The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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surgeon, I set up with assistant holding the scope and camera on
the patient’s left and me on the right (Fig. 29.28).
The first step after introducing the endoscope is to identify
the supraorbital neurovascular bundles (Fig. 29.29). Of note, 1 in
10 patients will have this neurovascular bundle exiting the skull
from a true foramen rather than a notch (Fig. 29.30).
Once the neurovascular bundles have been identified and
preserved, attention is turned to the corrugator and procerus
musculature. I separate these fibers bluntly, though in some cases
sharp excision or laser lysis is warranted (Fig. 29.31).
A key component of this procedure is the complete release of the
arcus marginalis, where the periosteum of the frontal bone attaches
just inside the orbital rim. Externally, this lies below the eyebrow at
the orbital rim. For the brow to be elevated, it is imperative that this
release take place so that the periosteum can be advanced superi-
orly. Upon release of the arcus, the surgeon will immediately see
retro–orbicularis oculi fat (ROOF) exposed (Fig. 29.32; Fig. 29.33).
Fig. 29.26 Elevation progresses blindly to a point one fingerbreath
above the orbital rim.
Fig. 29.28 Setup for the author as a left-handed surgeon with
assistant holding the scope and camera on patient’s left and the author
on the right.
Fig. 29.27 The 30° endoscope is then introduced into the adjacent
portal and the elevation is visualized.
Fig. 29.29 Identification of supraorbital neurovascular bundles.
Fig. 29.30 Supraorbital neurovascular bundles exiting the skull from a
notch (9 in 10 patients) and from a true foramen (1 in 10 patients).

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29.7.2 Temporal Incisions
Incision is made beveled with the hair follicles (Fig. 29.34; Fig.
29.35). Sharp dissection is carried down through the temporopa-
rietal fascia to, but not through, the fixed temporalis fascia (Fig.
29.36).
Initial elevation is carefully made with the back of the knife
handle (Fig. 29.37). Utilizing a 0ƒ scope, the temporal pocket is
joined to the central pocket from lateral to medial across the
temporal line (Fig. 29.38; Fig. 29.39).
An endoscopic view of the elevator coming from lateral to
medial is shown in Fig. 29.40. Elevation of the temporal pocket
then proceeds inferiorly (Fig. 29.41).
In a standard brow lift, the temporal elevation ends at the level
of the sentinel (medial zygomaticotemporal) vein (Fig. 29.42).
Fig. 29.31 Once the neurovascular bundles have been identified and
preserved, attention is turned to the corrugator and procerus muscu-
lature. The author separates these fibers bluntly, though in some cases
sharp excision or laser lysis is warranted.
Fig. 29.33 Artist’s rendition of arcus marginalis release.
Fig. 29.34 Artist’s rendition of temporal incisions.
Fig. 29.32 (a) Arcus marginalis, where frontal periosteum attaches just inside the orbital rim, must be completely released. (b) Release of the arcus
marginalis reveals retro–orbicularis oculi fat (ROOF).
a
b

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Fig. 29.39 Artist’s rendition of elevation of temporal pocket across
temporal line.
Fig. 29.35 Temporal incision is made beveled with the hair follicles.
Fig. 29.37 Initial elevation is carefully made with the back of the knife
handle.
Fig. 29.36 Sharp dissection is carried down through the temporopari-
etal fascia to, but not through, the fixed temporalis fascia.
Fig. 29.38 Utilizing a 0° scope, the temporal pocket is joined to the
central pocket from lateral to medial across the temporal line.
Fig. 29.40 Endoscopic view of elevator coming from lateral to medial.

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A key component of the elevation is release of the conjoined
tendon at the inferiormost aspect of the central and temporal
pockets (Fig. 29.43).
29.7.3 Temporal Fixation
The temporoparietal fascia is suspended along the planned vector
to the temporalis fascia using 3–0 PDS (Fig. 29.44; Fig. 29.45).
29.7.4 Central Fixation
My technique utilizes two Endotine Forehead fixation devices
(MicroAire Surgical Instruments, Charlottesville, VA; Fig. 29.46;
Fig. 29.41 After the temporal pocket is joined to the central pocket,
elevation of the temporal pocket then proceeds inferiorly.
Fig. 29.43 A key component of the elevation is release of the conjoined
tendon at the inferiormost aspect of the central and temporal pockets.
Fig. 29.42 In a standard brow lift, the temporal elevation ends at the
level of the sentinel (medial zygomaticotemporal) vein.
Fig. 29.44 Artist’s rendition of the temporal suspension suture. The temporoparietal fascia is suspended along the planned vector to the temporalis
fascia using 3–0 polydioxanone suture (PDS).
X’
Vector
Incision
3-0 PDS suture
Incision
Skin
Temporalis muscle
Temporoparietal fascia
(superficial layer)
Deep temporal fascia
(superficial layer)
Bone
X
Skin and
temporoparietal
fascia lifted

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Fig. 29.45 (a–e) Temporal suspension suture. The temporoparietal fascia is suspended along the planned vector to the temporalis fascia using 3–0
polydioxanone suture (PDS).
a
c
b
d
e

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Fig. 29.47). The first step in this technique involves hand drilling
of the outer cortex of the frontal bone at the desired position
(Fig. 29.48; Fig. 29.49). The drill hole is irrigated to remove bone
shavings (Fig. 29.50; Fig. 29.51). The Endotine Forehead is then
placed (Fig. 29.52; Fig. 29.53) and snapped into position using
moderate force (Fig. 29.54). At this point the device can be
Fig. 29.46 Artist’s rendition of Endotine fixation.
Fig. 29.48 Hand drilling of outer cortex.
Fig. 29.49 Hand drilling of outer cortex, close-up view.
Fig. 29.50 Irrigation of drill hole to remove bone shavings.
Fig. 29.51 Irrigation of drill hole to remove bone shavings, close-up view.
Fig. 29.47 Endotine Forehead fixation device.

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rotated to the desired vector of pull before removing the driver
(Fig. 29.55). The mobilized forehead flap is then pulled upward
to affect the desired brow elevation (Fig. 29.56) and then pressed
down on the device prongs to hold it in place, producing a palpa-
ble and audible ´crackleµ (Fig. 29.57). The scalp incision is then
closed with staples (Fig. 29.58).
29.8 Ancillary Procedures
29.8.1 Eyelid
Ptosis of the brow/eyelid complex is one of the earliest signs of
aging. Patients often present saying that people close to them are
constantly asking whether they are tired or don’t feel well. :hen
we meet someone, the first thing we see is the person’s eyes. If
these are ptotic, it can make the person look tired, sad, or even
angry. In patients with deep-set eyes, endoscopic brow lift is some-
times the only procedure needed for rejuvenation of the brow/lid
complex. More often than not, however, the brow lift is performed
Fig. 29.52 Endotine Forehead fixation device held in insertion tool
ready for placement.
Fig. 29.54 Moderate force applied to snap Endotine Forehead device
in place.
Fig. 29.53 Placement of Endotine Forehead fixation device through
incision.
Fig. 29.56 Forehead scalp is pulled up to achieve desired brow elevation.
Fig. 29.55 Endotine Forehead device in place.

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in conjunction with an upper-lid blepharoplasty for complete
rejuvenation. In such a case, it is imperative that the brow lift be
performed first to set the correct position before the upper bleph-
aroplasty is undertaken. Otherwise the brow is pulled down with
removal of upper lid skin, causing a foreshortening of the natural
space between the brow position and the upper lid crease.
29.8.2 Myomodulators
Myomodulators such as botulinum toxin are often used in the brow
and forehead region. Early in the development of the endoscopic
brow procedure, it was postulated that the depressor muscles
should be treated before the brow lift to avoid their downward pull
on the brow postoperatively while healing was occurring. This had
some validity in the earlier techniques, which were performed in
the subgaleal plane. In the more modern technique, however, the
elevation is in the subperiosteal plane and the depressor muscles
have been released, allowing in essence a bipedicled subperiosteal
flap that will readhere in an elevated and supported position to
the underlying bone in approximately 12 days.
29.9 Postoperative Care
After the procedure is completed, I place a head wrap consisting of 4
in. ð 4 in. dressings, .erlex (Cardinal Health, Dublin, OH), and .ling
conforming bandage (-ohnson -ohnson, 1ew Brunswick, 1-) to
keep pressure on the elevated forehead flap to prevent seroma
or hematoma formation. This will typically stay on for 24 hours.
:e have the patient avoid heavy lifting, straining, or bending and
sleep with head elevated at 30ƒ. At approximately 1 week postop,
patients will return for staple removal. At this point patients may
have their hair washed, but it is critical that they not run a brush or
comb through their hair, as doing so may disrupt the suspension
to the Endotine Forehead device. Based on our laboratory studies,
the periosteal readhesion of the forehead approaches preopera-
tive values at 12 days. Thus, posterior traction on the scalp must
be avoided throughout this period. :e place our patients on the
SinEcch regime (Alpine Pharmaceutical, San Rafael, CA) pre- and
postop to minimize bruising and swelling. They are also told to
avoid aspirin, ibuprofen, vitamin E, and other platelet inhibitors for
2 weeks before and after surgery. Some numbness and tightness
feelings are normal postoperatively and will resolve with time.
Rarely there will be some temporary alopecia at the incision sites,
though this has always resolved in my experience. At 1 month
postop, when patients return for follow-up, most of the swelling is
resolved, and they are typically looking good and happy with their
results. At this point they may have their hair colored, which is
the most common question. I then see them back at 1 year postop,
though they may return at any time with questions or concerns.
29.10 Results/Outcomes
Results with this procedure are quite positive, with 1-year
follow-ups showing excellent maintenance of brow position
and few postoperative issues. A couple of instances early on of
frontal branch neuropraxia both resolved completely in a few
weeks. Two cases in which the Endotine device (made of poly-
L-lactic acid) caused a cyst formation as it absorbed required a
local procedure for removal. My experience with patient overall
satisfaction with the procedure is excellent.
29.10.1 Brow Lift Alone
Fig. 29.59 shows pre- and postop views of a patient with brow
lift alone. 1ote the ´unfurlingµ of the brow to a more natural and
classical position above the orbital rim.
Fig. 29.60 shows the result of a brow lift alone in a patient with
brow ptosis and deep-set eyes.
29.10.2 Brow Lift and Upper
Blepharoplasty
Fig. 29.61 shows a patient who received a combination brow lift
and upper blepharoplasty.
Fig. 29.57 Pressure is applied directly over Endotine Forehead device
prongs, and a palpable and audible “crackle” occurs.
Fig. 29.58 Staple skin closure.

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29.11 Concluding Thoughts
The endoscopically assisted brow lift is one tool in the arma-
mentarium of the facial plastic surgeon. In measurement studies
the actual lift averages 0.5 cm. This procedure is really more an
unfurling and support of the ptotic brow back to a natural posi-
tion above the orbital rim. The advantages of this approach are
minimal incisions, though the wound is the same as with open
techniques. One of the bigger advantages is decreased incidence of
nerve injury and alopecia due to long incisions and tissue removal.
Long-term results have proven to be excellent and comparable to
more traditional open approaches. It is not, however, the correct
procedure for all patients. Those with higher hairlines are often
better served with a trichophytic approach, which can also be
utilized to lower the frontal hairline. Though the endoscopic
technique will raise the hairline in relation to the skull, it does not
raise it in relation to the brows, unlike the older coronal technique.
Clinical Caveats
• Proper patient selection is key to any rejuvenation procedure.
• A thorough understanding of the surgical anatomy is vital to
achieving the best results.
• During the subperiosteal elevation the periosteum must be
kept intact throughout in order for it to be elevated as essen-
tially a bipedicled flap and for secure suspension superiorly.
• Inferiorly below the level of the brow at the arcus marginalis
the periosteum must be completely released for a full eleva-
tion to occur.
• I do not believe that its possible to overcorrect at the lateral
temporal suspension; however, it is possible to overcorrect
the central suspension.
• If combining an endoscopic brow lift and an upper blepha-
roplasty, I believe that it is imperative that the brow lift be
performed first before the upper eyelid can be properly
marked and the blepharoplasty performed.
Fig. 29.59 (a) Frontal and (b) lateral before (left) and after (right) views of results with brow lift alone.
a
b
Fig. 29.60 (a) Pre- and (b) postoperative views for brow lift alone in a
patient with brow ptosis and deep-set eyes.
a
b
Fig. 29.61 (a) Pre- and (b) postoperative views of a patient who
received a combination brow lift and upper blepharoplasty.
a
b

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Suggested Reading
>1@ Brodner DC, Downs -C, Graham HD III. Periosteal readhesion after brow-lift in
1ew =ealand white rabbits. Arch Facial Plast Surg 2002;4(4):248–251
>2@ Core GB, Visconez LO, Graham HD III. Endoscopic browlift. Clin Plast Surg
1995;22(4):619–631
>3@ Duchenne de Boulogne G-B. The Mechanism of Human Facial Expression.
Cuthbertson RA, ed. Cambridge, U.: Cambridge University Press; 1990
>4@ Graham HD, Core GB. Endoscopic forehead lifting using fixation sutures. Oper
Tech Otolaryngol—Head Neck Surg 1995;6(4):245–252
>5@ Graham HD, Core GB. Endoscopic forehead lifting using fixation sutures. In:
Keller GS, ed. Endoscopic Facial Plastic Surgery. St. Louis, MO: Mosby Publishers;
1997:82–96
>6@ Graham HD. (Guest editor on endoscopic surgery.) Facial Plast Surg Clin North
Am 1997;5:2
>7@ Graham HD, Freeman MS. Endoscopic surgery of the forehead and midface.
Facial Plast Surg Clin North Am 1997:5:113–132
>8@ Graham HD. Methods of soft tissue fixation in endoscopic surgery. Facial Plast
Surg Clin North Am 1997;5:145–154
>9@ Graham HD, 4uatela V, Sabini P. Rejuvenation of brow and midface. In: Papel ID,
Frodel -L, Holt GR, et al, eds. Facial Plastic and Reconstructive Surgery, 2nd ed.
1ew >10@ Graham HD, .houry EP. Preoperative analysis, diagnosis, and evaluation of the
forehead and brow. Facial Plast Surg Clin North Am 2003;11(3):319–326
>11@ .eller GS, Graham HD, Freeman GS, eds. Endoscopic Facial Plastic Surgery. St.
Louis, MO: Mosby Publishers; 1997.
>12@ .im -C, Crawford Downs -, Azuola ME, Graham HD III. Time scale for periosteal
readhesion after brow lift. Laryngoscope 2004;114(1):50–55
>13@ Larrabee :F, Makielski .H. Surgical Anatomy of the Face. 1ew Press Ltd; 1993
>14@ Pearlman S-, Graham HD. Forehead rejuvenation in head and neck surgery. In:
DeSouza C, ed. Head & Neck Surgery. St. Louis, MO: -aypee Brothers Medical
Publishers; 2009:451

