, demonstrates outward
buckling of the lower lid with ectropion. No shortening of the tarsoligamentous sling
was performed. There is a disparity in tone between the anterior lamella (orbicu-
laris) and the posterior lamella (tarsoligamentous sling), which causes the lid to
buckle outward.
The intraoperative distraction test is the best method for detecting lower lid laxity.
Preoperative eyelid distraction tests have been described in the past, but we think it
is more meaningful to apply the distraction test intraoperatively. No more than 1 to
2 mm of distention from the globe should be seen with outward traction on the
lower lid with the patient in the recumbent position intraoperatively. In addition,
there should be a firm “snap back” to the globe after distention. If this amount of
tension is not seen in the lower lid, a tightening procedure of the tarsoligamentous
sling of the lower lid must be performed.
In patients with laxity of the tarsoligamentous sling, tightening only the orbicularis
muscle will not correct internal lower lid laxity and can produce outward buckling
of the lid because of redundancy in the posterior lamella. Tightening of the tarsoliga-
mentous sling itself must be performed.

Either canthopexy or canthoplasty is used until the proper tension is obtained. If
canthopexy is tried first and the tension of the lower lid against the globe does not
seem adequate, or there seems to be redundant tissue at the lateral canthus, the lower
lid should be resected and canthoplasty performed.
Variations in Placement of Lateral Canthal Anchoring
As mentioned earlier, the pull of lateral canthal anchoring on the eyelids against the
globe will influence the shape of the eyelid fissure according to the prominence of
the eye. To produce the desired youthful fissure shape, variations in placement of
the anchoring are used according to eye prominence. Because the lateral pull of can-
thal anchoring of the lower lid results in changes in the size, shape, and position of
the lateral scleral triangle, different placements of anchoring must be used in pa-
tients with differences in eye prominence.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
The position of the lower lid changes in response to traction at the lateral canthus.
The lower lid position will either remain stationary, “clothesline” downward, or
clothesline upward in response to the lateral pull of canthal anchoring, with differ-
ences in eye prominence. Lower eyelid movement depends on whether the eye is
deep-set (less than 15 mm), standard position (15 to 18 mm), or prominent (more
than 18 mm). In an eye with standard prominence, a lateral pull in line with the in-
ferior edge of the pupil will maintain a good lower lid position. In a deep-set eye,
this same vector of pull will result in upward clotheslining, giving the patient a small
Deep-set eye
Standard eye prominence
Prominent eye
18 mm
15 mm
Clothesline upward
Stationary
Clothesline downward

1034
Part VI  Eyelid Surgery
eye fissure postoperatively. In a prominent eye, the same pull will cause downward
clotheslining.
During a lower lid blepharoplasty, if the surgeon fails to take these factors into ac-
count and fails to modify lateral canthal anchoring accordingly, abnormalities of the
eye fissure may result. Preoperatively, the proper placement of canthal anchoring
can be planned according to preoperative measurement of eye prominence as mea-
sured with an exophthalmometer.
This approach to treatment is offered as a general guideline; the surgeon makes the
final determination on anchoring after assessing the behavior of the lower lid intra-
operatively. During surgery, if the final resting position of the edge of the lower lid
is at the desired level in relation to the cornea (usually just inside the lower limbus),
the position of anchoring can be deemed adequate.
The proper vectors of canthal anchoring are demonstrated in patients with deep-set
eyes, eyes with standard position, and prominent eyes. In patients with deep-set eyes,
canthal anchoring should be directed more downward and internally to compensate
for globe curvature. For patients with standard eye prominence, canthal anchoring
should be placed at the level of the inferior edge of the pupil inside the orbital rim.
For patients with prominent eyes, the vector of anchoring should be more upward,
with mild supraplacement.
Deep-set eye
Standard eye prominence
Prominent eye
18 mm
15 mm

Standard Eye Prominence
Lateral anchoring for an eye with standard prominence (16 to 18 mm) is usually
best accomplished by placement at the level of the inferior edge of the pupil.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
The image on the right depicts positioning of canthal anchoring in the various situ-
ations of eye prominence. The highest placement is for a prominent eye. The lowest
placement is for a deep-set eye. In the left image, the proper vector of fixation is in-
dicated by the black arrow. The red arrow indicates a placement that is too anterior
in most cases.
The Deep-Set Eye
In a patient with deep-set or inwardly recessed eyes, a lower lid clotheslining up-
ward may occur that narrows the fissure and reduces the size of the lateral scleral
triangle. This may cause the patient to complain of “little, squinty eyes” postopera-
tively. In these patients with deep-set eyes (less than 15 mm), anchoring is placed
more inferiorly and more internally to prevent the upward clotheslining of the lower
lid that may occur (see the preceding two figures). This also prevents narrowing of the
lateral scleral triangle and postoperative patient complaints of “small eyes.”
This patient with deep-set eyes (15 mm) is shown before a cheek lift (left). Because
she was at risk for narrowing of the eye fissure with standard placement of canthal
anchoring, a modified approach was used. On the right, the patient is shown after
a midface lift and canthal anchoring, which was modified with downward and in-
ward placement to compensate for her enophthalmos.
Deep-set eye
Standard eye
Prominent eye
Improper
fixation
Proper
fixation

The Prominent Eye
In a patient with prominent eyes, tightening the lower lid in the standard vector can
cause a clotheslining effect that produces a bowing downward of the lower lid or,
in more severe cases, scleral show. Currently we depend on slight supraplacement
of lateral canthal anchoring to position the lower lid upward to counteract this effect
in milder cases. We have found that the position of the canthal anchoring in the
prominent eye should not be higher than the center of the pupil, particularly in pa-
tients with more severe eye prominence.
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Part VI  Eyelid Surgery
This illustration depicts the limitations of supraplacement of the lateral canthal ten-
don, which can result in the weakening of upper lid closure because of the mechan-
ical factors involved. Canthal anchoring should not be supraplaced above the mid-
level of the pupil; leverage of upper lid closure is lost as the canthus is supraplaced.
This is particularly true in patients with prominent eyes.
Limitations of Canthal Supraplacement
If certain limits of lateral canthal supraplacement are exceeded in patients with in-
creasingly prominent eyes, there is an adverse effect on upper lid closure. This is be-
cause the fulcrum of upper eyelid movement may slide upward past the vertex of
the cornea as lateral anchoring moves upward, which causes reduced closure of the
upper lid with lagophthalmos. Increased tightening of the upper lid can aggravate
this situation; it is analogous to the clotheslining effect that occurs with tightening of
the lower lid in these patients. Excessive manipulation of the lateral tendons upward
may also intrinsically weaken the upper tendon attachment.
Weakens
upper lid
closure

This patient with prominent eyes and preexisting scleral show is shown preopera-
tively and postoperatively. Postoperatively, excess supraplacement of the canthal an-
gles is evident because of the retinacular suspension used to elevate the lower lid
margin. Note the weakening of upper lid closure.
Other Compensatory Procedures in Patients With Prominent Eyes
If mild lateral canthal supraplacement does not elevate the lower lid enough, the first
surgical step to be used to counteract any clotheslining tendency is a release or re-
cession of the inferior retractors, capsulopalpebral fascia (CPF), in the lower lids.
A gain of 1 to 2 mm in the lower lid position against scleral show can be achieved
with CPF recession.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
This illustration shows recession of the inferior retractors (CPF) of the lower lid to
elevate the lid margin.
Preoperative
Postoperatively
Capsulopalpebral fascia

1038
Part VI  Eyelid Surgery
This woman with prominent eyes (greater than 18 mm) is shown before and imme-
diately after canthal anchoring with slight supraplacement combined with recession
of the CPF in the lower lid. There is normalization of the lateral scleral triangles.
In patients with more severe eye prominence, loosening the CPF may not provide
enough lid elevation to prevent postoperative scleral show, and spacer material must
be inserted in the posterior lamella of the lower lid. For spacer placement, we pre-
fer a full-thickness blepharotomy in the posterior lamella 6 mm below the lower lid
margin (sparing the inferior arcade, which is approximately 4 mm below the lid mar-
gin). Most of the blood flow to the lower lid comes from the nasal arterial complex,
so care is taken not to dissect or cauterize unnecessarily in this area. It is convenient
to use AlloDerm of sufficient thickness as a spacer material in previously unoper-
ated patients.
Incision of the inferior retractors (CPF) and conjunctiva is shown, with full-thickness
blepharotomy of the posterior lamella of the lower lid and insertion of spacer ma-
terial to elevate the lid margin.
Spacer

This patient with prominent eyes (greater than 19 mm) is shown before and after
midfacial lid surgery combined with upper lid brow surgery, in which a primary
spacer of AlloDerm was used to prevent downward clotheslining and scleral show.
Our present approach for preventing postoperative problems in patients who have
prominent eyes is a progression from conservative lateral canthal supraplacement
to recession of the inferior retractors, followed by insertion of a spacer to produce
a desirable eye fissure shape.
Lower Lid Complications and Their Treatment
Abnormalities of eye fissure shape and lower lid retraction or ectropion are the most
common problems that may be seen after aesthetic lower lid surgery. Shape defor-
mities range from a simply undesirable eye shape (such as rounding, bowing, or nar-
rowing of the lateral scleral triangle) to lid malposition. Commonly these problems
result from inappropriate canthal anchoring. Patients with poor anchoring may also
have poor eyelid closure mechanics. The causes of ectropion or downward retrac-
tion of the lower lid are as follows:
 Overzealous skin removal
 Failure to surgically anchor supporting elements of the eyelid (the lateral can-
thal tendons or the orbicularis muscle flap)
 Failure to recognize preexisting lower lid laxity
 Failure to recognize significant variation in eye prominence
Lower lid malposition may have medical consequences in addition to aesthetic ones.
Postoperative exposure can be particularly intensified if lagophthalmos in the up-
per lid is present as well.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery

1040
Part VI  Eyelid Surgery
Nonsurgical Management
In the early postoperative period, some edema, with its fluid accumulation, causes
thickening, which exacerbates lower lid malposition. The conservative approach is es-
sential in patients who still have edema and thickening of the lower lid. It may take
several weeks for the fluid to be resorbed, the edema to resolve, and the lid tissue to
soften and elevate. Upward massage is therapeutic.
Watchful waiting and reassurance constitute the best approach during the early re-
covery. If mild edema is accompanied by excessive stiffness in the eyelid skin or sub-
cutaneous tissues, judicious injection of steroids may be useful. Caution must always
be exercised when injecting steroids to avoid subcutaneous fat atrophy, thinning of
the skin, and telangiectasia.
Corrective Surgical Procedures
Lower lid retraction or malposition that does not resolve with conservative mea-
sures requires surgical correction. These corrective procedures may have to be staged,
depending on the severity of the problem and the desire to avoid external skin grafts
in certain patients.
We classify lower lid complications in the following three broad categories:
1. Lower lid retraction
2. Eye fissure shape changes
3. Eyelid closure mechanics
These problems may occur independently, but for many patients they appear in com-
bination.
Common procedures to correct lower lid complications are anchoring (or reanchor-
ing) of the lateral canthus and anchoring (or reanchoring) of the inferior arc of the
orbicularis muscle. Both structures offer support for repositioning the lower lid, and
each, if appropriately anchored, can restore an undesirable eye fissure shape.
Poor eyelid
closure
Lower lid
retraction
Eye fissure
shape
problems

This is an example of a patient with eye fissure narrowing after blepharoplasty. The
patient complained of “little bitty eyes” after blepharoplasty; note the narrowing of
her eye fissures. After canthal reanchoring modified with downward and inward
placement, she was pleased with the enlargement of her eye fissures and thought that
her eyes had a more normal shape.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
On the left is a close-up of a patient with deep-set eyes after a lower lid bleph-
aroplasty in which the proper type of canthal anchoring was not performed. She had
a marked reduction in the size of the lateral scleral triangles in both eyes. On the
right, after canthal anchoring with downward, inward placement to compensate for
the deep-set eye, enlargement of the lateral scleral triangle is shown (see red out-
lines). If skin shortage is a significant factor in lower lid retraction, canthal vertical
anchoring of the inferior arc of the orbicularis muscle will recruit skin upward into
the lower lid and will, in most cases, correct retraction without the use of a skin
graft. Insertion of spacer material into the posterior lamella of the lower lid is par-
ticularly useful in patients with prominent eyes and those with retraction caused by
scarring of the middle lamella. Spacer material, interposed after scar release, acts as
a barrier against postoperative scar contraction. Autologous material such as der-
mis, ear cartilage, or hard palate is best used in reoperative cases.