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30 Other Approaches to Brow Lift
Foad Nahai
Abstract
Beyond endoscopic and temporal brow lifts, the direct brow lift,
coronal lifts, internal brow pexy, and toxins offer other options
for brow repositioning. These, their indications, operative details,
and alternate procedure are all described in this chapter.
Keywords
Coronal brow lift, direct brow lift, brow pexy, neurotoxins
30.1 Introduction
A variety of options are available for rejuvenation/repositioning
of the brow and forehead, ranging from the open coronal fore-
head lift to neurotoxins and including the following:
• Coronal brow lift
• Endoscopic forehead lift
• Lateral–temporal brow lift
• Transpalpebral excision of corrugator and procerus muscles
• Lateral–temporal brow lift combined with transpalpebral
excision of corrugator and procerus muscles
• Direct brow lift
• Transpalpebral brow pexy
• Injection of neurotoxins
Successful rejuvenation of the brow and forehead includes
repositioning of the hair-bearing brow, improvement of vertical
glabellar and horizontal forehead lines, reversal of the brow
descent, and conversion of a tired or angry expression into a
rested and contented look.
As surgeons we look for safe and efficacious procedures that
render lasting results, whereas our patients look for an effective
procedure with minimal scarring and a short recovery time.
The coronal lift remains the benchmark against which the
results, morbidity, and longevity of the other procedures can
be compared. 1ot everyone undergoing facial rejuvenation is
a candidate for or will consent to a coronal brow lift. Therefore
alternatives must be sought to provide the desired result without
the coronal incision.
1ot all the alternatives will match the results of the coronal
brow lift; however, they are all far less invasive. Each alternative
has its own benefits and limitations. Careful patient evaluation
facilitates matching the patient to the best option.
30.2 Coronal Brow Lift
Despite the popularity of the endoscopic forehead lift, the coro-
nal brow lift is still an excellent option. Many surgeons consider
it the method of choice for all patients; some surgeons limit the
coronal lift to patients who are not candidates for an endoscopic
approach.
This approach affords excellent exposure, facilitating release
of periorbital septa and adhesions, muscle excision, and brow
mobilization. Through scalp excision, the desired preplanned
brow elevation and brow shaping can be achieved.
30.2.1 Indications and Contraindications
The coronal brow lift may be applied universally to anyone who
is a candidate for forehead rejuvenation. It is my opinion that the
best candidates are those who are not suitable for the endoscopic
approach; these include patients with high foreheads, significant
frontal bone convexity, a high or receding hairline, extremely
thick skin or deep lines, and significant brow ptosis with excess
skin over the lateral brow and glabella. Patients who would have
similar results with less invasive procedures would not be candi-
dates for the coronal approach.
30.2.2 Preoperative Planning
Markings
As with other brow lift procedures, the coronal brow lift is rarely
performed in isolation. It is typically combined with other peri-
orbital procedures or full facial rejuvenation. This is a full, open
procedure; therefore, preoperative markings are not as critical as
the markings for the endoscopic approach. However, it is useful
to mark the sentinel vein, the temporal crest, and the course of
the supraorbital and supratrochlear nerves.
Incisions
The incision will vary, depending on the patient’s hairline and
the desired results. There are three options for planning the
incision: (1) a standard coronal incision, (2) a modified coronal
incision, and (3) an anterior hairline incision (Fig. 30.1). The
standard coronal incision is placed 6 to 8 cm behind the frontal
hairline. It is easily concealed within the hair in patients with
normal hair thickness. The modified coronal incision is curved
anteriorly in the frontal area. This is best for individuals who
have a normal temporal hairline but a very high frontal hair-
line. By modifying the incision and bringing it to the hairline
in the frontal area, the height of the forehead may be reduced.
The frontal portion of the incision may be visible. The anterior
hairline incision is best reserved for an individual with a high
forehead and a receding hairline in both the temporal and fron-
tal areas. In such individuals this incision allows reduction in
the forehead height and temporal hairline. This entire scar may
be visible, and most surgeons and patients prefer to avoid this
incision. Any or all of these incisions, particularly the anterior
hairline incision, may be made in a zigzag fashion to break up
the resultant scar.

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Vectors of fixation are also marked on the forehead; these will
include a line projected onto the head from the most convex por-
tion of the hair-bearing brow. These vectors are a guide to scalp
excision and brow positioning (Fig. 30.2).
30.2.3 Operative Technique
Although the procedure can be performed with either a local or a
general anesthetic, our preference is general anesthesia, because
other procedures are usually performed in combination. :ith
the patient lying supine on the operating table, with the head
slightly elevated to decrease venous engorgement, the hair is
washed with soap and braided, and the proposed area of scalp
excision may be shaved. The entire area is infiltrated with 0.5
lidocaine and epinephrine 1:200,000. The field is then prepared
with povidone–iodine (Betadine) and draped.
After allowing sufficient time (8–10 minutes) for the epinephrine
to take effect, the surgeon makes the incision through the scalp,
down to the deep temporal fascia in the temporal area, and more
centrally down to the periosteum. The knife blade is beveled so that
it runs parallel with the hair roots to preserve as many hair follicles as
possible. This is more critical with the modified and anterior hairline
incisions. The anterior hairline incision is not made anterior to the
hairline, as its name indicates, but must be made 1 or 2 mm behind
the hairline so that some hair follicles are left within the cut edges.
Once the incision is made, the elevation of the forehead flap
proceeds very rapidly in a bloodless field between the temporo-
parietal fascia and deep temporal fascia laterally and the subperi-
osteal plane centrally. The flap is elevated to the orbital rims. This
elevation will release the periorbital septa and allow easy access
to the glabellar musculature (Fig. 30.3).
The anterior hairline approach will allow dissection in the
subcutaneous plane. This subcutaneous plane is directly over the
frontalis muscle. This allows significant reduction of transverse
forehead lines through the release of the fibrous septa that run
between the muscle and the overlying skin. An added advantage
of this approach is better preservation of the scalp’s sensory
innervation (Fig. 30.4).
Fig. 30.1 Three possible incisions for a coronal approach depending
on the patient’s hairline and goals: standard bicoronal, modified, and
anterior hairline incision.
Fig. 30.4 The anterior hairline approach is performed in the subcuta-
neous plane above the frontalis muscle, allowing release of the fibrous
septa, and preserves the scalp’s sensory innervation.
Fig. 30.3 Once the incision is made, the flap is raised in the bloodless
plane between the galea/aponeurotic system and periosteum.
Fig. 30.2 Vectors for fixation should be determined and marked to
help guide scalp excision and brow positioning.

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Once the flap is elevated, the corrugator, procerus, and
depressor supercilii muscles are easily identified. These muscles
are divided, avulsed, or cauterized, according to the surgeon’s
preference (Fig. 30.5). To weaken the frontalis muscle, the lowest
portions of the muscle are incised. The surgeon notes the course
of the supratrochlear and supraorbital nerves and divides the
frontalis muscle, carefully avoiding the nerves. A variety of
techniques have been used to weaken the frontalis in this area,
including horizontal division, crisscross division, and even a 1-cm
strip excision. The scalp flap is then retracted superiorly and the
degree of elevation is adjusted.
1ext the scalp is incised at key sites, and fixation sutures or
staples are placed. Usually the scalp is fixed at three sites: one
centrally and one on each side, according to the preoperative
vectors (Fig. 30.6).
The intervening scalp is excised and closed in two layers with
sutures and staples (Fig. 30.7).
30.2.4 Postoperative Care
The patient’s head is elevated, ice packs are placed over the eyes,
and measures are taken to prevent an elevation in blood pressure
and nausea and vomiting. Most patients undergoing a brow
lift with additional procedures are kept overnight. Staples and
sutures are removed 5 to 7 days postoperatively, and physical
activities are restricted for 2 to 3 weeks.
30.2.5 Outcomes
This procedure has proved effective, with acceptable morbidity.
The results have stood the test of time. Complications include
alopecia, dysesthesias, and sensory loss in the scalp.
30.3 Direct Brow Lift
A direct brow lift is an effective method for elevating the brow,
particularly the lateral brow. However, the direct lift is rarely
used, because it may leave a visible scar. This approach offers
excellent brow elevation through direct excision of the redun-
dant skin. It will also allow access to the muscles. It is a quick,
simple procedure that can be performed with a local anesthetic
and carries minimal risk to the sensory nerves.
30.3.1 Indications and Contraindications
The best candidates are older individuals with heavy lateral
brows and deep transverse forehead creases where the scar can
be hidden. This is a relatively quick procedure and may be an
acceptable alternative for patients who are not candidates for
other options that require lengthier operations. The disadvan-
tage is the scar.
30.3.2 Preoperative Planning
The incision choices include an incision directly above the
hair-bearing brow, which follows the shape of the brow, or an
incision higher up, within a pre-existing crease (Fig. 30.8).
Fig. 30.5 Direct excision of the procerus and corrugator muscles is performed while avoiding injuring the supratrochlear and supraorbital nerves.

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For the incision along the hair-bearing brow, a mark is made
that follows the upper border of the hair-bearing brow. The skin
above is then pinched to bring the brow into the proposed posi-
tion, and the upper border of the skin excision is marked.
The design is varied to allow direct upward elevation of the
brow (Fig. 30.9a) or lateral elevation (Fig. 30.9b). The incision
within the crease is marked with the patient actively elevating the
brow. The amount of forehead skin to be excised is then assessed
and marked by pinching the forehead skin.
30.3.3 Operative Technique
The procedure is performed with a local anesthetic unless it is
combined with other procedures.
Following the markings for a central brow elevation, the surgeon
excises the predetermined skin. This is limited to a skin excision
to avoid injury to the frontal branch of the facial nerve and the
sensory nerves (Fig. 30.10). It is possible through the transverse
Fig. 30.6 The scalp is fixed centrally and laterally according to the
predetermined vectors.
Fig. 30.8 Preoperative markings for incisions. A direct brow lift
should be made directly overlying the hair bearing brow or higher in a
pre-existing crease.
Fig. 30.7 Once set in the desired position, the scalp is serially excised
and closed in layers with suture and staples.
Fig. 30.9 Excision directly above the brow should be designed based on the movement desired: (a) directly above for upward brow elevation and (b)
laterally for lateral elevation.
a
b

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incision to access the glabellar musculature as well; however, this
is not commonly performed. This operation is usually limited to
skin excision.
The wound is then closed in two layers with 5–0 poliglecaprone
(Monocryl, -ohnson -ohnson, 1ew Brunswick, 1-) sutures to
the dermis, and the skin is closed with intracuticular Monocryl
or simple 6–0 polypropylene (Prolene, -ohnson -ohnson, 1ew
Brunswick, 1-) sutures (Fig. 30.11).
30.3.4 Postoperative Care
Postoperative swelling is prolonged and noticeable. To minimize
this, it is important to keep the patient’s head elevated, with ice
packs on the eyelids. :e also consider the use of diuretics and a
short course of methylprednisolone (Medrol DosePak; Upjohn,
.alamazoo, MI).
30.3.5 Outcomes
The direct brow lift is an effective way of elevating the
lateral brow. In carefully selected patients, the scar may be
imperceptible.
30.3.6 Results
The elderly man shown in Fig. 30.12 underwent a direct brow
lift with upper and lower lid blepharoplasties. His postoperative
result shows lateral brow elevation with an imperceptible scar.
30.4 Transpalpebral Brow Pexy
The transpalpebral approach offers minimal lateral brow elevation
through an upper lid blepharoplasty and is best as an adjunct to upper
lid blepharoplasty rather than as a primary brow lift procedure.
30.4.1 Indications and Contraindications
The limited elevation seen with this approach limits its applica-
tion to patients with mild lateral brow ptosis and with no medial
brow ptosis or excess skin at the nasal radix.
30.4.2 Preoperative Planning
The brow is held in the projected position, and the upper eyelid
is marked for an upper lid blepharoplasty.
Fig. 30.10 Direct excision of only the skin being performed to mobilize the brow upward.
Fig. 30.11 A layered closure of the direct brow lift is performed after excision of the skin.

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30.4.3 Operative Technique
The incisions are made and the skin–muscle excision for the
blepharoplasty is completed. The orbicularis muscle is retracted
upward with two Blair retractors and with the cutting current
and a Colorado 1eedle (Stryker CMF, .alamazoo, MI). The dissec-
tion is continued deep to the orbicularis to the lateral orbital rim,
staying above the periosteum. The dissection continues upward
laterally for 2 to 3 cm. Care should be taken to preserve the
sentinel vein (medial zygomaticotemporal vein), which is easily
identified. This dissection releases some of the adhesions and
septa of the lateral orbital area. The plane of dissection is deep to
the course of the frontal branches of the facial nerve (Fig. 30.13).
The calipers are then used to mark a point 5 to 10 mm above the
orbital rim. Then a 5–0 absorbable polydioxanone suture (PDS) or
permanent clear nylon suture is used to fix the hair-bearing brow
to the periosteum. The suture is first placed through the orbicularis,
the retro–orbicularis oculi fat (ROOF), and the deep layers of the
dermis, right in the middle of the hair-bearing brow. 1ext, the needle
is passed through the previously marked periosteum. The suture is
then tied, moving the brow upward. The eyelid skin is closed (Fig.
30.14). Dimpling may result if the suture through the orbicularis and
ROOF extends too far into the skin. Skin redundancy may result above
the point of fixation if the lateral brow is inadequately undermined.
30.4.4 Postoperative Care
Postoperative care is the same as for upper lid blepharoplasty.
30.4.5 Outcomes
Only minimal elevation is possible with this technique. The
results have been effective and maintained over time.
30.4.6 Results
The patient shown in Fig. 30.15 was seen in consultation for upper
and lower lid blepharoplasty. He requested improvement of the
heaviness of his upper eyelids and the excess skin and bags of his
lower eyelids. In addition to excess skin in the upper lids and aging
Fig. 30.12 (a) Pre- and (b) postop images following a direct excision
and quad blepharoplasty. Courtesy Clinton D. McCord, Jr., MD.
a
b
Fig. 30.13 (a) The technique for a transpalpebral brow pexy through
an upper blepharoplasty incision. Dissection is continued through
the orbicularis oculi, along the periosteum for 2 to 3 cm, clearing
adhesions. (b) Calipers are used to mark a point 10 to 15 mm above the
orbital rim.
a
b
Fig. 30.14 (a,c) For pexy of the brow, the central hair bearing area is
chosen to place a suture through the orbicularis oculi and (b) retro–
orbicularis oculi fat (ROOF) to the new position on the periosteum.
(d) Once pexy is tied down, (e) the eyelid skin is then closed.
a
b
d
c
e