Canthal Anchoring (Reanchoring)
In patients who have minimal scarring and an intact lateral rim periosteum, canthal
reanchoring may be performed as one would in an unoperated patient. In patients
with unusual scarring or tissue deficiency in the canthal area, extra tissue may be
needed for lateral reinforcement. In milder cases, a periorbital rim–based periosteal
strip can be used for support.
1042
Part VI  Eyelid Surgery
Techniques of canthal anchoring using reinforcement with additional tissue are
shown. A reflected flap of lateral rim periosteum can be used as a reconstructive pro-
cedure at the lateral canthus and can act as additional support. In lieu of periosteum,
free grafts of fascial tissue, either temporalis or fascia lata, can be used for additional
support of canthal reanchoring.
A free fascia patch graft may also be used. This approach, in which additional soft
tissue is introduced, is particularly helpful in cases in which there is a shortage of
eyelid tissue in the lateral lid.
After an earlier eyelid surgery, this patient had a loss of normal lateral canthal at-
tachments in the right eye and phimosis from tissue loss in the left eye. Both lateral
canthi were reconstructed with reanchoring and periosteal flap placement, as shown
on the right.
Periosteal strip
Free fascia graft

Our procedure of choice for the most secure canthal anchoring is refixation of the
lateral canthus through a drill hole in the lateral orbital rim. This is a useful tech-
nique in patients with poor periosteum and weakness of soft tissue support at the
lateral canthus. It is best used for patients with severe distortion of the eye fissure
or patients who have poor eyelid closure caused by lateral anchoring deficiency.
Drill-hole fixation enhances the permanency of anchoring.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
The technique of canthal anchoring using drill-hole fixation to the lateral orbital
rim is shown. A single drill hole can be used. The double-armed suture (4-0 Mersi-
lene) is passed through the single drill hole and secures the canthus inside the lateral
orbital rim. The double-armed suture can then be fixed to the deep temporal fascia.
The use of a single drill hole allows greater precision in canthal placement and pos-
sibly a more secure attachment to the orbital bone.
The doubled-armed suture attached to the canthal structures is brought out through
the drill hole and secured to the deep temporal fascia.

On the left, this patient shows deformity of the right canthus that had resisted con-
ventional forms of canthal reanchoring; on the right, the same patient is seen after
drill-hole canthal anchoring.
The need for drill-hole canthal fixation commonly occurs in patients with promi-
nent eyes who also have eyelid retraction and stiffness of the upper and lower lids. In
these patients a double drill-hole fixation is necessary in which the lateral tendons of
the upper and lower lid are independently fixed to drill holes in different positions.
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Part VI  Eyelid Surgery
To obtain the proper vectors of pull at the lateral canthus to ensure good lid closure,
a crisscross attachment can be used. This is particularly important in patients with
prominent eyes and poor closure. The vector of pull that improves closure in the up-
per lid is obtained by placing it in the inferiorly placed drill hole. A cantholysis is
performed, and the edge of the upper lid is attached to the lower drill hole. The lat-
eral tendon of the lower lid can be placed in the superiorly placed drill hole, allow-
ing a higher supraplacement of the lower lid without affecting upper lid closure. This
improves the upper lid closure mechanics and also allows more supraplacement of the
lower lid. This crisscross drill-hole fixation is commonly used in conjunction with
the other reconstructive procedures.

Vertical Reanchoring of the Inferior Orbicularis Muscle
The upward redraping of the inferior arc of the orbicularis, with tightening and firm
attachment to the temporal fascia, will add support to the lower lid.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
The skin is recruited upward into the lower lid, with vertical reanchoring of the in-
ferior arc of the orbicularis muscle.
Vertical reanchoring of the orbicularis muscle is demonstrated, with recruitment of
skin into the lower lid. Reanchoring the orbicularis also acts as the supportive sling
for lower lid repositioning. The vector of orbicularis anchoring is performed in ac-
cordance with eye prominence. A more vertical vector of fixation, to the temporal
fascia and periosteum, is used when more skin recruitment is required and in pa-
tients with more prominent eyes.

1046
Part VI  Eyelid Surgery
Orbicularis reanchoring is usually combined with canthal reanchoring, as described
earlier. One may use a more limited orbicularis dissection and reanchoring in milder
cases of lower lid retraction in which the skin shortage is not severe.
This woman exhibits mild retraction and skin shortage in the lower lid before and
after recruitment using vertical reanchoring of the orbicularis muscle. In patients
with increased or severe skin deficiency, extensive vertical repositioning of the infe-
rior arc of the orbicularis may be needed to recruit greater amounts of skin upward
into the lower lid, which usually eliminates the need for skin grafts in these patients.
Moderate retraction and skin shortage in the lid is evident in this patient both be-
fore and after recruitment using vertical reanchoring of the orbicularis muscle.

This patient has retraction and skin shortage in the left lower lid before and after
recruitment using vertical reanchoring of the orbicularis muscle. In the past this pa-
tient would have required a skin graft for correction.
Spacers
The use of spacer inserts in the lower lid posterior lamella in patients undergoing
primary surgery was described earlier in this chapter. The same procedure is used in
patients with secondary lower lid retraction for corrective surgery. Spacer inserts in
the lower lid (AlloDerm, ear cartilage, autogenous dermis) lengthen the posterior
lamella and elevate the lower lid margin upward in patients with significant eye
prominence (defined as 19 mm or more as measured by an exophthalmometer).
1047
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
On the left, this woman is shown after lower lid blepharoplasty with extremely
prominent eyes and moderately severe lower lid retraction. She required transcuta-
neous placement of spacer material in the posterior lamella of the lower lid with ver-
tical recruitment of skin. Her postoperative result is shown on the right.
Even in patients with normal eye prominence with significant middle lamella scar-
ring, spacers can help prevent postrepair contracture of scar tissue. On occasion, in
reconstructive patients who do not require skin recruitment, the spacer may be placed
internally without a transcutaneous approach.

1048
Part VI  Eyelid Surgery
Spacer
Capsulopalpebral
fascia
The position of the spacer material is shown after internal placement in the lower
lid. Spacers are usually needed in patients with very prominent eyes or those who
have retraction from scarring of the middle lamella. In more severe cases, transcu-
taneous spacer placement may be required, in conjunction with orbicularis eleva-
tion for skin recruitment.
Complications of Autologous Fat Injections
Correction of aging lower lids and blending of the lid-cheek junction with autolo-
gous fat microinjections is becoming increasingly popular. Although some of the re-
sults have been impressive, we have seen a number of patients in whom the fat has
been injected superficially, subcutaneously, or in the superficial layers of the orbi-
cularis, leading to unsightly “beading” of the lower lid. These problems may be dif-
ficult to correct. The fat may be removed through the transconjunctival approach.
As with any complication or problem, avoiding the problem from the outset is prefer-
able to correction. Injection of the fat deep and directly over the periosteum is best
to prevent postoperative irregularities and beading.
Treatment Options
Steroid injections may induce atrophy of the injected fat but are not always success-
ful and carry the risk of skin changes and telangiectasia. Suctioning the fat with a
fine needle is not uniformly successful. Injections of phosphatidylcholine and deoxy-
coline may result in resolution but such treatments have not been established. Surgi-
cal removal of the injected fat is the treatment of choice. The fat may be accessed
through the conjunctiva, transcutaneously, or with a skin-muscle flap.