340
V Brow Lift
of the lower lids, he had lateral brow ptosis. He underwent upper
and lower lid blepharoplasty with an internal transpalpebral brow
pexy. The split-face image shows his result at 2 years. 1ote the
elevation of the brow through the internal brow pexy suture.
30.5 Concluding Thoughts
The popularity and effectiveness of injectable neurotoxins has led
to a decline in the number of brow lifts performed. Despite that,
there is still a role for these alternative procedures. Patient selec-
tion and matching the procedure to the patient is the key. Although
coronal brow lifts and direct brow lifts have limited application in
my practice, the transpalpebral brow pexy has proved very useful.
Clinical Caveats
Coronal brow lift:
• The surgeon can avoid creating a surprised look by limiting
traction and scalp excision.
• The incision line is beveled to preserve hair follicles.
• The anterior hairline incision should be placed 1 to 2 mm
behind the hairline to preserve hair roots rather than in front
of the hairline.
• Supraorbital and supratrochlear nerve branches should be
preserved while dividing the frontalis muscle.
Direct brow lift:
• Incisions are best placed within pre-existing creases.
• The excision should be limited to skin only to avoid nerve injury.
Transpalpebral brow pexy:
• Dimpling can be avoided by limiting the suture placement to
the deep dermis.
• An overhang can be avoided by adequately undermining the
lateral brow.
Suggested Reading
>1@ Byun S, Mukovozov I, Farrokhyar F, Thoma A. Complications of browlift tech-
niques: a systematic review. Aesthet Surg J 2013;33(2):189–200
>2@ Castaxares S. Forehead wrinkles, glabellar frown and ptosis of eyebrows. Plast
Reconstr Surg 1964;34(4):406–413
>3@ Connell BF, Lambros VS, 1eurohr GH. The forehead lift: techniques to avoid com-
plications and produce optimal results. Aesthetic Plast Surg 1989;13(4):217–237
>4@ Friedland -A, -acobsen :M, Ter.onda S. Safety and efficacy of combined upper
blepharoplasties and open coronal browlift: a consecutive series of 600 patients.
Aesthetic Plast Surg 1996;20(6):453–462
>5@ .aye BL. The forehead lift: a useful adjunct to face lift and blepharoplasty. Plast
Reconstr Surg 1977;60(2):161–171
>6@ .latsky SA. Foreheadplasty for facial rejuvenation. Aesthet Surg J
2000;20:416–427
>7@ .nize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg 1996;97(7):1334–1342
>8@ .nize DM. Transpalpebral approach to the corrugator supercilii and procerus
muscles. Plast Reconstr Surg 1995;95(1):52–60, discussion 61–62
>9@ Mahmood U, Baker -L -r. Lateral subcutaneous brow lift: updated technique.
Aesthet Surg J 2015;35(5):621–624
>10@ Matarasso A, Terino EO. Forehead-brow rhytidoplasty: reassessing the goals.
Plast Reconstr Surg 1994;93(7):1378–1389, discussion 1390–1391
>11@ McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct to blepharoplas-
ty. Plast Reconstr Surg 1990;86(2):248–254
>12@ Mc.inney P, Mossie RD, =ukowski ML. Criteria for the forehead lift. Aesthetic
Plast Surg 1991;15(2):141–147
>13@ Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr
Surg 2001;108(5):1409–1424
>14@ Pelle-Ceravolo M, Angelini M. Transcutaneous brow shaping: a straight-
forward and precise method to lift and shape the eyebrows. Aesthet Surg J
2017;37(8):863–875
>15@ Pitanguy I. Section of the frontalis-procerus-corrugator aponeurosis in the cor-
rection of frontal and glabellar wrinkles. Ann Plast Surg 1979;2(5):422–427
>16@ Riefkohl R, .osanin R, Georgiade GS. Complications of the forehead-brow lift.
Aesthetic Plast Surg 1983;7(3):135–138
>17@ Sweis IE, Hwang L, Cohen M. Preoperative use of neuromodulators to optimize
surgical outcomes in upper blepharoplasty and brow lift. Aesthet Surg J
2018;38(9):941–948
>18@ Tirkanits B, Daniel R.. The ´biplanarµ forehead lift. Aesthetic Plast Surg
1990;14(2):111–117
>19@ Vinas -C, Caviglia C, Cortinas -L. Forehead rhytidoplasty and brow lifting. Plast
Reconstr Surg 1976;57(4):445–454
>20@ Vogel -E, Hoopes -E. The subcutaneous forehead lift with an anterior hairline
incision. Ann Plast Surg 1992;28(3):257–265
>21@ :olfe SA, Baird :L. The subcutaneous forehead lift. Plast Reconstr Surg
1989;83(2):251–256
Fig. 30.15 Split-face comparison of pre- and postoperative views of
upper and lower lid blepharoplasty with internal transpalpebral brow
pexy for lateral brow ptosis

Part VI
Eyelid Surgery
VI

(Trang không có chữ)

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31 Eyelid and Periorbital Anatomy
Amy Patel and Guy G. Massry
Abstract
A fundamental understanding of the anatomy of the eyelid and
periorbital region is critical to achieve an optimal aesthetic
outcome and maintain appropriate function. Sound surgical
technique can be achieved only with a thorough understanding
of the intricate details of the periorbital structures. With this
foundation, appropriate surgical intervention can lead to satisfied
patients and avoid significantly adverse events that can threaten
vision and impair quality of life. This chapter thoroughly reviews
eyelid anatomy and critical principles while emphasizing sur-
gical pearls to help guide an aesthetic surgeon. In addition, it
outlines the anatomy of the forehead, temples, and midface in
relation to the periorbital region, as well as details how these
anatomic areas transition together. The goals of this chapter are
to lay a foundation for the aesthetic surgeon and provide a better
understanding of the anatomic nuances of the periorbital region
and adjacent structures.
Keywords
periorbital anatomy, midface, forehead, temples, eyelid anatomy,
upper eyelid, lower eyelid, levator, blepharoplasty, temporal
fascia
31.1 Introduction
The fundamental basis of surgery starts and ends with a
detailed knowledge of anatomic constructs. This is especially
true in reference to the delicate eyelid and periorbital regions.
In these areas sound surgical technique and principles can be
applied only with a thorough comprehension of the various
anatomic structures that make up this aesthetic subunit
of the face. This basic premise allows maintenance of form
and function, both of which are critical to attaining optimal
outcomes, achieving high patient satisfaction, and avoiding
adverse events. This chapter is presented as an overview of
what the authors have identified as clinically relevant concepts
of eyelid and periorbital anatomy. In addition to the eyelids,
the adjacent forehead, temples and midface are included, as
these adjacent structures are in continuity with the eyelids,
making them critically relevant anatomically and surgically
to the aesthetic eyelid surgeon. The authors’ goal is that upon
completion of this chapter, the reader will understand the
anatomic nuances of these facial subregions and how their five
tissue layers transition with each other. Each chapter section
will include highlighted “clinical pearls,” in italics and bold,
emphasizing how knowledge of anatomy directs surgical tech-
nique and enhances surgical proficiency.
31.2 Temple and Brow
The upper third of the face can be subdivided into two regions:
the forehead, which is centrally based, and the temples laterally.
Externally, without animation, the two regions blend together
without a discrete boundary. :hen the frontalis muscle con-
tracts, horizontal rhytids are noted within the forehead to its
lateral extent. :here these rhytids end, the temple begins. The
subcutaneous transition of these facial structures is more com-
plicated. At the level of bone, this occurs at the superior temporal
line (STL), a concave, curvilinear bony groove composed of the
zygomatic, frontal, and parietal bones (Fig. 31.1). The STL forms
Lower temporal quadrant
Upper temporal quadrant
• Superior temporal line (STL) at level
of bone
• Superior temporal septum (STS)
= fusion of supertemporal fascia (STF)
and deep temporal fascia (DTF)
• Conjoint tendon (CT)
= STS with periosteum of frontal bone
Frontal nerve (TFN)
Zygomatico temporal nerves (ZTN)
Zygomatico facial nerves (ZFN)
Sentinel vein (SV)
Lateral orbital
thickening (LOT)
Inferior temporal septum (ITS)
Temporal ligamentous
adhesions (TLA)

S
T
L
/
S
T
S
/
C
T
Deep temporal fascia (DTF)
Lateral orbital fat
compartment (LOFC)
Inferior temporal septum (ITS)
Lower temporal
compartment (LTC)
Upper temporal compartment (UTC)
Supertemporal fascia (STF)
Lateral temporal fat compartment (LTFC)
Superior temporal septum (STS)
Skin
Fig. 31.1 (a) Important anatomic quadrants and landmarks of the temple and forehead region. (b) Cross-sectional view of the layers of the temple region.
a
b

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VI Eyelid Surgery
the superior medial boundary of the temporalis fossa, where
the temporalis muscle resides. The deep temporal fascia (DTF),
a dense fascial layer overlying the temporalis muscle, inserts on
this landmark. The DTF also fuses with the more superficial and
flimsier superficial temporal fascia (STF) at this point. This line of
fusion forms one of two septa in the temple, this one called the
superior temporal septum (STS). The name given to the continu-
ity of the STF/DTF (STS) and the periosteum of the frontal bone is
the conjoint tendon (CT) or the area of fusion between the fascial
layers of the temple and the soft tissue of the forehead (Fig. 31.1).
The CT is an important landmark in brow lifting surgery, as its
division makes the surgical planes of the temple and forehead
continuous.
31.2.1 Temple
The temple is externally bounded by the hairline superolaterally,
the STL medially, and the zygomatic arch below. Like all regions
of the face, it is composed of 5 layers (Fig. 31.1b):
1. Skin
2. Subcutaneous tissue/fat
3. Superficial fascia (STF, also known as the temporoparietal fascia,
TPF)
4. Loose areolar tissue (a potential space)
5. The DTF overlying the temporalis muscle
As described, the STS is the medial fusion of the STF and DTF,
which overlies the transition of the temple and forehead.
Similarly, there is a second and inferior septum of the temple
region, the inferior temporal septum (ITS), which is also a
fusion of the STF and DTF. The ITS traverses a dense adhesion
above the lateral brow, referred to as the temporal ligamentous
adhesion (Fig. 31.1a), and continues to the helix of the ear. It
divides the temple anatomically into two separate superficial
and deep compartments. In superficial Layer 2 of the temple,
the ITS divides the subcutaneous fat into an upper temporal
fat compartment and the lateral orbital fat compartment (Fig.
31.1b). In the deeper Layer 4 of the temple, the ITS divides this
plane into the upper temporal compartment (UTC) and the
lower temporal compartment (LTC). This space between the
STF and DTF of the temple is the surgical plane for endoscopic
brow lifting surgery. The UTC is an extension of the sublegal
plane of the forehead, is a true potential space, and is defined
medially by the STS and inferiorly by the ITS. The UTC is
composed of loose areolar tissue, and surgical dissection can
proceed bluntly and easily to its boundaries (Fig. 31.2). At its
boundaries, more meticulous dissection is required to avoid
complications. At the medial boundary of the UTC, dividing
the CT is a necessary step in endoscopic brow lift surgery
(Fig. 31.3). During this step, if an elevator is used to divide
the CT, it is critical to divide the tendon from the temporal
subaponeurotic space to the central subperiosteal space.
The deep lateral branch of the supraorbital nerve runs just
above the frontal periosteum, parallel and medial to the CT
(Fig. 31.4). Dissection must be subperiosteal over the frontal
bone to protect this nerve. If this nerve is damaged, prolonged
scalp numbness/paresthesia or itching can occur. Also, if the
inferior release of the CT proceeds medial to lateral, the STF
can be inadvertently entered, with subsequent damage to the
frontal branch of the facial nerve. Of note, while motor nerve
injury has greater functional and aesthetic implications than
sensory injury during endoscopic brow lift surgery, sensory
deficit is far more common.
Inferiorly, below the ITS, the LTC, which is functionally an
extension of the midface below, is bounded by denser adhesions.
Dissection in this area to access the lateral brow or midface
requires caution so as to avoid injury to critical neurovascular
structures. These include the frontal branch of the facial nerve
and both the sentinel (medial zygomaticotemporal) vein and
various branches of the zygomaticotemporal nerves. Preserving
Fig. 31.2 Upper temporal quadrant dissection. The dissection
proceeds easily in a blunt fashion. It demarcates superficial temporal
fascia above, deep temporal fascia below.
Fig. 31.3 Surgical endoscopic view of the conjoint tendon. Dissection
proceeds in a subperiosteal manner.

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the sentinel vein during endoscopic brow lift and midface sur-
gery is important to prevent the development of new and vis-
ible postoperative periorbital veins and prolonged edema (Fig.
31.5). Of all these structures, understanding the course of the
frontal branch of the facial nerve is most important. Externally,
the nerve courses along the Pitanguy line, from a point 0.5 cm
below the tragus to a point 1.5 cm lateral to the supraorbital
rim (Fig. 31.1a). Internally, it lies in the roof of the LTC in the
innermost aspect of the STF.
Of note, just above the ITS the DTF divides into two lami-
nae, with a fatty layer between (the superficial temporal fat).
Disruption of this fat pad during surgery can lead to postop-
erative temporal wasting. Below this division the superficial
layer of the DTF is known as the innominate or intermediate
fascia. The two layers of the DTF insert on the zygomatic arch.
The superficial layer of the DTF continues beyond the zygomatic
arch and blends with the parotideomasseteric fascia of the face.
The arterial supply of the temple is from the superficial temporal
artery (STA), which courses in the STF in this location. Care must
be taken with filler and fat injections superficially within the
temple, as the STA communicates within the forehead with the
supraorbital artery. Inadvertent intra-arterial injection can
lead to vision loss via this route. Venous drainage is from the
superficial temporal vein, while lymphatic drainage is via the
preauricular nodes. Motor innervation of the temporalis muscle
is from branches of the mandibular division of the trigeminal
nerve (cranial nerve V3). These branches are called the deep
temporal nerves. Sensory innervation of the temple is from the
zygomaticotemporal nerve, a branch of the maxillary division
(V2) of the trigeminal nerve that exits the lateral orbit to arrive
at the temple, and the auriculotemporal nerve, a branch of the
mandibular division (V3) of the trigeminal nerve that runs supe-
riorly with the superficial temporal artery and veins to ascend to
the temple.
Deep branch of
supraorbital
nerve
Superficial branches
of the supraorbital
nerve
Conjoint tendon
Fig. 31.4 The deep branch of the supraorbital nerve runs just above the frontal bone periosteum, parallel and medial to conjoint tendon. Dissection must
be subperiosteal to prevent sensory deficit. (Reproduced from Pu L. Aesthetic Plastic Surgery in Asians. Principles & Techniques. New Superficial fascia
Deep fascia
Sentinel vein
Fig. 31.5 Surgical endoscopic view of the sentinel vein, which should
be preserved in surgery to avoid new and visible postoperative
periorbital veins and prolonged edema.

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VI Eyelid Surgery
31.2.2 Forehead
The forehead is delineated superiorly by the hairline; inferiorly
by the glabella, frontonasal groove, and eyebrows; and laterally
by its boundary to the temple as already described. It is also
composed of five layers, which include the following (Fig. 31.6):
1. The skin
2. Subcutaneous tissue/fat
3. Galea aponeurotica
4. Loose areolar tissue
5. Periosteum
The main retractor of the forehead is the paired and ver-
tically oriented frontalis muscles, which tighten the scalp,
raise the eyebrows, and create horizontal forehead rhytids.
The frontalis is encased by the superficial and deep layers of
the galea aponeurotica as part of layer 3 (Fig. 31.6). It fuses
with the occipitalis muscle posteriorly (some consider it part
of the occipitofrontalis muscle), is continuous (as part of the
galea) with the STF of the temple, and interdigitates with the
procerus, corrugator supercilii, and orbicularis oculi muscles
inferiorly, before inserting into the dermis underlying the
eyebrows. As the frontalis has no bony origin or attachment,
it serves only to provide facial expression. Finally, the lateral
forehead and eyebrows receive their blood supply from the STA,
while the medial forehead is supplied by terminal branches of
the ophthalmic artery, including the supraorbital and supra-
trochlear arteries. Venous drainage for the forehead is via the
supraorbital, supratrochlear, and superficial temporal veins,
while lymphatic drainage is to the preauricular and parotid
lymph nodes. The forehead (frontalis muscle) receives motor
innervation from the frontal branch of the facial nerve and
sensory input from the supraorbital and supratrochlear nerves,
both terminal branches of the ophthalmic division (V1) of the
trigeminal nerve. The supraorbital nerve has two branches (see
Fig. 31.4):
1. A medial superficial branch, which pierces the corrugator super-
cilii muscle before supplying the central forehead
2. A deep lateral branch that runs just above the periosteum lat-
eral to the conjoint tendon, supplying the lateral forehead and
posterior scalp
This deep lateral branch should be protected in endoscopic
brow lifting surgery (dissect subperiosteally below it) to prevent
protracted postoperative sensory deficit.
At the level of the brow, the deep layer of the galea splits and
envelops the brow fat pad, also called the retro–orbicularis oculi
fat (ROOF). The ROOF continues into the eyelid proper as the
postorbicularis fascia in Caucasians and the preseptal fat in Asians.
The lateral extent of frontalis is bounded by the STL. Beyond
this landmark the tail of the brow has no elevator. Therefore,
neuromodulation of the lateral brow depressors (lateral orbi-
cularis oculi muscle) is a common intervention for chemical
lateral brow lifts. In addition, the ROOF descends and deflates
with age. Elevating (with brow lifts or suspension sutures) or
chemical filling (i.e., hyaluronic acid gel) of the ROOF can also lift
and/or project the tail of the brow. The authors prefer the term
brow recontour rather than brow lift, as in their view it is the
shape, arch, and contour of the brow that are more important
than height. A detailed knowledge of anatomy is what allows
consistent and reproducible results to these interventions.
:hile there is one elevator of the eyebrows, there are multiple
depressors. These include the glabellar muscles medially, consisting
of the corrugator supercilii and procerus muscles, and the orbicularis
oculi muscle laterally. Unlike the frontalis, these muscles do have
bony attachments. The frontal branch of the facial nerve innervates
the orbicularis and corrugator muscles, while the buccal and zygo-
matic branches of the facial nerve innervate the procerus muscle.
Subcutaneous tissue
Superficial temporal fascia
Temporalis muscle
Superficial temporal fat pad
Pericranium
Frontal branch of facial nerve
Skin
Deep temporal fascia
Frontalis muscle
Deep (lateral) branch
of supraorbital nerve
Supratrochlear nerve
Superficial (medial) branch
of supraorbital nerve
Postseptal
preaponeurotic fat
Brow fat
Superficial galea
Deep galea
Posterior leaf
of deep galea
Anterior leaf
of deep galea
Fig. 31.6 Layers of the forehead. (a) Frontal view. (Reproduced from Sokoya M, Inman J, Ducic <. Scalp and forehead reconstruction. Semin Plast Surg
2018;32(02):90–94.) (b) Parasagittal section through eyeball. (Reproduced from Codner M, McCord C, eds. Eyelid & Periorbital Surgery, 2nd ed. New
a
b

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31.3 Eyelid Anatomy
31.3.1 General Considerations
The supraorbital ridge marks the transition of the upper to the
middle third of the face. The upper and lower eyelids are, thus,
in the middle third. They are complicated, multilayered, and
dynamic structures that act to protect the ocular surface and
preserve vision. Failure to maintain the anatomic integrity and
biomechanics of the eyelids during surgery can lead to aesthetic
and functional disability, including visual compromise. They
span the lateral to medial canthi, with the upper eyelid bounded
by the brows above and the lower eyelids by the midface below.
These transitions are not distinct but rather blend together,
so that the brows and upper eyelids and the lower eyelids and
midface behave, and are considered, as individual functional
and aesthetic facial subunits (Fig. 31.7). The area between the
brows and upper lids at their junction is called the superior
sulcus. Avoiding hollowing of this area by overresection of
skin, muscle, and fat is an important paradigm of upper bleph-
aroplasty for aesthetic enhancement.
Externally, the eyelids are topographically subdivided into a
palpebral (pretarsal and preseptal) and an orbital segment, based
on the internal anatomic structure underlying the eyelid skin and
muscle in this area (Fig. 31.7). Internally, the eyelids are composed
of three distinct lamellae: anterior, composed of thin skin and
orbicularis muscle; middle, defined by the orbital septum; and
posterior, made up of conjunctiva, tarsus, and retractors depend-
ing on topographic location on the eyelid (Fig. 31.8). Eyelid closure
is controlled in both the upper and lower eyelids by the orbicularis
oculi muscle, the only protector of the eyelids. Conversely, eyelid
opening is driven by separate and differing structures in the upper
and the lower eyelids, generally referred to as eyelid retractors,
discussed hereafter. Finally, the eyelids are internally separated
from the orbit proper by a thin connective tissue structure called
the orbital septum. The orbital septum is a critical landmark
in eyelid surgery, as the eyelid/orbital fat, which is excised or
transposed in blepharoplasty, is always posterior to the septum.
31.3.2 Key Points
The orbicularis oculi is a concentric muscle that, depending on
its subdivision, originates and inserts on the orbital rim, lateral
raphe, or canthi. As it is a circular sphincter, it requires counterfix-
ation at the canthi to allow appropriate vertical eyelid excursion.
Poor canthal stability after blepharoplasty surgery can lead to
a biomechanical deficit in eyelid closure, medialization of the
lateral canthus, with subsequent shortening of the horizontal
palpebral fissure, collectively referred to as “fishmouthing.” The
pretarsal orbicularis lies above the tarsal plate and is thought to
contribute (with the preseptal orbicularis) to involuntary upper
eyelid excursion such as blink. The muscle continues to the eyelid
margin, where it can be seen as the ´grey line,µ also referred to as
the muscle of Riolan. The muscle has both superficial and deep
components that contribute to the medial and lateral canthal
tendons. The preseptal orbicularis overlies the orbital septum;
is mobile as compared with its pretarsal counterpart, which is
fixed to the tarsus; and also has superficial and deep segments,
which contribute to the canthal tendons. Both these segments of
orbicularis contribute to the lacrimal pump mechanism for tear
drainage. As the eyelids close, the orbicularis muscle contracts.
The pretarsal component compresses the canaliculi, driving
tears to the lacrimal sac. As the preseptal orbicularis (which
inserts into the lacrimal sac) contracts, it expands the lacrimal
Upper lid crease
Upper lid fold
Canthal tilt
(2 mm higher
laterally)
Lateral canthus
Tarsal platform
show
Lower lid crease
Eyelid–cheek
junction
Superior sulcus
Medial canthus
Nasojugal
groove
Fig. 31.7 Normal eyelid surface anatomy.
Inferior rectus
muscle
Lockwood’s inferior
suspensory ligament
Inferior tarsal muscle
Capsulopalpebral fascia
Inferior oblique muscle
Fig. 31.8 (a) Upper lid cross section. (b) Lower lid cross section.
Middle lamella
septum
Orbital
orbicularis
Preseptal
orbicularis
Posterior lamella
(tarsus, conjunctiva)
Anterior lamella
(skin, orbicularis)
Pretarsal
orbicularis
Orbital
segment
Palpebral
segment
a
b

348
VI Eyelid Surgery
sac, creating a negative pressure that draws the tears into the
sac. As the eyelid opens, the orbicularis muscle relaxes, which
in turn opens the puncta and collapses the lacrimal sac, and the
cycle repeats. The bottom line is that normal eyelid function is
critical to prevent postsurgical tearing. The orbital orbicularis
is the largest segment of the orbicularis muscle and controls
voluntary upper eyelid closure as well as medial and lateral brow
depression. Fig. 31.8 and Fig. 31.9 demonstrate the anatomic
subdivision of the orbicularis muscle.
The eyelids are anchored medially and laterally by the medial and
lateral canthal tendons. The medial canthal tendon is formed by
fibrous extensions of the orbicularis muscle and has both anterior
and posterior crura, which attach to the anterior and posterior lac-
rimal crests, respectively. The anterior lacrimal crest is an extension
of the frontal process of the maxilla. The posterior lacrimal crest is
part of the lacrimal bone. The lacrimal sac lies between the anterior
and posterior crura of the medial canthal tendon and within the
lacrimal fossa. The lateral canthal tendon is similarly formed by
fibrous extensions of the orbicularis muscle that connect the tarsal
plate to the lateral orbital rim, and it also has anterior and posterior
crura. The anterior crus attaches to the anterior orbital rim, while
the posterior crus attaches to :hitnall’s tubercle, a bony promi-
nence 3 mm posterior to the lateral orbital rim and 10 mm below
the frontozygomatic suture. Four anatomic structures attach to
Whitnall’s tubercle (the 4 Ls): the lateral rectus check ligament,
the levator aponeurosis (LA), Lockwood’s suspensory ligament,
and the lateral canthal tendon. In addition, the lateral canthal
tendon sits approximately 2 mm higher than the medial canthal
tendon. This is known as the normal canthal tilt (Fig. 31.7). It is
critical to re-create this posterior/superior attachment of the LCT
in surgery, as it allows appropriate apposition of the lid to the
globe and directionality of the horizontal palpebral fissure. Fig.
31.10 shows critical structures and landmarks in canthal anatomy.
The upper and lower tarsal plates are dense connective tissue
structures that provides structural integrity and support to the
eyelids. The upper tarsus measures approximately 10 mm in
height and 25 mm in width. It tapers medially and laterally and
tends to decenter temporally with age. The lower tarsal plate
measures 4 mm in height and is approximately the same width.
Finally, in both the upper and lower eyelids, the orbital septum
originates at a periosteal fusion site at the orbital rim called the
arcus marginalis and inserts onto the LA on the upper lid and the
eyelid retractors of the lower lid (Fig. 31.11).
31.3.3 SSeFiÀF 8SSer (yeOid AnDWRmy
The critical layers of the upper lid are the anterior lamellae (skin
and orbicularis muscle), the middle lamella (orbital septum), and
the posterior lamella (conjunctiva, retractors, and tarsus). The
anterior lamella overlies the tarsus and orbital septum, which, as
stated, separates superficial eyelid tissue from the deeper orbit
proper. The orbital septum, which originates at the arcus margin-
alis of the superior orbital rim, fuses with the LA approximately
2 to 3 mm above the tarsal plate in Caucasians and below the
Orbital orbicularis muscle
Superior preseptal
orbicularis muscle
Superior pretarsal
orbicularis muscle
Inferior pretarsal
orbicularis muscle
Inferior preseptal
orbicularis muscle
Fig. 31.9 Orbicularis oculi muscle is classically divided into three
portions: orbital, preseptal, and pretarsal.
Lockwood’s
inferior
suspensory
ligament
Lateral
canthal
tendon
Whitnall’s ligament
Arcuate
expansion
Posterior reflection
of medial canthal
tendon
Lacrimal sac fossa
Anterior reflection
of medial canthal
tendon
Posterior lacrimal crest
Anterior lacrimal crest
Fig. 31.10 Critical structures and landmarks in canthal anatomy.
SOOF
Müller’s muscle
Levator palpebrae
superioris muscle
Inferior oblique
muscle
Inferior orbital rim
Arcus marginalis
Superior orbital rim
Eyebrow
Brow fat pad (ROOF)
Postseptal fat
Orbital septum
Levator aponeurosis
Dermal insertions forming
upper eyelid crease
Conjunctiva
Superior tarsal plate
Pretarsal orbicularis muscle
Inferior tarsal plate
Inferior pretarsal muscle
Capsulopalpebral fascia lid retractors
Postseptal fat
Inferior septum
Orbitomalar ligament
Fig. 31.11 Relevant anatomic structures for upper and lower lid anat-
omy. ROOF, retro–orbicularis oculi fat; SOOF, sub–orbicularis oculi fat.

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superior border of the tarsal plate in Asians (Fig. 31.12). Dermal
attachments of this fusion point create the eyelid crease (Fig.
31.11). Posterior to the septum, the upper eyelid has two fat pads:
1. Nasal or medial
2. Central or preaponeurotic fat (PAF)
The fat pads are separated by the trochlea, the tendinous sling of
the superior oblique muscle (Fig. 31.13). In contrast to the lower
eyelid, there is no lateral fat pad in the upper lid, but a prolapsed
lacrimal gland can clinically appear as a full lateral upper lid. It
is important to familiarize oneself with the appearance of the
lacrimal gland in surgery so as not to resect it in error, assum-
ing that it is eyelid/orbital fat. The nasal fat pad, which is paler
than the more yellow PAF, is an extension and in continuity with
deeper orbital fat. Conversely, the PAF lies above the LA, which
separates it from the deeper orbital fat. The nasal fat, as compared
with PAF, tends to be relatively stem cell rich and becomes more
prominent clinically with age. As the nasal fat pad is laterally
bounded but not divided by the LA, it can be accessed from a
transconjunctival approach. Also, as the nasal fat pad is richer
in progenitor cells and tends toward prominence with age, it can
be transposed centrally within the eyelid to potentially maintain
volume and prevent postoperative superior sulcus hollowing
during blepharoplasty. While there is no distinct lateral fat pad in
the upper lid, the PAF can have lateral extensions that mimic this
appearance. The PAF is a critical landmark in eyelid surgery, as
it overlies the LA, which must be preserved in blepharoplasty to
avoid postoperative ptosis. Do not continue dissection through
the eyelid if fat is not identified.
The levator palpebrae superioris (LPS) muscle is the main
retractor of the upper eyelid (Fig. 31.11). It is skeletal muscle,
under voluntary control, and originates within the orbital apex
just above the optic foramen, from the lesser wing of the sphenoid
bone, and inserts on the anterior tarsal plate and the orbicularis
muscle and skin (to form the eyelid crease). It is innervated by the
superior division of the oculomotor nerve (OM1; cranial nerve
III) and is composed of a muscular portion measuring 40 mm in
length and a tendinous portion (aponeurosis) measuring 14 to 20
mm in length. :hitnall’s ligament (the superior transverse liga-
ment) lies at the junction of the muscular and tendinous portions
of the levator complex, is partially formed by the fascia of the
levator muscle, and inserts medially at the trochlea of the superior
oblique tendon and laterally at the lacrimal gland pseudocapsule
and frontal bone of the lacrimal sac fossa, 10 mm above :hitnall’s
tubercle (Fig. 31.10). Whitnall’s ligament, interestingly, does not
attach to Whitnall’s tubercle. The ligament acts as a fulcrum to
change direction of the LPS from anterior to posterior to superior
and inferior. This allows the levator muscle to function as an
eyelid elevator and helps maintain eyelid/globe apposition. As
the levator aponeurosis continues inferiorly, it expands to medial
and lateral horns. The lateral horn divides the lacrimal gland into
orbital and palpebral and inserts on the lateral orbit at Whitnall’s
tubercle. Some of its fibers contribute to the lateral canthal
tendon. The medial horn inserts into the posterior reflection of
the medial canthal tendon and posterior lacrimal crest. These
horn insertions are important to maintain optimal lid contour.
Projections of the distal LA continue anteriorly to the orbicularis
muscle and skin to form the eyelid crease (Fig. 31.11). With age,
the levator aponeurosis tends to attenuate and/or dehisce from
its insertion. This leads to the characteristic clinical presentation
of ptosis, a hollow sulcus (recessed PAF), and an elevated eyelid
crease (levator recession)
The second upper eyelid retractor is Mller’s muscle (Fig.
31.11). This smooth muscle is responsible for involuntarily lift-
ing the eyelid approximately 2 mm (i.e., during the fight or flight
response), is sympathetic innervated, and loosely adheres to the
levator aponeurosis anteriorly and tightly connects to the con-
junctiva posteriorly. It originates from the undersurface of the
levator muscle and inserts onto the superior tarsal plate. In the
presence of ptosis, topical phenylephrine drops can be placed in
ASIAN
NON-ASIAN
Preseptal fat
ROOF
Pre-aponeurotic
fat
Attachments of
levator to the dermis
Levator
muscle
Müller’s
muscle
Levator
muscle
Müller’s
muscle
Fig. 31.12 Asian eyelids are fuller than those of non-Asians, as preaponeurotic fat rides lower in the lid and there is a preseptal fat layer, which is
continuous with the brow fat pad. Also, note potentially blunted attachments of the levator to the dermis, which can lead to an incomplete or absent
crease in many patients.