This woman had undergone autologous fat injections
into the lower lid in an attempt to improve lower lid
aging and descent of the lower lid–cheek junction.
The excess superficially injected fat is quite evident.
She also had bilateral lid retraction that was worse
on the right than on the left.
1049
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
Through the skin-muscle flap approach, the autologous fat within and superficial to
the orbicularis muscle was easily located. The excess fat was dissected and removed.
After all the excess fat was successfully removed, the orbicularis was mobilized and
redraped.
Preoperative and postoperative views demonstrate improved lid appearance, more
effective lid-cheek junction blending after removal of the injected fat, orbicularis
muscle flap redraping, and canthopexy. The split view shows the improvement on
the left side.
Injected autologous fat
10 mm
10 mm
10 mm

1050
Part VI  Eyelid Surgery
AESTHETIC GOALS IN THE UPPER LID
Spacing and Definition
Harmony of positioning with the upper lid and brow is of the utmost importance
for patient satisfaction. It is important to produce the desired contours of the eye-
lid crease, the position of the eyelid margin, and even the brow spacing the patient
desires. In practice, the desired result can be highly individualized, and the same fixed
formula of spacing and positioning should not be arbitrarily used in all patients.
This aspect of the proposed surgery should be discussed with the patient in detail
for surgical planning to determine the patient’s preferences and to avoid dissatisfac-
tion when the result does not meet the patient’s aesthetic goals.
After upper lid blepharoplasty with a very high upper lid crease and a very wide
“eye shadow space,” this woman was unhappy because her appearance was too dra-
matic a change from her previous appearance. Her previous eyelid spacing is seen
on the left, before the upper lid blepharoplasty had been performed.
Old photographs of the patient may be helpful in defining goals and the amount of
defined eye shadow space the patient desires. Preoperative planning is even more
important in Asian patients, who may vary in their desire for a “Westernized” look.
It is important to recognize the tendency for the upper crease to migrate upward in
patients with prominent eyes, and this should be pointed out to the patient.
Position of Upper Lid Margin
It is important to make note of the relationship of the upper lid margin to the pupil
of the eye. How much color of the iris can be seen above the pupil? Compensatory
brow arching or severe dermatochalasis may mask preexisting ptosis. True upper lid
ptosis should be pointed out and discussed before surgery.

Prevention of Upper Blepharoplasty Complications
An important functional goal in upper blepharoplasty is that surgery should not
compromise the strength and velocity of upper lid closure. Among patients who have
poor eye moisture or reduced ocular motility, any lagophthalmos, however subtle,
may cause distressing symptoms. Severe lagophthalmos in any patient can cause
damage or disability of the eye as a result of corneal exposure.
Differences Between the Nasal and Temporal
Upper Lid
Lagophthalmos in the nasal half of the upper eyelid is less well tolerated than lagoph-
thalmos in the temporal half of the upper lid, either with symptoms or corneal
changes. Cautious skin removal in the nasal half of the upper lid is advised. In some
patients, skin laxity and unwanted fullness in this area can be improved by brow el-
evation and fat removal alone. Minimizing skin removal in the nasal half of the up-
per lid reduces the chance of symptomatic lagophthalmos.
1051
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
Considerations in the nasal half of the upper lid and the temporal half of the upper
lid are illustrated with regard to problems, pitfalls, and corrective procedures. Stiff-
ness in the outer half of the upper lid is much better tolerated by the eye, so more
complete removal of redundant skin may be carried out in this area. Lateral brow
stability influences the amount of residual folding that may occur in the lateral up-
per lid postoperatively. To avoid annoying residual folds in this area and ensure a
continuous space with the pretarsal area, we recommend stabilizing the lateral brow,
either with a temporal lift or an internal browpexy. It is our practice to include a
transblepharoplasty internal browpexy with almost every upper lid blepharoplasty.
TEMPORAL
NASAL
Maximum skin excision
Minimal skin excision
(must use brow)
• Avoid orbicularis excision
• Maximal nasal fat removal
(no transitional fat)
• Sculpting of ROOF
• Plication of lacrimal gland
• Internal brow support

Techniques of Upper Lid Blepharoplasty
Design of the Upper Blepharoplasty Skin Excision
The amount of skin that is surgically removed in the upper lid is not as important
as the skin that remains postoperatively in the lid. The general placement of skin
markings for excision is shown below.
1052
Part VI  Eyelid Surgery
This illustration shows the recommended excision of skin and underlying orbicu-
laris and septum in the so-called open-sky approach to upper lid blepharoplasty.
This approach emphasizes the principle that the most important consideration in
the upper lid is how much skin is left behind rather than how much is excised.
One should minimize the excision of skin in the nasal half of the eyelid, because, as
previously described, nasal lagophthalmos causes the most severe exposure. Exces-
sive laxity in this area can be addressed with cautious skin excision, but correction
of any brow laxity may reduce the amount of skin excision needed. The open-sky
technique, with removal of skin and the underlying orbicularis and septum, is safer
and gives the surgeon more options at the time of upper blepharoplasty surgery. De-
bulking the subcutaneous tissue produces less skin tightness on closure, and the
added exposure provided allows access to the levator aponeurosis if ptosis surgery is
required. One should avoid creating scarring in any orbicularis or septal layers that
remain. Postoperative upper lid lagophthalmos from middle lamella scarring is most
difficult to correct. The open-sky technique of upper blepharoplasty may require ex-
cision of the orbicularis and septum near the insertion of the levator aponeurosis,
which may in some cases, particularly in patients who are predisposed to ptosis,
weaken the levator aponeurotic insertion and produce postoperative ptosis.
Aponeurotic Safety Stitch
When upper blepharoplasty is performed, even in patients in whom no ptosis is pres-
ent, plication of the upper pretarsal skin edge to the aponeurosis is a safeguard against
levator dehiscence and controls the position of the upper crease. This is easily per-
formed with the open-sky technique.
10 mm
6 mm
5 mm
15 mm
Junction
of thick and
thin skin

This illustration demonstrates the “safety stitch” used in conjunction with the open-
sky technique to ensure levator aponeurosis attachments and to control the position
of the upper lid crease.
1053
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
Surgical images show placement of the safety stitch using 6-0 Vicryl. The stitch is
placed through the skin at the upper edge of the incision and then into the levator
aponeurosis. The suture is tightened, but not enough to cause eyelid gapping.
Brow Treatment
For significant eyebrow laxity, the surgeon should use a formal brow procedure, en-
doscopic forehead lift, or temporal lift for stabilization of the eyebrow/eyelash dis-
tance. In milder cases, the problem can be addressed in the lateral upper eyelid with
transblepharoplasty internal browpexy. Fixation of the subbrow fat pad (retroor-
bicularis fat) to the deep temporal fascia with permanent sutures can reduce or elim-
inate brow sagging and avoid residual lateral folding in many patients.
Pretarsal skin
Levator
aponeurosis