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VI Eyelid Surgery
the affected eye to potentially stimulate muscle contraction and
accordingly plan posterior approach ptosis repair surgery based
on a predetermined algorithm. Posterior approach ptosis
repair (müllerectomy) requires no patient cooperation and
less detailed knowledge of anatomy, is technically easier, and
is more consistent and reproducible than levator-dependent
ptosis surgery.
Asian Upper Eyelid Anatomy Variations
It is important to recognize the differences in Asian upper eyelid
anatomy (Fig. 31.12). Approximately 50 of Asian eyelids have
a partial or no eyelid crease. This occurs because the orbital
septum can attach lower on the LA. This more inferior attach-
ment of the septum allows PAF to ride lower in the eyelid and
potentially blunt the terminal attachments of the LA to the
orbicularis muscle and skin. The lower-riding fat is also one of
the factors predisposing to fuller eyelid in Asians. The other
factor is that in Asians there is a preseptal fat layer in the eyelid,
which is a continuation of the brow fat pad (ROOF). In Caucasians
the brow fat pad continues into the upper lid as postorbicular
fascia. Finally, Asians often have a shorter vertical tarsal height.
31.3.4 Lower Eyelid Anatomy
Lower eyelid anatomy can be more challenging to conceptualize
three-dimensionally than the anatomy of its upper lid coun-
terpart. This anatomy often wreaks havoc on novice surgeons,
especially when performing surgery transconjunctivally. In
addition, lower lid blepharoplasty is fraught with more frequent
and potentially disabling functional and aesthetic complications
than similar upper lid surgery. Accordingly, familiarization with
the complex and delicate nature of lower lid structure is critical
to maintain both form and function after surgery (Fig. 31.11).
As in the upper eyelid, the anterior lamella of the lower lid con-
sists of skin and orbicularis muscle subdivided into orbital and pal-
pebral (preseptal and pretarsal) segments, and the middle lamella
is composed of orbital septum. While it can be safe to excise
preseptal orbicularis during lower blepharoplasty surgery, care
must be taken to preserve the pretarsal orbicularis muscle during
this procedure so as to avoid lower eyelid malposition. What is
different in the lower lid is that the retractors are structured differ-
ently and are composed of both the capsulopalpebral fascia (CPF)
and the inferior tarsal muscle (ITM). The orbital septum fuses
with the retractors approximately 5 mm below the tarsal plate.
This fusion point is important when performing transconjunctival
blepharoplasty, as it allows both a preseptal and a postseptal surgi-
cal dissection plane, depending on where the incision is made (Fig.
31.14). It has been shown with transconjunctival surgery that
both pre- and postseptal surgery lead to a negligible incidence of
lower lid malposition. In addition, with the postseptal approach,
an incision 6.5 mm below the tarsus has been shown to attain
direct fat access in 82% of cases. Posterior to the orbital septum
are three fat pads: nasal, central, and lateral. The nasal and central
Nasal fat pad
Inferior oblique
muscle
Lacrimal gland
Arcuate expansion
of Lockwood’s
ligament
Lateral canthal
tendon
Medial canthal
tendon
Lateral fat pad
Interpad septum
under trochlea
Nasal fat pad
Central fat pad
Central fat pad
Fig. 31.13 Fat pads of the upper and lower eyelids. The trochlea sepa-
rates the upper nasal and preaponeurotic fat pad. The inferior oblique
separates the nasal and central fat pad of the lower eyelid. The arcuate
expansion separates the lateral fat pad of the lower eyelid.
Conjunctiva
Transconjunctival
pre-septal approach
Transconjunctival
post-septal approach
Lower lid
retractors
Orbicularis
oculi muscle
Orbital
septum
Fig. 31.14 Preseptal versus postseptal transconjunctival blepharoplasty.

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fat pads are superficially divided by the inferior oblique muscle
(IOM), which originates from the medial orbital floor and courses
superolaterally to insert on the posterior aspect of the globe. It is
responsible for extorsion, abduction, and elevation of the globe,
and iatrogenic trauma to the muscle during blepharoplasty can
lead to postoperative diplopia (Fig. 31.13).
Like the upper lid, the lower lid also has a suspensory structure,
called Lockwood’s ligament (Fig. 31.10). It functions as a ham-
mock below the globe to support it and prevent its downward dis-
placement. It is attached to the medial and lateral orbit (laterally
inserts on :hitnall’s tubercle), is a thickening of Tenon’s capsule
(bulbar sheath) and is intimately associated with both the IR
muscle and IOM. The arcuate expansion of Lockwood’s ligament
is a projection of the ligament that inserts on the inferolateral
orbital rim and separates the central and lateral fat compartments
of the eyelid (Fig. 31.13). Surgically, the nasal and central fat pads
typically override the IOM as the muscle arises deep to the orbital
rim. Conversely, the central and lateral fat pads do not override
the arcuate expansion, which is a more superficial structure.
Accordingly, during clinical evaluation of a patient for lower
blepharoplasty, the nasal and central fat pads appear as one fat
pad, while a demarcation is often noted between the central and
lateral fat pads. These findings are more pronounced when the
patient looks up. :hile the IOM and the arcuate expansion are
structural landmarks that separate the lower lid fat pads, these
fat pads are continuous, as can be seen when pulling in opposite
directions sequentially on the nasal and central fat pad under the
IOM. This maneuver has been called the “inverse shoeshine sign.”
The posterior lamella of the lower lid is composed of the tarsus
and conjunctiva for the first 5 mm below the lashes (where the
tarsus ends). Below the level of the tarsus, the posterior lamella
consists of the lower eyelid retractors, including the CPF, ITM, and
conjunctiva (Fig. 31.8b). The lower lid retractors are intimately
associated with the conjunctiva. The capsulopalpebral head orig-
inates from the fascia of the IR muscle, then envelopes the IOM
to become the CPF, which fuses with the orbital septum to insert
on the inferior tarsal border. The ITM, similar to Mller’s muscle
of the upper eyelid, is a sympathetically driven smooth muscle
that lies posterior to the CPF. The lower eyelid crease is formed by
small fibrous attachments of the CPF to the skin of the lower lid
a few millimeters below the tarsus. As the lower lid retractors
have origins at the IR muscle, strabismus surgery involving the
IR muscle can change eyelid position.
31.3.5 Neurovascular Supply of the
Eyelids
Arterial Supply
The arterial supply of the eyelids is derived from both the inter-
nal carotid artery (ICA) and the external carotid artery (ECA).
The ophthalmic artery (OA), the first branch of the ICA, gives off
multiple orbital branches including the lacrimal and supraorbital
arteries. These terminal branches primarily contribute to the
marginal and peripheral arcades of the eyelids. In the upper
eyelid, the marginal arterial arcade lies 2 mm superior to the
eyelid margin and anterior to the tarsal plate. The peripheral
marginal arcade lies superior to the tarsus between the levator
aponeurosis and Mller’s muscle. In the lower eyelid, there is only
one arterial arcade, which is located at the inferior tarsal border.
From the ECA the STA gives off three branches that contribute
to eyelid arterial blood supply. These include the frontal branch,
which communicates with both the lacrimal and supraorbital
arteries; a zygomatico-orbital branch, which in part supplies the
upper lid; and a transverse facial branch, which anastomoses
with the infraorbital arteries supplying the lower lids. Finally,
the infraorbital artery (a branch of the internal maxillary artery,
from ECA) provides a rich arterial supply to the peripheral lower
lid. It is important to understand the varied communication of
the ICA and ECA. These connections provide potential access of
facial injections of filler, fat, or particulate material into the
ICA circulation via retrograde flow with injection pressure.
The subsequent antegrade flow to the ophthalmic artery, when
injection pressure is released, can lead to blindness via infarc-
tion of arterial branches to the anterior and posterior optic
nerve or retinal circulation. Refer to Fig. 31.15 for vascular
supply of the eyelids.
Venous and Lymphatic Drainage-
The venous drainage of the eyelids is divided into pretarsal
and posttarsal components. The pretarsal tissue drains into
the angular veins medially and the superficial temporal vein
laterally. The posttarsal drainage is into the orbital veins and
the deeper branches of the anterior facial vein and pterygoid
plexus. Lymphatic vessels that serve the medial eyelid drain into
the submandibular lymph nodes, while those serving the lateral
portions of the eyelids drain first into the superficial preauricular
nodes and then into the deeper cervical nodes.
Eyelid Innervation
Motor eyelid innervation is supplied by branches of the facial
nerve (F1; cranial nerve VII), the OM1 (cranial nerve III), and
sympathetic nerve fibers. The OM1 and sympathetic fibers
are responsible for eyelid retraction (opening), while the F1 is
responsible for eyelid protraction (closing). The superior branch
of the OM1 innervates the main upper eyelid retractor, the levator
palpebrae superioris. Sympathetic nerve fibers innervate the
ancillary eyelid retractors, including Mller’s muscle of the upper
eyelid and the ITM of the lower eyelid. First-order neurons of the
sympathetic pathway begin centrally at the hypothalamus and
descend caudally to the cervical spinal cord. Second-order neu-
rons exit the cervical cord and travel with the brachial plexus as
part of the cervical sympathetic chain and synapse in the superior
cervical ganglion. Third-order neurons leave the superior cervical
ganglion and travel into the cranium, entering in proximity to the
internal carotid artery (internal carotid nerve), after which they
enter the orbit with the optic nerve and ophthalmic artery through
the optic foramen. Disruption of the sympathetic pathway can
lead to Horner’s syndrome, which presents with a combination of
the classic findings of ptosis, miosis, and anhidrosis.
Eyelid protraction is controlled by various branches of the F1,
including the frontal, zygomatic, and buccal branches. The frontal
branch innervates the upper eyelid orbicularis, while the lower
lid orbicularis is innervated by both the zygomatic and buccal
branches. Recent cadaveric dissections have demonstrated that

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VI Eyelid Surgery
the lower orbicularis is not innervated by multiple vertically
oriented motor nerve fibers as had been thought. In fact, it was
shown that these vertical fibers emerge from the infraorbital
foramen, indicating that they are sensory nerves. Furthermore,
it has been shown that the zygomatic branch of the facial nerve,
with buccal branch contribution, travels obliquely through the
anterior cheek and supplies the orbicularis oculi of the lower
eyelid and the medial portion of the upper eyelid.
Sensory innervation to the eyelids is supplied by the ophthal-
mic (V1) and maxillary (V2) divisions of the trigeminal nerve.
Terminal branches of V1 that innervate the upper eyelid include
the lacrimal, supraorbital, and supratrochlear nerves from lateral
to medial. Similarly, in the lower lid, sensory branches emerge
from V2 and include the zygomaticofacial and infraorbital nerves,
lateral to medial (Fig. 31.16).
31.4 Midface Anatomy
The midface, which transitions from the lower eyelid at the
infraorbital rim, completes the middle third of the face. It
has been traditionally bounded superiorly by the lid–cheek
junction and inferiorly by a line from the inferior tragus to the
oral commissure. It is also divided into a lateral and more central
anterior compartment by a line from the lateral canthus to the
oral commissure. This lateral/central division has anatomic and
clinical relevance, as laterally the five tissue layers of the face
are thin and functionally fused over the muscles of mastication;
thus, there is little facial expression in this location. In the central
(anterior) midface, by contrast, the five tissue layers are robust
and act in consort to convey facial expression.
The layers of the midface are the same as in other regions of the
face and include the following (Fig. 31.17):
1. Skin
2. Subcutaneous tissue
3. A fibrous layer investing the muscle of facial expression: the
superficial musculoaponeurotic system (SMAS)
4. A loose areolar tissue plane
5. Periosteum or deep fascia
Marginal arcade
Superior arcade
Supraorbital artery
Supratrochlear artery
Dorsal nasal
artery
Medial palpebral
artery (superior)
Medial palpebral
artery (inferior)
Angular artery
Lateral
nasal
artery
Angular artery
Infraorbital
artery
Transverse
facial artery
Zygomatico-
facial artery
Lacrimal artery
Superficial
temporal
artery
Superior
palpebral vein
Supraorbital vein
Supratrochlear
vein
Nasofrontal vein
Medial palpebral
vein (superior)
Medial palpebral
vein (inferior)
Angular vein
Nasal vein
Anterior facial vein
Infraorbital vein
Superficial
temporal
vein
Fig. 31.15 (a) Arterial and (b) venous supply of the eyelid.
a
b
Supraorbital nerve
Supratrochlear
nerve
Infraorbital nerve
Zygomaticofacial
nerve
Zygomaticotemporal
nerve
Fig. 31.16 Sensory innervation to the eyelids.

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As stated, in the lateral midface, all tissue layers are essentially
fused. Accordingly, they cumulatively act as one structural retain-
ing ligament. In the anterior midface, there are three prominent
ligamentous attachments, which traverse all fi ve facial tissue
layers (deep fascia to dermis) to support the dynamic midfacial
soft tissue in this location. These include the orbicularis retaining
ligament (ORL), the zygomaticocutaneous ligament (=CL), and the
masseteric ligament (Fig. 31.17, Fig. 31.18). Critical to eyelid and
midfacial aging changes are the ORL and =CL. At the medial lower
lid/cheek junction, there is a dense attachment of orbicularis
fi bers to the upper maxilla. This is a true ligament, which has been
called the tear trough ligament. With age, a multitude of factors,
including volume loss, orbital septal attenuation, and midface
ptosis, create a topographic depression over this area, which has
been called the tear trough or nasojugal groove (Fig. 31.17, Fig.
31.18). At the midpupil the ligamentous attachment of the infe-
rior orbital rim to the dermis becomes less dense and longer as it
traverses thicker tissue planes including fat. At this point the lig-
ament is called the ORL, and its associated age-related depression
above the orbito- or palpebromalar groove. In combination, the
nasal-to-lateral age-related lid–cheek depression is often referred
to as a prominent ´lid–cheek junctionµ (Fig. 31.19). Eff acement
of periorbital hollows, including the tear trough, has been
attempted by fi lling with synthetic materials, autologous fat or
allografts, native fat transposition, and a variety of tissue lift-
ing techniques. Familiarization with lower eyelid and midface
anatomy is critical to attaining successful results and avoiding
sometimes permanent complications with these innervations.
The =CL, like the ORL, is an osteocutaneous ligament that
originates from the periosteum of the zygoma and/or the anterior
and lateral border of the zygomatic arch (posterior to the origin
of the zygomaticus minor muscle) and insets into the dermis of
the cheek. As with the lid–cheek junction, age-related volume loss
and tissue descent lead to a characteristic groove (malar groove)
overlying the ligament, with tissue bulges or bags around the
groove (malar mound, Fig. 31.17, Fig. 31.19). As a general rule,
potential spaces are present in the loose areolar plane of the
anterior midface, and these spaces are bounded by the ligaments
described. These spaces are glide planes between the muscles of
facial expression above (within the SMAS) and the periosteum or
deep fascia below. These glide planes allow the facial soft tissue to
move freely over fi xed tissue. With age, diff erential laxity occurs
between these spaces and their accompanying ligament-sup-
ported boundaries. These diff erences account for much of what
we see in facial aging (bags and depressions).
Volume is an essential part of midface structure. Much of this
volume is attained from the midface fat pads. These fat pads are
critical to facial shape and appearance, involute with age in a
nonuniform way, and are target sites for facial volumization with
synthetic fi llers or autologous fat. These fat pads can be divided
into two groups. The fi rst is subcutaneous or superfi cial in depth
and above the SMAS, while the second is deep and sub-SMAS in
location. The superfi cial fat has nasolabial, medial, middle, and lat-
eral temporal compartments. The deep fat is divided into the sub–
orbicularis oculi fat (SOOF), which has both a medial and lateral
segment; a deep medial cheek fat, also with a medial and lateral
segment; and a deeper medial fat in a location called Ristow’s space
(lateral to piriform aperture, medial to deep medial fat).
The midface musculature functions to elevate the lip and the
corner of the mouth. These include the levator labii superioris
Orbital retaining ligament
Orbital septum
Zygomatic
cutaneous
ligament
Skin
Superficial fat
Orbicularis oculi muscle
SOOF
Bone
Prezygomatic space
Preperiosteal fat
Malar
mound
Nasojugal groove
Fig. 31.17 Layers of the midface from skin to periosteum with associated grooves and mounds which develop with age.