1054
Part VI  Eyelid Surgery
The steps in the internal browpexy are illustrated. On the left, the area to be under-
mined in the preperiosteal plane is shown, and on the right, the exposure of the deep
temporal fascia is shown.
In these images of internal browpexy, the image on the left shows the fixing suture
being placed in the deep temporal fascia. The image on the right shows insertion of
the suture in the retroorbicularis oculi fat at the level of the inferior edge of the brow.
The vector of pull is usually in an upward/outward direction.
This patient is seen after upper lid blepharoplasty with an internal browpexy. On
the left, the temporal half of the upper lid and tail of the brow are shown preoper-
atively. The desired postoperative result is shown on the right. This includes firm
support of the tail of the brow, an upper lid crease, and an eye shadow space that
extends past the canthal angle without residual skin folds.

Prevention of Ptosis
Correction of Coexistent Ptosis
In a patient requesting upper lid blepharoplasty, the usual cause of ptosis is a dehis-
cence of the levator aponeurosis. Aponeurotic repair can easily be performed through
the upper lid blepharoplasty incision if surgical exposure is adequate. The open-sky
approach to upper lid blepharoplasty provides adequate exposure of the levator
muscle and aponeurosis so that repair can be performed in these patients.
Mechanism and Cause of Levator Dehiscence
Levator aponeurotic attachments to the upper lid travel to the anterior surface of
the tarsal plate and to eyelid skin in the crease area. With levator dehiscence, be-
cause of thinning and disinsertion, the aponeurotic portion of the levator pulls away
from its tarsal attachments and with its retraction the upper lid becomes ptotic.
1055
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
This illustration shows the normal levator on the left with its aponeurosis sending
attachments to the anterior surface of the tarsal plate and to the eyelid skin to form
the upper lid crease. With dehiscence of the levator aponeurosis, as seen on the right,
the aponeurotic attachments dehisce, allowing the lid to relax downward and caus-
ing ptosis combined with upward pulling of the skin attachments; this produces a
visibly high upper lid crease (unless there is severe dermatochalasis).
Persistent aponeurotic attachments to the upper eye-
lid skin may cause a characteristically high upper
lid crease, depending on the fullness of the upper
lid. In susceptible individuals, surgical trauma or
the postoperative edema of surgery may cause leva-
tor dehiscence, resulting in postoperative ptosis, as
seen in this patient.
Dehisced levator
Normal levator
Tarsus
Müller’s muscle
Levator muscle
Residual
attachment
to skin

1056
Part VI  Eyelid Surgery
Correction of Ptosis
Ptosis repair can be performed in patients with preexisting ptosis while they are un-
dergoing upper blepharoplasty, or it can be performed to repair ptosis, which may
occur as a complication. The technique for ptosis repair in these patients is anatomic
reattachment of the levator aponeurosis. A single suture is used for the attachment
of the tarsal plate to the musculoaponeurotic junction of the levator. Other anatomic
changes that commonly occur with age must be taken into account for proper con-
touring of the lid. With the use of the single-suture repair (double-armed 6-0 silk),
suture placement must be in a vertical line with the midpupil near the superior edge
of the tarsal plate.
The normal levator attachments and landmarks are illustrated. In most adults, be-
cause of dehiscence of nasal attachments of the lid, there is a lateral shift of the tarsal
plate. To produce the desired contour in the upper lid, the required placement of the
single lifting suture used in acquired ptosis (placed in the tarsus near the superior
edge of the tarsal plate) must be in line with the pupil.
Suture placement
Normal
Lateral tarsal shift
Dehisced
Normal
Tarsus
Levator muscle
Levator
aponeurosis

Suture alignment with the apex of the upper tarsal curve cannot be used because in
patients of this age there is a lateral shift of the tarsus.
1057
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
In cases of bilateral ptosis, the anatomic placement of sutures should be symmetri-
cal. Placement of the suture for ptosis at the junction of the muscular portion of the
levator and its aponeurosis is illustrated.
Placement of the lifting suture in the musculoaponeurotic junction of the levator
muscle is illustrated. After suture placement in the tarsal plate, the suture arms are
brought under the levator aponeurosis; the edge of the dehisced aponeurosis has
been dissected free of Müller’s muscle, and the suture is placed through the levator
at the musculoaponeurotic junction.
Musculoaponeurotic
junction

1058
Part VI  Eyelid Surgery
This patient had bilateral levator dehiscence. She is seen after blepharoplasty and
bilateral aponeurotic repair using the technique described. No secondary surgery for
symmetry was necessary in this patient.
After suture placement and temporary tightening, adjustments should be made to
ensure symmetry (in cases in which the ptosis is bilateral). This can be done under
general anesthesia without patient cooperation. After the suture has been tightened,
the intraoperative gapping of the lid fissure that occurs should be even between the
lids. An additional test—the “spring-back test”—is needed to help achieve symme-
try. When one of the upper lids is pulled closed and quickly released, the velocity of
upward spring should be the same in each eye. If these adjustments are observed, in
most cases there will be postoperative symmetry in the ptosis correction. Patients
with unilateral ptosis may require postoperative adjustments.
Complications in the Upper Lid and Treatment
of Postoperative Lagophthalmos
Poor upper lid closure after blepharoplasty can be attributed to these causes:
 Surgically induced upper lid stiffness
 Patients without stiffness, because of loss of lateral canthal anchoring
 Poor closure mechanics
Intrinsic upper lid stiffness can result from excessive skin removal causing skin short-
age or from internal scarring.