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VI Eyelid Surgery
(LLS), levator labii superioris alaeque nasi (LLSA1), and the leva-
tor anguli oris (LAO) medially, and the zygomaticus major (=M)
and minor (=m) laterally. The LLS originates on the medial infe-
rior orbital rim, courses over the infraorbital foramen to insert
on the orbicularis oris, and functions to elevate the lip vertically.
The LLSA1 originates on the frontal process of the maxilla course
inferiorly and splits into a medial and lateral head, inserting
onto the skin of the lateral nostril and upper lip. It functions to
flare the nostril and raise the lip. The LAO originates 1 cm below
the infraorbital foramen and inserts on the modiolus and outer
edge of the lip. It functions to elevate the angle of the mouth.
The =M originates at the zygomatic arch, inserts on the modiolus
of the mouth, and serves to move the lip laterally and vertically.
Finally, the =m originates on the maxillary process of the zygoma,
inserts on the lip just lateral to the LLS, and also functions as a
lip elevator.
31.4.1 Innervation
All midface muscles described above are primarily innervated
by the buccal branch of the facial nerve, with some overlap with
the zygomatic branch (Fig. 31.20). Damage to the facial nerve
with subsequent aesthetic and functional impairment has been
a major concern to surgeons operating in the midface. For this
reason, subperiosteal midface lifts gained popularity as to avoid
neuroinjury. However, in the midface, the facial nerve branches
run outside the walls of the glide planes described near the
retaining ligaments. Accordingly, surgical dissection is safe with
appropriate knowledge of anatomy. The sensory innervation
OL
ZL
MCL
Fig. 31.18 Osseocutaneous ligaments of the midface. OL, orbicularis
retaining ligament (ORL in text); =L, zygomaticocutaneous ligament
(=CL in text); MCL, masseteric ligament.
A
B
Orbital rim
indentation
Malar mound
Midfacial fold
Nasolabial
crease
Tear trough and
nasojugal fold
Fig. 31.19 Common aging changes in the periorbital and midface region. (a) The aged face with associated changes. (b) The youthful face.
a
b

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of the midface is from the maxillary division of the trigeminal
nerve (V2) via its infraorbital and zygomaticofacial branches.
31.4.2 Vasculature
The arterial supply of the midface is primarily from the ECA via
its terminal branches, including the infraorbital artery (from
the maxillary branch) and transverse facial artery (from the
STA). There is also a small contribution from the ICA through its
zygomaticofacial branch.
31.4.3 Venous and Lymphatic Drainage
The venous drainage of the midface is via the inferior ophthalmic
vein into the pterygoid plexus and from various facial veins that
drain into the external jugular vein. The lymphatic drainage can
be variable, with medial drainage to the submental and subman-
dibular nodes and lateral midface drainage to the preauricular
nodes.
31.5 Concluding Thoughts
As can be gleaned from reading this chapter, the anatomy of the
forehead, temples, eyelids, and midface are intimately associ-
ated and transition in a characteristic way from one structure
to the next. Understanding these interrelationships provides
the critical foundation necessary to proceed to sound surgical
interventions. It can be difficult for the novice surgeon to appre-
ciate the anatomy described three-dimensionally. It is highly
recommended that this text, and others like it, solely serve as
guides to a more thorough comprehension that can be attained
in dissections courses and anatomy labs.
Suggested Reading
>1@ Babakurban ST, Cakmak O, .endir S, Elhan A, 4uatela VC. Temporal branch
of the facial nerve and its relationship to fascial layers. Arch Facial Plast Surg
2010;12(1):16–23
>2@ Bricexo CA, Massry GG. Minimally invasive complementary adjuncts to upper
blepharoplasty. In: Azizzadeh B, Murphy MR, -ohnson C, Massry GG, Fitzgerald
R, eds. Master Techniques in Facial Rejuvenation, 2nd ed. 1ew 2018;107–119
>3@ Bricexo C, Undavia S, Massry GG. 4uantified incision placement for postsep-
tal approach transconjunctival blepharoplasty. Ophthal Plast Reconstr Surg
2016;32:191–194
>4@ Camirand A, Doucet -, Harris -. Anatomy, pathophysiology, and prevention of se-
nile enophthalmia and associated herniated lower eyelid fat pads. Plast Reconstr
Surg 1997;100(6):1535–1546
>5@ Choi <, .ang HG, 1am oculi around the lower eyelid: anatomy and its clinical implications. Plast Recon-
str Surg 2017;140(2):261–271
>6@ Czyz C1, Hill RH, Foster -A. Preoperative evaluation of the brow-lid continuum.
Clin Plast Surg 2013;40(1):43–53
>7@ Ettl A, Priglinger S, .ramer -, .oornneef L. Functional anatomy of the levator
palpebrae superioris muscle and its connective tissue system. Br J Ophthalmol
1996;80(8):702–707
>8@ Fitzgerald R. Contemporary concepts in brow and eyelid aging. Clin Plast Surg
2013;40(1):21–42
>9@ Fitzgerald R. Addressing facial shape and proportions with injectable agents in
youth and age. In: Azizzadeh B, Murphy MR, -ohnson C, Massry GG, Fitzgerald
R, eds. Master Techniques in Facial Rejuvenation, 2nd ed. 1ew 2018:15–54
>10@ Furnas D:. Landmarks for the trunk and the temporofacial division of the facial
nerve. Br J Surg 1965;52:694–696
>11@ Gausas RE. Advances in applied anatomy of the eyelid and orbit. Curr Opin Oph-
thalmol 2004;15(5):422–425
>12@ Harris PA, Mendelson BC. Eyelid and midcheek anatomy. In: Fagien S, ed. Putter-
man’s Cosmetic Oculoplastic Surgery, 4th ed. Philadelphia, PA: Elsevier Saunders;
2008:45–62
>13@ Hartstein ME. Levator ptosis repair in the aesthetic patient with and without blepha-
roplasty. In: Massry GG, Murphy M, Azizzadeh B, eds. Master Techniques in Blepha-
roplasty and Periorbital Rejuvenation. 1ew Temporal branch (frontal)
Parotid duct
Buccal branch
Marginal mandibular branch
Cervical branch
External jugular vein
Great auricular nerve
Postauricular nerve
Deep temporalis fascia
Superficial temporalis fascia
(temporoparietal fascia)
Zygomatic branch
Fig. 31.20 Illustration of the facial anatomy, including motor innervation of the midface via the zygomatic and buccal branches of the facial nerve.

356
VI Eyelid Surgery
>14@ Huang RL, Xie <, :ang :, et al. Anatomical study of temporal fat compart-
ments and its clinical application for temporal fat grafting. Aesthet Surg J
2017;37(8):855–862
>15@ -ordan DR, Anderson RL. Surgical Anatomy of the Ocular Adnexa: A Clinical Ap-
proach. San Francisco, CA: American Academy of Ophthalmology; 1996
>16@ .akizaki H, =ako M, 1akano T, Asamoto ., Miyaishi O, Iwaki M. The levator
aponeurosis consists of two layers that include smooth muscle. Ophthal Plast
Reconstr Surg 2005;21(5):379–382
>17@ .awai ., Imanishi 1, 1akajima H, Aiso S, .akibuchi M, Hosokawa .. Arterial ana-
tomical features of the upper palpebra. Plast Reconstr Surg 2004;113(2):479–484
>18@ .orn BS, .ikkawa DO, Hicok .C. Identification and characterization of adult
stem cells from human orbital adipose tissue. Ophthal Plast Reconstr Surg
2009;25(1):27–32
>19@ .ossler AL, Massry GG. The spectrum of canthal suspension techniques in lower
blepharoplasty. In: Azizzadeh B, Murphy MR, -ohnson C, Massry GG, Fitzger-
ald R, eds. Master Techniques in Facial Rejuvenation. 1ew 2018;152–165
>20@ Lam VB, Czyz C, :ulc AE. The brow eyelid continuum: An anatomic perspective.
Clinics in Plastic Surgery
>21@ Lee .-, .aram AM, Lam SM. Modern advances in Asian blepharoplasty. In: Massry
GG, Murphy M, Azizzadeh B, eds. Master Techniques in Blepharoplasty and Perior-
bital Rejuvenation. 1ew >22@ Massry GG. The external browpexy. Ophthal Plast Reconstr Surg
2012;28(2):90–95
>23@ McCord CD, Miotto GC. Dynamic diagnosis of ´fishmouthingµ syndrome, an over-
looked complication of blepharoplasty. Aesthet Surg J 2013;33(4):497–504
>24@ Malik .-, Lee MS, Park D-, Harrison AR. Lash ptosis in congenital and acquired
blepharoptosis. Arch Ophthalmol 2007;125(12):1613–1615
>25@ Massry GG. 1asal fat preservation in upper eyelid blepharoplasty. Ophthal Plast
Reconstr Surg 2011;27(5):352–355
>26@ Massry GG, 1assif PS. Transconjunctival lower blepharoplasty: fat excision or
repositioning. In: Massry GG, Murphy M, Azizzadeh B, eds. Master Techniques
in Blepharoplasty and Periorbital Rejuvenation. 1ew 2011:173–184
>27@ Massry G. ´The inverse shoe shine signµ in transconjunctival lower blepharoplas-
ty with fat repositioning. Ophthal Plast Reconstr Surg 2012;28(3):234–235
>28@ Meyer DR, Linberg -V, :obig -L, McCormick SA. Anatomy of the orbital septum
and associated eyelid connective tissues. Implications for ptosis surgery. Ophthal
Plast Reconstr Surg 1991;7(2):104–113
>29@ Moss C-, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous
attachments in the temple and periorbital regions. Plast Reconstr Surg
2000;105(4):1475–1490, discussion 1491–1498
>30@ Most SP, Mobley SR, Larrabee :F -r. Anatomy of the eyelids. Facial Plast Surg Clin
North Am 2005;13(4):487–492, v
>31@ Murchison AP, Sires BA, -ian-Amadi A. Margin reflex distance in different ethnic
groups. Arch Facial Plast Surg 2009;11(5):303–305
>32@ Panella 1-, :allin -L, Goldman 1D. Patient outcomes, satisfaction, and
improvement in headaches after endoscopic brow-lift. JAMA Facial Plast Surg
2013;15(4):263–267
>33@ Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of
its variations in face lifting. Plast Reconstr Surg 1966;38(4):352–356
>34@ Putterman AM, Urist M-. Surgical anatomy of the orbital septum. Ann Ophthal-
mol 1974;6(3):290–294
>35@ Rohrich R-, Pessa -E. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–2227,
discussion 2228–2231
>36@ Rohrich R-, Pessa -E, Ristow B. The youthful cheek and the deep medial fat com-
partment. Plast Reconstr Surg 2008;121(6):2107–2112
>37@ Sajja ., Putterman AM. Posterior approach ptosis repair in the aesthetic patient
with or without blepharoplasty. In: Massry GG, Murphy M, Azizzadeh B, eds.
Master Techniques in Blepharoplasty and Periorbital Rejuvenation. 1ew Springer; 2012:137–146
>38@ Samimi DB, Massry GG. Transconjunctival lower blepharoplasty with and
without fat repositioning. In: Azizzadeh B, Murphy MR, -ohnson C, Massry
GG, Fitzgerald R, eds. Master Techniques in Facial Rejuvenation. 1ew Elsevier; 2018;131–141
>39@ Schwarcz R, Fezza -P, -acono A, Massry GG. Stop blaming the septum. Ophthal
Plast Reconstr Surg 2016;32(1):49–52
>40@ Seiff SR, Seiff BD. Anatomy of the Asian eyelid. Facial Plast Surg Clin North Am
2007;15(3):309–314, v
>41@ Stuzin -M, :agstrom L, .awamoto H., :olfe SA. Anatomy of the frontal branch
of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg
1989;83(2):265–271
>42@ Stuzin -M, Baker T-, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg
1992;89(3):441–449, discussion 450–451
>43@ Sykes -M, Suarez GA, Trevidic P, Cotofana S, Moon H-. Applied facial anatomy.
In: Azizzadeh B, Murphy MR, -ohnson C, Massry GG, Fitzgerald R, eds. Master
Techniques in Facial Rejuvenation. 1ew >44@ Tan .S, Oh S-R, Priel A, .orn BS, .ikkawa DO. Surgical anatomy of the forehead,
eyelids and midface for the aesthetic surgeon. In: Massry GG, Murphy MR, Aziz-
zadeh B, eds. Master Techniques in Blepharoplasty and Periorbital Rejuvenation.
1ew >45@ :hipple .M, Oh SR, .ikkawa DO, .orn BS. Anatomy of the midface. In Hartstein
ME, :ulc AE, Holck DE, eds. Midface Rejuvenation. 1ew 2012:1–14
>46@ :ong CH, Hsieh M., Mendelson B. The tear trough ligament: anatomical basis
for the tear trough deformity. Plast Reconstr Surg 2012;129(6):1392–1402

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32 Clinical Decision Making in Aesthetic Eyelid Surgery
Foad Nahai
Abstract
There are numerous surgical and nonsurgical options for rejuve-
nation of the eyelids. Our clearer understanding of loss of volume/
deflation in the aging process has led to the more common,
almost routine addition of volume to the eyelids, be it fat or filler.
All surgical and nonsurgical options are presented and through
patient selection, the indications for each is presented.
Keywords
fat grafting, skin muscle flap, transconjunctival blepharoplasty,
skin pinch, canthopexy
32.1 Evaluation
The hallmark of youthful-appearing eyelids (Fig. 32.1) is a
smooth contour that extends from the brow to the upper lid
and from the lower lid to the cheek and midface. The lid–cheek
junction lies over the infraorbital rim and is usually 5 to 12 mm
below the lid margin. The skin is tight and the tissues are full.
There is an upward slant from the medial canthus to the lateral
canthus, and eyelid tone is normal: a snapback test results in
rapid lid recovery, and lid distraction will be 6 mm or less.
In contrast, the aged eye (Fig. 32.2) appears hollow, with a
definite demarcation from the brow to the upper lid and the lower
lid to the cheek and midface. In most individuals, the eye fissure
becomes smaller and rounder with age. The lid–cheek junction
lies well below the infraorbital rim, 15 to 18 mm from the lid
margin. There is a downward slant from the medial canthus to
the lateral canthus, and eyelid tone is significantly reduced, with
a very slow result to the lid snapback test and a lid distraction of
6 mm or greater.
These aging changes, which develop gradually over time, are a
combination of volume loss, loss of skin elasticity, and downward
descent of the tissues. These changes are classified into the follow-
ing four types (Fig. 32.3):
• Type I: Aging confined to the lower lid, with skin and muscle
laxity and pseudoherniation of the fat
• Type II: Aging no longer confined to the lower lid; in addition
to skin and muscle laxity, there is skin excess and minimal
descent of the lid-cheek junction
• Type III: Lower lid aging with volume loss, descent of the
lid–cheek junction, and malar eminence; skeletonization of
the orbital rim, deepening of the nasolabial fold, loss of skin
elasticity, and lid laxity are also common findings
• Type IV: Further volume loss and descent of the lid–cheek
junction; deepening of the nasojugal groove; presence of malar
bags; further loss of skin elasticity, lateral canthal descent, and
lid laxity with scleral show
This classification is most useful in selecting appropriate
procedures to address specific problems for each patient type. In
addition to addressing the lower eyelid, it also demonstrates that
aging of the lower lid and aging of the midface are intertwined.
Rejuvenation of one without the other will lead to a suboptimal
or patchwork result. Concomitant with the aging changes of the
lower lid and lid–cheek junction, there is a real or apparent loss of
volume that must be addressed (Fig. 32.4).
Fig. 32.1 Youthful-appearing eyelids.
Fig. 32.2 Aged eyelid.

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VI Eyelid Surgery
A component evaluation of the eyelids to determine aesthetic
options will also minimize complications. Components of eyelid
evaluation are discussed next.
Decision-Making Factors in Eyelid Surgery
Aesthetic factors:
• Skin
̑ 4uality
̑ 4uantity
• Muscle
• Fat
• Lid–cheek interface
• Scleral triangles
̑ Medial
̑ Lateral
Safety factors:
• Upper lid ptosis
• Lid tone
• Eye prominence
• Canthal position
Fig. 32.3 The four types of eyelid aging changes.
Fig. 32.4 (a) Type I; (b) Type II; (c) Type III; (d) Type IV.
a
c
b
d

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32.1.1 Skin
As an individual ages, the elasticity of eyelid skin diminishes,
causing the skin to appear loose and wrinkled. There is real
and apparent skin excess. The physician evaluates the quality
and quantity of the skin. In assessing upper eyelid skin excess,
the brow should be held in its ideal position. The eyelids should
always be evaluated with the eyes open as well as with them shut.
32.1.2 Muscle
Muscle activity and morphology are noted. :ith aging, the
orbicularis oculi muscle may become lax and hypertrophic,
especially in the pretarsal area. Infratarsal fullness may also be
present. Although this fullness is often associated with a youth-
ful eye, some patients are concerned about infratarsal fullness.
32.1.3 Fat
Two pockets of periorbital fat are contained within the upper
lid, with three in the lower lid. The surgeon notes these and
decides whether to preserve, redistribute, or remove this fat. In
addition, the retro–orbicularis oculi fat (ROOF) lying along the
lateral orbital rim between the orbicularis oculi muscle and the
periosteum is also assessed. Under rare circumstances, some of
this fat will need to be resected to improve the contour of the
lateral orbital rim.
32.1.4 Upper Lid Ptosis
The presence or absence of upper lid ptosis should always be
recorded. If present, it is pointed out to the patient, and plans are
discussed to correct it at the time of blepharoplasty.
32.1.5 Lid Tone
Lower eyelid tone is evaluated with the lid distraction test and
lid snapback test previously described. Routine correction of
lower lid laxity is essential to minimize complications.
32.1.6 Eye Prominence
(Hertel Measurement)
Eye prominence is assessed by means of the Hertel ophthalmom-
eter, which measures the distance between the cornea and the
lateral orbital rim (Fig. 32.5).
1ormal eye prominence, which is seen in 65 of the population,
ranges from 15 to 17 mm. Deep-set or anophthalmic eyes mea-
sure less than 15 mm, and any measurement of 18 mm or greater
indicates a prominent eye. These measurements play a significant
role in determining risk, procedure selection, and lid-anchoring
techniques (Fig. 32.6).
32.1.7 Canthal Position
The surgeon notes the position of the lateral canthus in relation
to the medial canthus. The lateral canthus should normally be
higher than the medial canthus. A lateral canthus at the same
level or lower than the medial canthus indicates significant lid
laxity, requiring horizontal lid shortening (canthoplasty) (Fig.
32.7).
32.1.8 Scleral Triangles
The triangle between the cornea and the medial canthus is
called the medial scleral triangle, and the triangle between the
Fig. 32.5 Use of the Hertel ophthalmometer to measure eye prominence.

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VI Eyelid Surgery
cornea and lateral canthus is called the lateral scleral triangle.
:ith increasing lid laxity and age, these triangles, especially the
lateral scleral triangle, are lost. Eye shape is judged by the shape
and size of the lateral scleral triangle. The tighter the triangle,
the more almond-shaped the eye; conversely, the looser the
triangle, the rounder the shape of the eye (Fig. 32.8).
32.1.9 SigniÀFDnFe RI (YDOuDWiRn
Components
Evaluation of skin, muscle, and fat plays a role in selecting the
best treatment option. However, of more importance is evalu-
ation of the lid–cheek interface and midface aging for lower lid
options. For the upper eyelid, the relationship between the upper
lid and the brow is an important determining factor.
Fig. 32.6 Normal eye prominence, which is seen in 65% of the population, ranges from 15 to 17 mm. Deep-set or anophthalmic eyes measure less
than 15 mm, and any measurement of 18 mm or greater indicates a prominent eye.
Fig. 32.7 Canthal position in the youthful and aged eye.
Fig. 32.8 Scleral triangles in the youthful and aged eye.

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Evaluation of lid tone, eye prominence, and canthal position
plays a pivotal role in determining which lid-anchoring procedure
is appropriate to minimize the potential for complications.
32.2 Preoperative Planning
32.2.1 Treatment Options
A variety of surgical and nonsurgical options are available
for treating upper and lower eyelid aging. Fat grafting and
injectables offer volume restoration of the upper lid and the
lid–cheek junction. Surgical options include transcutaneous
and transconjunctival approaches. Procedures range from the
simple transconjunctival removal of fat from both upper and
lower lids to complex procedures, including transpalpebral pro-
cerus and corrugator muscle modification, brow pexy through
the upper eyelid, and transpalpebral midface lift through the
lower eyelid.
32.2.2 Options for Fat Management
In recent years there has been a tremendous revolution in our
thinking about and approach to facial rejuvenation. This is espe-
cially true for concepts of fat preservation and augmentation,
not only in face lifts but even more so in blepharoplasty. Gone
is the standard skin, muscle, and fat excision blepharoplasty
that I was taught many years ago. Our current choices are to
preserve or redistribute the periorbital fat and occasionally
remove or even augment the fat. For augmentation, options
include autologous fat, autologous dermis, fillers, and even
alloplastic materials.
I base my options for fat management on evaluation of the
lid–cheek junction and choose a procedure to improve this area.
Although most surgeons continue to rejuvenate the lower lid
surgically, including fat grafting, injectable fillers are a safe and
effective option for lower lid rejuvenation, especially for correc-
tion of the tear-trough area (Fig. 32.9). I feel that the results of
surgical procedures are better, last longer, and are in the long run
more cost-effective than injectables.
Options for Fat Management
• Preserve
• Redistribute
• Augment
• Remove
If the patient has an adequate volume of fat, my preferred
technique for improving the lid–cheek junction is a combi-
nation of fat redraping and a transpalpebral midface lift with
orbicularis muscle flap redraping. If the patient does not
have fat herniation or enough fat for redraping, I plan no fat
manipulation, I do not open the periorbital septum, and I rely
on the transpalpebral midface lift and on orbicularis muscle
flap redraping.
If I think that these approaches are not adequate for correction
of the lid–cheek junction, I consider autologous tissue augmen-
tation. I have no experience with alloplastic implants around
the orbital rim, and I think that autologous tissue is better and
as effective. Occasionally, I do resect fat from the lower lid, most
often from the lateral compartment when the fat bulges out. The
patient shown in Fig. 32.10 had no fat removal from either lower
eyelid. The patient shown in Fig. 32.11 had fat removed only from
the lower left eyelid.
A previous review of a personal series of 100 consecutive
blepharoplasties revealed 49 with fat redraping, 38 with no
fat manipulation, 9 with fat excision, and 4 with autologous
grafting in the lower lid (Fig. 32.12). More recently, fat graft-
ing of the lower lid and lid cheek junction, with or without
skin excision, has become more common in my practice (Fig.
32.13). In the upper eyelid in the same series, I resected fat
from the medial nasal pocket in 76 and from the lateral
pocket in only 24 of cases (Fig. 32.12). Today it is very rare
that I resect fat from the central compartment. Those num-
bers were indicative of my practice a few years ago. Today fat
Fig. 32.9 Although most surgeons continue to rejuvenate the lower lid
surgically, injectable fillers are being established as a safe and effective
option for lower lid rejuvenation, especially for correction of the
tear-trough area.
Fig. 32.10 Periorbital rejuvenation without fat removal.

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VI Eyelid Surgery
preservation and augmentation are far more common in my
practice.
Resection of the ROOF was very popular a decade or two ago
and was part of my approach to the upper eyelid and lateral brow
in selected patients. Today, with a better understanding of the
aging process and the role of volume, I do not resect the ROOF.
Patients with a full subcutaneous pocket, deep to the lateral
hair-bearing brow, who would benefit from ROOF resection are
few and far between (Fig. 32.14).
:ith the current interest in fat preservation and adding
volume to the lower eyelid, it is possible that the surgeon may
injudiciously inject excessive amounts of autologous fat into the
periorbital area, as had been done to the patient shown in Fig.
32.15. Given the unpredictability of the survival of the grafted
fat, this is not an uncommon finding. Injecting deep and limiting
overcorrection will reduce or eliminate the chances of overinjec-
tion of fat. Transconjunctival and transcutaneous fat removal has
proved to be a relatively straightforward and effective procedure
for correction of this problem. The injected fat bears little resem-
blance to the periorbital fat and maintains the appearance and
morphologic character of the area from which it was harvested.
The transcutaneous approach was chosen for this patient so that
her lid retraction and skin excess could be addressed, along with
removal of the excess injected fat (Fig. 32.16).
Transconjunctival fat removal is shown in another patient in
Fig. 32.17.
32.2.3 Upper Eyelid
Options for upper eyelid rejuvenation are fewer than those for
the lower eyelid. Most upper eyelids are approached through a
standard skin–muscle incision. Rarely, the transconjunctival
approach is an option to resect excess fat in the medial pocket.
Fig. 32.11 This patient’s bulging lower left eyelid required resection of fat on that side only.
Fig. 32.12 Frequencies of fat management approaches in the author’s
practice in lower and upper blepharoplasties.
Fig. 32.13 Woman aged 64 (a) before and (b) after face- and neck lift
with fat grafting of cheeks and upper and lower eyelids.
a
b

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Fig. 32.17 Transconjunctival fat removal.
Fig. 32.14 Lower lid fat management.
Fig. 32.15 Patient who had undergone injection of an excessive amount of autologous fat in the periorbital area.
Fig. 32.16 The transcutaneous approach was chosen for the patient
in Fig. 32.15 so that her lid retraction and skin excess could be
addressed, along with removal of excess injected fat. (a) Pre- and (b)
postoperative images are shown here following the removal of the
excess fat, canthopexy, and transpalprebral mid facelift.
a
b

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VI Eyelid Surgery
A skin excision with muscle preservation may sometimes be
the best option to preserve orbicularis muscle so as to maintain
volume in the upper eyelid.
Options for Upper Eyelid Rejuvenation
• Transconjunctival fat removal from the medial pocket
• Skin and muscle excision
̑ Gateway to the lateral brow
̑ Gateway to the glabellar muscles
̑ Ptosis repair
• Skin excision with muscle and fat preservation
Options for rejuvenating the upper eyelid include transconjunc-
tival and transcutaneous approaches (Table 32.1). The transcon-
junctival approach has a limited role, confined to excision of fat
from the medial or nasal fat pocket. The most versatile approach
to the upper lid is excision of skin and muscle (the open-sky
approach), which allows access to the periorbital fat, ROOF, lateral
brow, glabellar muscles, and levator muscle. Recently the skin
excision with muscle preservation approach to the upper eyelid
has been popularized. :ith this volume-preserving procedure,
the orbicularis is preserved to increase the volume of the upper
eyelid. Access deep to the orbicularis is possible by merely divid-
ing the muscle rather than resecting it.
Transconjunctival Approach
The transconjunctival approach has limited application for
removal of the medial or nasal fat pocket only. I have found this
to be a safe, efficacious technique in primary as well as second-
ary fat removal from the medial pocket. Ideal candidates have
a bulging medial fat pocket of the upper eyelid with no excess
upper eyelid skin.
The lateral fat pocket, preaponeurotic fat, in the upper eyelid
lies anterior to the levator aponeurosis, whereas the medial or
nasal fat pocket lies medial to the aponeurosis. The insertion of
the levator aponeurosis into the tarsal plate prevents herniation
of the lateral fat pocket (Fig. 32.18); however, the medial horn
of the levator aponeurosis is much higher than the lateral horn.
This allows herniation of the medial fat as well as access to the
medial fat through the conjunctiva. The incision is made in the
conjunctiva medial to the medial border of the tarsal plate.
The advantage of this transconjunctival approach is that it
eliminates the need for an incision in the upper eyelid skin. This
approach has been free of complications in my hands, and I have
not seen any ptosis. The limitation of this approach is that only one
aspect of upper eyelid aging³medial fat herniation³is addressed.
Skin-Muscle Excision
Skin–muscle excision is the most versatile approach to the upper
eyelid, allowing manipulation and excision of fat from both
periorbital fat pockets; excision of ROOF, if indicated; access
to the lateral brow; and access to the glabellar muscles. The
skin–muscle excision approach also affords exposure of the leva-
tor and its aponeurosis for ptosis repair. It is a proven approach
with minimal morbidity. Potential problems include inadvertent
disruption of the levator aponeurosis, leading to postoperative
ptosis, and misplaced scars.
Skin Excision
In keeping with recent trends to preserve and restore volume in
facial rejuvenation, a volume-preserving upper lid skin excision
has been described (Fagien). If access deep to the orbicularis
is needed, the orbicularis is divided rather than resected. It is
thought that the small amount of orbicularis that is spared with
this approach adds volume to the upper lid.
32.2.4 Lower Eyelid
My approach to the lower eyelid is based on management of fat,
skin, muscle, and the lid–cheek junction. Options include the
transconjunctival and transcutaneous approaches. A detailed
evaluation of the eyelid and periorbital area helps determine
the appropriate selection of surgical technique. A variety of
procedures are available to manage the skin laxity and excess,
periorbital fat, muscle, and the lid–cheek interface and lid laxity.
Some are relatively straightforward, with minimal if any mor-
bidity (for example, skin-pinch blepharoplasty and transcon-
junctival fat removal), whereas others, especially those designed
to improve on the lid–cheek junction, not only are complex and
technically demanding but also may lead to lid retraction and
exposure. Correction of lid laxity and routine lid anchoring at
Table 32.1 Options for upper eyelid rejuvenation
&RmSRnenWV
7rDnVFRnMunFWiYDO
SNin Dnd
muVFOe
excision
SNin
excision
Skin
—
++++
++++
Muscle
—
++++
—
Fat
++++
(medial pocket only)
++++
—
Lateral brow
—
++++
—
Glabellar muscles
NA
++++
—
Ptosis repair
NA
++++
—
Degree of effectiveness indicated by the number of plus signs. NA: not applicable.
Fig. 32.18 The insertion of the levator aponeurosis into the tarsal plate
prevents herniation of the lateral fat pocket.