The three possible areas of restriction are shown; these may cause lagophthalmos
in the upper lid after surgery. In the top figure, poor closure resulting from a short-
age of skin is represented, which, if it is not overcome by firm canthal reanchoring,
will require skin replacement. In addition to a skin shortage, patients may have scar-
ring of the middle lamella with adhesions of the orbicularis and septum to the su-
perior orbital rim, as seen in the middle figure. These adhesions must be separated
to restore closure of the upper lid. The most severe situation occurs when the leva-
tor is bound to structures at the superior orbital rim, as seen in the image on the far
right. The levator adhesions can be released, but it is common to produce ptosis post-
operatively in these patients.
Corneal symptoms are more severe, with lagophthalmos occurring in the nasal half
of the upper lid than in the lateral half, as mentioned earlier. The lateral half of the
eye seems to be more forgiving of lagophthalmos because of lateral brow laxity.
Scarring in the internal structures of the upper lid, orbital septum, and fat pads (mid-
dle lamella scarring) produces lagophthalmos, which is more difficult to correct.
Care should be taken to avoid scarring of the middle lamella by inappropriate cautery,
particularly if the tissue is to be left behind in the upper lid. The orbicularis and or-
bital septum are best treated with excision using the open-sky technique as described
earlier; however, one may leave varying amounts of orbicularis to avoid excessive
crease formation, if indicated.
Approach to the Treatment of Upper Lid Lagophthalmos
Surgery in the upper lid directly to correct lagophthalmos after blepharoplasty can
be problematic, because it usually requires skin grafts and can be upsetting to the
patient who is undergoing a cosmetic procedure. Direct surgical intervention is re-
stricted to patients who have vision-threatening problems and in whom all else has
1059
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
Levator
adhesions
Middle
lamella
scarring
Skin
shortage

failed. In patients with poor eyelid closure after blepharoplasty, every attempt should
be made to relieve the problem by first attempting corrective surgery in the lower
lid. It is important to ensure that canthal anchoring is firm, because deficiencies in
that area can significantly contribute to poor eyelid closure mechanics. When faced
with definite upper lid tethering from skin shortage or internal scarring, the surgeon
can reposition the lid upward by the methods described in the previous section to
help reduce the exposure by narrowing the eyelid separation. This approach often
precludes the need for direct surgery on the upper lids. Improvement in eyelid clo-
sure mechanics, preferably by drill-hole fixation, as described earlier, can overcome
some of the resistance of a stiff upper lid and improve upper lid closure. This is par-
ticularly true if lagophthalmos is accompanied by the fish-mouthing effect, a sure
sign of inadequate canthal attachment.
1060
Part VI  Eyelid Surgery
This woman is shown (left) after blepharoplasty with a reasonably normal eye fis-
sure appearance but poor eyelid closure as a result of weakened canthal anchoring.
On the right, the same patient is shown immediately after firm reanchoring of the
lateral canthus with improved eyelid closure. The double drill-hole technique is in-
dicated in such a patient if the eye is prominent.

This patient shows adequate restoration of eyelid closure with lower lid reposition-
ing and canthal anchoring, even in the face of significant upper lid stiffness. She pre-
sented with retraction of the lower lid and lagophthalmos of the upper lids after bleph-
aroplasty and laser resurfacing. Poor closure in the upper lids was caused by a skin
shortage as well as canthal dehiscence, resulting in poor eyelid closure mechanics.
After bilateral canthal anchoring with the use of drill-hole fixation of the canthal
tendons, her situation is much improved. Lower lid repositioning was also performed
with recruitment of skin, with orbicularis vertical reanchoring and spacer implants
of autogenous dermis. No skin grafts were placed in the upper lid. Closure of the
upper lid was restored by firm reanchoring of the lateral canthus and repositioning
of the lower lid only. The upper lid stiffness resulting from the presence of a skin
shortage was overcome by strengthening the eyelid closure mechanics by means of
canthal reanchoring.
Only after restoring lower lid position and improving closure mechanics should one
resort to direct surgery to the upper lid. However, some patients, because of the sever-
ity of upper lid stiffness from a skin shortage or internal scarring, may be improved
by the approaches described but will still have inadequate closure and corneal ex-
posure problems. In these patients, skin grafts to the upper lid are needed.
1061
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery

The proper placement of a full-thickness skin graft in the upper lid is illustrated for
correction of lagophthalmos resulting from skin shortage. In most cases the skin can
be released with an incision just above the lashes, allowing the skin edge to retract
upward to the crease area. The graft can then be placed in the space between the
lashes and the crease to maintain a standard eye shadow space and crease position.
1062
Part VI  Eyelid Surgery
This patient is seen after blepharoplasty (left) with extreme upper and lower lid re-
traction, poor eyelid closure, and corneal damage from exposure. The skin shortage
in the upper eyelids was profound. The position of the lower lids was improved,
with drill-hole canthal anchoring, but exposure problems were not totally elimi-
nated. Upper lid skin grafting is needed. When skin grafts are indicated, they should
be positioned so as not to alter the crease formation of the upper lid or disturb the
aesthetic contours of the upper lid. Graft placement should not span the crease area,
and grafts are best placed between the lashes and the crease or above the crease if a

second graft is needed. After the placement of upper lid skin grafts (right), this pa-
tient was able to achieve more normal eyelid closure. Middle lamella scarring was
also encountered in this patient, and lysis of adhesions from the lid to the superior
orbital rim was required.
In some cases, even after release of the skin between the lashes and the crease, the
upper lid may still show resistance to closure. This is a sign of internal, middle lamella,
or septal scarring, which requires release before the graft is placed. The patient on
p. 1062 is seen after drill-hole canthal anchoring, a reconstructive cheek lift with
autogenous spacers, and full-thickness skin grafts to the pretarsal area of her up-
per lids. She also had internal scar tissue adhesions in the middle lamella that re-
quired release.
Upper Lid Crease: Sulcus Abnormalities
The most common sulcus abnormality that causes distress to the patient is an ex-
cessively high upper lid crease or a hollowed-out appearance in the upper lid.
Overzealous removal of fat from the upper lid in patients who are not used to a deep
crease or do not want a high crease is a common cause of this problem and can pro-
duce an unwanted deep-set look. Even a standard amount of fat removal, if the eye
is very prominent, can produce an unwanted high crease. Excessive removal of fat
in the nasal third of the upper lid may produce a peaking of the crease in that area
producing an “A-frame” deformity. Another uncommon but definitely occurring
complication of aggressive fat removal in this area is injury to the superior oblique
tendon, either by direct trauma or cauterization of bleeding in that area.
Restoration of fullness in these areas is difficult. The most fortuitous situation en-
countered is when there is still available preaponeurotic fat present in the upper lid
that can be brought out and sutured forward to the crease area in the upper lid. An
open incision through the orbital septum is necessary. This approach may not be
available in many patients.
Attachment of dermis fat strips to the arcus marginalis for augmentation in this area
has been helpful in some patients, but the possibility of tethering upper lid move-
ment always exists if secondary fibrosis occurs and affects the levator muscle. Di-
rect grafts that may adhere to the levator are ill advised.
An undesirable high upper lid crease can be seen in some patients with early dehis-
cence of the levator aponeurosis in which retraction of the aponeurotic skin crease
attachments precedes the actual ptosis. In these patients, conservative repair of the
levator aponeurosis may restore upper lid crease position and ward off an incipient
true ptosis.
1063
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery

Clinical Caveats
 Patients who have suspicious symptomatology or unusual findings on an eye ex-
amination, and those with a history of eye problems, should be evaluated by means
of slit-lamp examination, tear tests, or consultation with an ophthalmologist.
 The anatomic classification of the orbicularis into orbital, preseptal, and pretarsal
orbicularis is convenient for surgical labeling, but a functional classification of the
orbicularis into an inner canthal orbicularis and an extracanthal orbicularis should
be adopted for better understanding of eyelid function.
 Loss of eyelid innervation from the buccal branch of the facial nerve to the inner
canthal area will cause profound changes in eyelid function, with reduction or ab-
sence of eyelid blinking, poor lower lid tone and position, and a weakening of the
lacrimal pump mechanism causing tearing.
 Firm anchoring laterally is needed for counterpull against canthal contracture
to convert the vector of the blink movement into a vertical one for proper eyelid
closure.
 The skeletonization of the orbital rim area associated with age is a major contrib-
utor to the aging appearance in the midface area. Surgery that fails to address the
eyelid and cheek area as an aesthetic unit falls short of producing a true reversal
of aging changes in this area.
 In persons with prominent eyes, a downsliding of the lower lid, scleral show, and
enlargement of the lateral scleral triangle may occur. Proper canthal anchoring re-
stores a more youthful look to the eye fissure by changing the shape of the fissure.
 It has been shown mathematically that protrusion of the eye against the eyelid af-
fects the shape of the eye fissure.
 In cases of lower lid laxity, reinforcement with shortening of the lower lid is nec-
essary.
 In patients who have laxity of the tarsoligamentous sling, tightening only the or-
bicularis muscle will not correct internal lower lid laxity and can produce out-
ward buckling of the lid because of the redundancy in the posterior lamella. Tight-
ening of the tarsoligamentous sling itself must be performed.
 The position of the lower lid changes in response to traction at the lateral canthus.
 If skin shortage is a significant factor in lower lid retraction, vertical canthal anchor-
ing of the inferior arc of the orbicularis muscle will recruit skin upward into the
lower lid and will, in most cases, correct retraction without the use of a skin graft.
 Spacer inserts in the lower lid (AlloDerm, ear cartilage, autogenous dermis) lengthen
the posterior lamella and elevate the lower lid margin upward in patients with
significant eye prominence.
1064
Part VI  Eyelid Surgery

 Harmony of positioning with the upper lid and brow is of the utmost importance
in terms of patient satisfaction.
 It is essential to note the relationship of the upper lid margin to the pupil of the eye.
 An important functional goal in upper blepharoplasty is that surgery should not
compromise the strength and velocity of upper lid closure.
 Lagophthalmos in the nasal half of the upper eyelid is not as well tolerated as
lagophthalmos in the temporal half of the upper lid, either with symptoms or
corneal changes.
 When upper blepharoplasty is performed, even in patients in whom no ptosis is
present, plication of the upper pretarsal skin edge to the aponeurosis is a safe-
guard against levator dehiscence and controls the position of the upper crease.
This is easily performed with the open-sky technique.
 Only after restoring lower lid position and improving closure mechanics should
one resort to direct surgery on the upper lid.
 In some cases, even after the release of the skin between the lashes and the crease,
the upper lid may still show resistance to closure. This is a sign of internal, mid-
dle lamella, or septal scarring, which requires release before the graft is placed.
1065
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
Annotated Bibliography
Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous lower blepharoplasty with rou-
tine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg
121:241-250, 2008.
This study reviewed the outcome of a surgeon’s 10-year experience with primary lower
transcutaneous blepharoplasty and lateral canthal support consisting of canthopexy,
canthoplasty, and orbicularis suspension. The authors conclude that lateral canthal sup-
port should be considered a routine component of lower transcutaneous blepharoplasty
to obtain the desired aesthetic result and maintain the natural appearance of the eyelid
shape, and that the associated complication rate is acceptable.
Malbouisson JM, Baccega A, Cruz AA. The geometrical basis of eyelid contour. Ophthal
Plast Reconstr Surg 16:427-431, 2000.
The authors derived a two-dimensional, frontal-view model of eyelid contour. After per-
forming an observational study of palpebral fissure images from 110 normal subjects,
they concluded that the parabolic shape of the upper ciliated contour seen in two-
dimensional images can be justified geometrically in a simple way, allowing a precise
quantification of its shape. The same was not true for the lower eyelid. The parabolic
shape of the upper eyelid can be demonstrated, using the Taylor series, to be a close ap-
proximation of the arc of a circle.

McCord CD. The correction of lower lid malposition following lower blepharoplasty. Plast
Reconstr Surg 103:1036-1039, 1999.
Lower eyelid malposition is the most common complication after lower eyelid blepharo-
plasty. When this problem occurs, it is imperative to correct the malposition by the most
efficient method. The author presents methods for correcting minor as well as severe
cases.
McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring. Plast Reconstr Surg 112:222-
237, 2003.
Any surgeon performing cosmetic or reconstructive surgery procedures on the lower lid
or midface through the lower lid should be comfortable with canthal anchoring proce-
dures. This article discusses the principles involved in canthal support for patients un-
dergoing cosmetic and reconstructive surgery, variations in surgical techniques required
to perform canthal anchoring in a variety of patients, the significance and techniques of
canthal anchoring (canthoplasty and canthopexy) as they relate to cosmetic and recon-
structive lower lid surgery, and the effect of canthal anchoring on the function of the up-
per and lower lids and eyelid fissure shape.
Pacella SJ, Codner MA. Minor complications after blepharoplasty: dry eyes, chemosis, gran-
ulomas, ptosis, and scleral show. Plast Reconstr Surg 125:709-718, 2010.
The authors discuss several of the most common minor complications, including
hematoma, dry-eye syndrome, infections, atypical lesions, lid malposition, and scarring.
In addition, preoperative assessment of risk factors, treatment, and management of these
minor complications are presented.
Putterman AM. Regarding comprehensive management of chemosis following cosmetic
lower blepharoplasty. Plast Reconstr Surg 124:313-314, 2009.
The author reports patient finger compression as an effective treatment method for con-
junctival chemosis.
Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis follow-
ing cosmetic lower blepharoplasty. Plast Reconstr Surg 122:579-586, 2008.
This article focuses on chemosis associated with cosmetic lower blepharoplasty. The
cause is multifactorial and includes exposure, periorbital edema, and postoperative lym-
phatic dysfunction. The incidence of chemosis was 11.5 percent of the 312 primary bi-
lateral lower transcutaneous blepharoplasties reviewed. Chemosis presented intraoper-
atively or up to 1 week postoperatively; the median duration was 4 weeks, with a range
from 1 to 12 weeks. Associated etiologic factors included conjunctival exposure, peri-
orbital and facial edema, and lymphatic dysfunction. Successful treatment existed along
a continuum from liberal lubrication to ophthalmic steroid preparations and ocular de-
congestants to eye-patching to minor surgical procedures such as drainage conjunctiv-
otomy and temporary tarsorrhaphy. In all cases, chemosis ultimately resolved.
1066
Part VI  Eyelid Surgery

Suggested Readings
Day C. Anatomic dissections as Paces Plastic Surgery Fellow 1999 (unpublished data).
Difrancesco L, Codner MA, McCord CD, et al. EMG and video studies of patients before
and after subciliary blepharoplasty incisions. Presented at the Thirty-sixth Annual Meet-
ing of the American Society of Aesthetic Plastic Surgery, Boston, April 2003.
Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial
aging using the transblepharoplasty subperiosteal cheeklift. Aesthetic Surg Q 16:51,
1996.
Hester TR, Codner MA, McCord CD, et al. Evolution of technique of the direct transbleph-
aroplasty approach for the correction of lower lid and midfacial aging: maximizing re-
sults and minimizing complications in a 5-year experience. Plast Reconstr Surg 105:393-
406, 2000.
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, 2002.
Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg 125:1007-1017,
2010.
Lowery JC, Bartley GB, Litchy WJ. Electromyographic studies of the reconstructed lower
eyelid after a modified Hughes procedure. Am J Ophthalmol 119:225-228, 1995.
McCord CD. The correction of lower lid malposition following lower blepharoplasty. Plast
Reconstr Surg 103:1036-1039, 1999.
McCord CD. Lower lid reconstruction. In McCord CD, ed. Eyelid Surgery. Philadelphia:
Lippincott-Raven, 1995.
McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Recon-
str Surg 102:2471-2479, 1998.
McCord CD, Ellis DS. The correction of lower lid malposition following blepharoplasty.
Plast Reconstr Surg 92:1068-1072, 1993.
McCord CD, Shore J, Coles W, et al. Treatment of essential blepharospasm. I. Comparison of
facial neurectomy vs muscle stripping. Arch Ophthalmol 120:250-268, 1984.
Shore JW. Changes in lower eyelid resting position, movement, and tone with age. Am
J Ophthalmol 99:415-423, 1985.
Weber PJ, Wulc AE, Moody BR, et al. Electrosurgical modification of orbicularis oculi hy-
pertrophy. Ophthal Plast Reconstr Surg 16:407-416, 2000.
1067
Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery

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Credits
C-1
Figure, p. 52: WHO Surgical Safety Checklist, available at
© World Health
Organization 2010.
Figure, p. 61: From the Malignant Hyperthermia Association of the United States (MHAUS).
Sherburne, NY: The Association, 2008. Available at

Figure, pp. 64-65: Reproduced with the kind permission of The Association of Anaesthetists of
Great Britain and Ireland.
Box, p. 62: Modified from the Malignant Hyperthermia Association of the United States
(MHAUS). Sherburne, NY: The Association, 2010. Available at

20C3-4537-948C098DAB0777E3.cfm.
Figures, pp. 90, 93 (top and bottom), 97: From Odunze M, Rosenberg DS, Few JW. Periorbital
aging and ethnic considerations: a focus on the lateral canthal complex. Plast Reconstr Surg
121:1002-1008, 2008.
Table, p. 271: From Fitzpatrick TB. The validity and practicality of sun-reactive skin types I
through VI. Arch Dermatol 124:869, 1988. Copyright American Medical Association, 1988. All
rights reserved.
Table, p. 272: From Baumann L. The Baumann Skin Typing System. In Cosmetic Dermatology,
Principles and Practice. 2nd ed., 2009. copyright © The McGraw-Hill Companies, Inc.
Figures, pp. 306, 312 (bottom): From Matarasso A, Shafer D. Botulinum neurotoxin type
A-ABO (Dysport): clinical indications and practice guide. Aesthet Surg J 29:S72-S79, 2009. With
permission from Sage.
Figures, pp. 514-519, 521-524, 527-529, 530 (top): From Bensimon RH. Croton oil peels. Aes-
thet Surg J 28:33-45, 2008. With permission from Sage.
Box, p. 564: Modified from Goldman MP. Sclerotherapy treatment for varicose and telangiectatic
leg veins. In Coleman WP, Hanke CW, Alt TH, et al, eds. Cosmetic Surgery of the Skin. Philadel-
phia: BC Dekker, 1991, pp 197-211.
Figures, page 566: These figures were published in Treatment of Leg Veins, Second Edition, Eds
Alam M, Silapunt S, Presentations of venous disease, Copyright Elsevier, 2010.
Box, p. 570: Data from Goldman MP. Sclerotherapy treatment for varicose and telangiectatic leg
veins. In Coleman WP, Hanke CW, Alt TH, et al, eds. Cosmetic Surgery of the Skin. Philadelphia:
BC Dekker, 1991, pp 197-211; and Duffy DM. Small vessel sclerotherapy: an overview. Adv Der-
matol 3:221-242, 1988.
Table, p. 573: Modified from Weiss RA, Dover JS. Leg vein management: sclerotherapy, ambula-
tory phlebectomy, and laser surgery. In Kaminer MS, Dover JS, Arndt KA, eds. Atlas of Cosmetic
Surgery. Philadelphia: WB Saunders, 2002, pp 309-328.

Figures, pp. 608, 609 (top): From Hair transplant surgery, by Norwood OT, Shiell R. Copyright
1984 by Charles C. Thomas, Publisher. Reproduced with permission of Charles C. Thomas, Pub-
lisher, via Copyright Clearance Center.
Figure, p. 609 (bottom): From Ludwig E. Classification of the types of androgenetic alopecia
(common baldness) occurring in the female sex. Br J Dermatol 97:247-254, 1977.
Figures, pp. 656 (top), 675, 676 (top): Modified from Uebel CO. Hair Restoration: Micrografts and
Flaps. São Paulo, Brazil: OESP Grafica S/A, 2001.
Figure, p. 757: Modified from Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the lig-
amentous attachments in the temple and periorbital regions. Plast Reconstr Surg 105:1475-1490,
2000.
Figure, p. 884: Modified from Trussler AP, Rohrich RJ. MOC-PSSM CME article: blepharoplasty.
Plast Reconstr Surg 121(1 Suppl):S1-S10, 2008.
Figures, pp. 970, 973, 979, 983, 985 (top), 987 (top and center), 989 (top), 991 (top and bottom
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1412, 2005.
C-2
Credits

MIDFACIAL
REJUVENATION
PART VII

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