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365
the time of the primary procedure are prerequisites to minimize
these potential complications.
The lid–cheek junction can be improved and the lower lid reju-
venated through augmentation with fillers or fat and manipulation
of the superficial musculoaponeurotic system (SMAS) with open
facelift procedures, such as the high SMAS technique, SMASectomy,
and the extended minimal-access cranial suspension (MACS) lift
technique with a skin-pinch blepharoplasty. Although all of these
will improve on the lower lid, in my experience the results do not
match those of a skin-muscle flap blepharoplasty approach.
Options for Lower Eyelid Rejuvenation
• Fillers and fat
• Pinch blepharoplasty
• Transconjunctival fat removal
• Transconjunctival fat redistribution
• Transcutaneous:
̑ Skin flap
̑ Skin–muscle flap
̑ Fat management
̑ Orbicularis redraping
• Midface lift:
̑ Full open approach
̑ Limited or endoscopic approach
• Certain facelift techniques
Fillers
Autologous fat as a filler in the periorbital area is increasing in
popularity and effectiveness. A variety of hyaluronic acid fillers
(nonanimal stabilized hyaluronic acid fillers, or 1ASHAs), are
available for volume restoration of the lower lid, especially the
nasojugal groove.
Pinch Blepharoplasty
The pinch technique is safe and effective for removal of excess,
inelastic eyelid skin without disturbing the underlying orbicu-
laris muscle. Although it has a role as a stand-alone procedure,
a pinch blepharoplasty is most often combined with transcon-
junctival fat removal from the lower lid. It may also be used as
an adjunct to facelift procedures such as the extended MACS lift
and high-SMAS procedures that elevate the midface, resulting in
excess lower lid skin. Although a canthopexy can be performed
with a skin pinch blepharoplasty, it is not imperative.
In this procedure, the excess eyelid skin is pinched with one
pair of forceps in the left hand while the second pair of forceps in
the right hand progressively pinches and squeezes the extra skin,
proceeding from lateral to medial (Fig. 32.19). This ´pinchedµ skin
is then trimmed with a pair of scissors (Fig. 32.20).
The skin excision is completed (Fig. 32.21). Because the skin has
been pinched, there is very little bleeding after the skin excision.
By spreading the skin, the extent of the resection can be seen, and
bleeding points can be cauterized with bipolar cautery (Fig. 32.22).
Fig. 32.19 Pinch blepharoplasty. The excess eyelid skin is pinched with one pair of forceps in the left hand while the second pair of forceps in the right
hand progressively pinches and squeezes the extra skin, proceeding from lateral to medial.
Fig. 32.20 Pinch blepharoplasty. Once pinched, the excess skin is trimmed with a pair of scissors.

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VI Eyelid Surgery
Transconjunctival Approach
The transconjunctival approach offers two treatment options:
preseptal and postseptal (Table 32.2). The postseptal approach is
the most popular, as well as the safest and easiest route to access
the periorbital fat compartments. This approach generally is pre-
ferred for fat excision. The incision is made 4 to 5 mm below the
tarsal border at the level of the vascular arcade. The conjunctiva
and lid retractors are incised together, and the fat pockets are
immediately identified and excised as needed.
The preseptal approach affords the opportunity to resect fat as
well as the option to redrape the fat; it also provides access to
the midface region. The incision is made along the tarsal border
through the conjunctiva and lid retractors, then over the perior-
bital septum toward the orbital rim.
These transconjunctival approaches obviously will not allow
excision of skin or muscle. Some have advocated approaching
the fat and the midface through the transconjunctival approach
and adding a simple skin-pinch excision to deal with the excess
lower eyelid skin. Laser resurfacing with transconjunctival
blepharoplasty is another option. The major advantage of the
transconjunctival approach is that no incisions are made in the
orbicularis, thus minimizing, if not totally eliminating, the risk
of lid retraction. I have found the transconjunctival approach
for fat excision to be safe and effective with minimal, if any, risk
of lid retraction. I have also found that it is much more difficult
to manipulate fat and to access the midface through a preseptal
transconjunctival approach. I prefer to manipulate the fat and
approach the midface through a transcutaneous muscle–skin flap.
Transcutaneous Approach
The traditional transcutaneous skin–muscle flap is still my
preferred approach to the lower eyelid in a patient who requires
more than simple fat excision. This approach, especially any
incision in the orbicularis, has come under considerable attack
and scrutiny over the past few years. Some believe that any
incision within the orbicularis will lead to its denervation and
result in lid retraction. However, the cause of lid retraction is
multifactorial, with orbicularis denervation merely one of the
many potential causes.
Causes of Lid Retraction
• Anterior lamellar insufficiency
• Middle lamellar scarring
• Lid laxity
• High-risk patient
• Orbicularis muscle excision/denervation
The anterior lamella is composed of skin and the orbicularis
muscle. Overresection of skin and muscle will lead to lid retraction.
This is easily avoided through judicious skin excision. The middle
lamella is composed of the periorbital septum and periorbital fat.
:ithout doubt, scarring of the middle lamella is a major cause of
lid retraction, and any procedure requiring manipulation within
the middle lamella will increase the risk of lid retraction. This risk
is minimized through meticulous dissection and hemostasis in
the middle lamella and aggressive treatment of any postoperative
bleeding or hematoma.
Unrecognized or untreated lid laxity is also a major cause of
lid retraction. The routine application of lid-anchoring techniques
in patients undergoing the transcutaneous skin–muscle flap
approach and middle lamellar manipulations significantly reduces
the risk of lid retraction. Horizontal lid shortening, if indicated,
is also my routine. This is particularly appropriate for high-risk
patients, including those with prominent or enophthalmic eyes,
Table 32.2 Options for lower eyelid rejuvenation
&RmSRnenWV
7rDnVFRnMunFWiYDO
preseptal
7rDnVFRnMunFWiYDO
postseptal
7rDnVFRnMunFWiYDO Dnd ODVer
reVurIDFing Rr VNin SinFK
SNin-muVFOe
SNin-muVFOe
Dnd RrEiFuODriV
ÁDS
Trans-
SDOSeErDO
midIDFe OiIW
Skin
+
+
++
++++
++++
++++
Muscle
+
+
+
++++
++++
++++
Fat
++++
++++
++++
++++
++++
++++
Lid-cheek interface
++++
+++
++++
Degree of effectiveness indicated by the number of plus signs.
Fig. 32.21 Pinch blepharoplasty. The skin excision is completed.
Fig. 32.22 Pinch blepharoplasty. Because the skin has been pinched,
there is very little bleeding after the skin excision. By spreading the
skin, the extent of the resection can be seen, and bleeding points can
be cauterized with bipolar cautery.

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367
and for anyone undergoing a secondary blepharoplasty. There is
no question that true and complete denervation of the orbicu-
laris, especially the pretarsal portion, will lead to lid retraction.
Similarly, there is no question that a 5-mm rim of innervated
orbicularis should remain on the tarsal plate.
The question of denervation is currently a topic of much
debate. The orbicularis is innervated by the zygomatic and buccal
branches of the facial nerve. The bulk of the orbicularis muscle,
the extracanthal orbicularis, is innervated by the zygomatic
branches; classically, these branches run from below upward,
almost perpendicular to the tarsal plate, and there is no ques-
tion that division of the orbicularis as in the skin–muscle flap
approach will divide these branches. The extracanthal orbicularis
is responsible for squeezing the eyelid, whereas the inner canthal
orbicularis (that part of the orbicularis within 5 to 10 mm of the
medial canthus) is responsible for eyelid closure, blinking, lower
lid tone, and the tear pump.
This extracanthal portion of the muscle is innervated by the
buccal branches and is usually preserved with the standard
skin–muscle incision unless the incision in the muscle is contin-
ued all the way to the medial canthus. Leaving a 5-mm segment
of pretarsal muscle on the tarsal plate and limiting the incision in
the orbicularis to within 10 to 15 mm of the medial canthus will
preserve a functioning, fully innervated portion of the orbicularis
with adequate lid tone and closure (Fig. 32.23).
I individualize the extent of the incision in the orbicularis
muscle. I approach the lower eyelid through the skin incision and
elevate a small skin flap; the orbicularis muscle is then divided
separately and elevated as a combined skin–muscle flap. The
extent of the incision I make in the orbicularis depends on my
plans for the middle lamella, as follows.
If I do not plan any middle lamellar manipulations, such as
fat excision or redraping, I make a limited-access incision in the
orbicularis starting 10 mm lateral to the lateral canthus and
extending up to 10 mm medial to the lateral canthus. This short
incision allows access to the entire midface complex. It also
enables release of the arcus marginalis all the way to the medial
canthus, identification and preservation of the infraorbital nerve,
and full subperiosteal dissection of the midface. I prefer to do the
dissection with a headlight and a slim retractor, although others
have advocated the use of the endoscope (Fig. 32.24).
If fat redraping or dermis fat augmentation is planned, however,
then the orbicularis incision is extended to within 10 to 15 mm
of the medial canthus with a full-access incision. Both of these
incisions allow me to excise as much skin as needed, elevate and
fix the midface, redrape the orbicularis, and resect any orbicularis
excess. Occasionally, in a patient who has excess periorbital fat,
the limited-access incision may be combined with transconjunc-
tival fat removal (Fig. 32.25).
Fig. 32.23 Motor innervation in the periorbital region.
Fig. 32.24 Limited-access incision in the orbicularis starting 10 mm
lateral to the lateral canthus and extending up to 10 mm medial to the
lateral canthus.
Fig. 32.25 If fat redraping or dermis fat augmentation is planned, then the orbicularis incision is extended to within 10 to 15 mm of the medial
canthus with a full-access incision.

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VI Eyelid Surgery
Orbicularis Flap
All of the transcutaneous skin–muscle flap procedures on the
lower lid include orbicularis oculi muscle flap redraping. This
serves two purposes: functional and aesthetic. The orbicularis
is redraped so that it sits snugly against the lower lid tarsus and
adds extra support to the lower lid. Redraping with a vertical or
combined diagonal and vertical vector will elevate the midface
complex, especially the diagonal vector, and will further enhance
the youthful appearance of the lower lid (Fig. 32.26).
32.2.5 Transpalpebral Midface Lift
Many approaches are available to rejuvenate the midface area.
I prefer this combined approach, because it allows the lower lid
and midface to be treated as a single unit. I make a limited-access
or full-access incision, depending on the need for middle lamella
manipulation. Through either approach, a full subperiosteal
dissection and elevation of the midface are performed. I include
some subperiosteal dissection below the infraorbital rim on all
blepharoplasties in type II, III, and IV patients.
32.2.6 Regional Procedures
Blepharoplasty is one component of periorbital rejuvenation.
Often upper lid blepharoplasty is combined with some type of
brow or forehead rejuvenation. The lower lid is so intimately
involved with the midface complex that I think of the lower lid
and cheek as one entity. Therefore, in almost all blepharoplasties
for type II, III, and IV patients, I perform a midface lift; the extent,
of course, is individualized, depending on the degree of aging
and our goals for the patient. These regional procedures reflect
the approach to facial rejuvenation, addressing facial zones or
the entire face rather than individual components, such as the
eyelids, brow, or midface.
32.3 Ancillary Procedures
The surgical procedures just described will rejuvenate the upper
and lower eyelids, improve the relationship of the upper lid and
brow, and improve the lower lid–cheek junction and midface.
Frequently, additional ancillary procedures are performed
to enhance the result. These include peels, laser resurfacing,
alloplastic implants, and fat grafting or fillers as an adjunct.
Laser resurfacing or peeling of sun-damaged, wrinkled skin at
the time of blepharoplasty is a safe procedure, because the skin
has been elevated as a reliable musculocutaneous flap with a full
blood supply.
Fat is the filler material of choice around the eyelids and cheek.
Although autologous fat injections are frequently the primary
treatment for aging in the periorbital area, they also have a signif-
icant role as an adjunct to lower lid blepharoplasty and midface
lift. As discussed previously, dermis fat is placed along the orbital
rim to enhance the results in patients who have a deficiency in
this area. Alloplastic materials, especially cheek implants, may
also enhance the results.
32.4 Results
32.4.1 Short-Term Results
The woman shown in Fig. 32.27 in her mid-40s exhibited type
II aging of the lower lid–cheek junction. She also had lid laxity,
a round eye, and scleral show bilaterally. She underwent upper
and lower lid blepharoplasties with a transpalpebral midface lift
and lid anchoring to correct the lid laxity and scleral show. She
also had a facelift and neck lift. Her postoperative result shows
correction of the aging changes of the lower lid and correction of
the lid laxity and round eye.
The middle-aged woman shown in Fig. 32.28 had type II aging
of the lower lids, brow ptosis, grade IV glabellar and forehead
lines, and grade III aging of the lower lid–cheek junction and
nasolabial folds. She was treated with an endoscopic brow lift,
upper and lower lid blepharoplasties with a transpalpebral
midface lift, and erbium laser resurfacing of the forehead and
glabella. Postoperative views show an improved brow position,
lidcheek junction, midface, and nasolabial folds. The split-face
view more dramatically demonstrates the rejuvenative effect of
these procedures.
The woman in her late 40s shown in Fig. 32.29 had type II aging
changes of the lower lids, midface, and jowls. She underwent a
short-scar facelift, rhinoplasty, and lower lid blepharoplasty, with
fat redistribution and orbicularis redraping. She was very pleased
with the improvement in the lower lid–cheek junction, nasolabial
folds, and perioral area.
The woman shown in Fig. 32.30, who is in her 60s, had type III
aging of the lower lids, as well as lid laxity, tear-trough deformity,
nasojugal grooves, and early development of malar bags. Upper
and lower lid blepharoplasties with a transpalpebral midface lift,
orbicularis redraping, and canthopexy were performed. She also
underwent concomitant erbium laser resurfacing of the perior-
bital area. The postoperative result shows improvement in the
lid–cheek junction, with amelioration of the malar mound and
early festoons.
More severe aging changes are evident in the 60-year-old
woman shown in Fig. 32.31, who had type IV aging of the lower
eyelids. She had lid laxity; the lateral canthus was significantly
lower than the medial canthus. She also had malar mounds and
Fig. 32.26 Orbicularis flap.

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Fig. 32.27 This woman in her mid-40s exhibited type II aging of the lower lid–cheek junction. She also had lid laxity, a round eye, and scleral show
bilaterally. She underwent upper and lower lid blepharoplasties with a transpalpebral midface lift and lid anchoring to correct the lid laxity and scleral
show. She also had a short scar facelift and neck lift. Her postoperative result shows correction of the aging changes of the lower lid and correction of
the lid laxity and round eye short scar.
Fig. 32.28 This middle-aged woman had type II aging of the lower lids, brow ptosis, grade IV glabellar and forehead lines, and grade III aging of the
lower lid–cheek junction and nasolabial folds. She was treated with an endoscopic brow lift, upper and lower lid blepharoplasties with a transpalpe-
bral midface lift, and CO2 laser resurfacing of the forehead and glabella. Postoperative views show an improved brow position, lid–cheek junction,
midface, and nasolabial folds. The split-face view more dramatically demonstrates the rejuvenative effect of these procedures.

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VI Eyelid Surgery
festoons. To address these problems, she underwent lower lid
blepharoplasty with a transpalpebral midface lift, horizontal lid
shortening with cantholysis and canthoplasty, and a facelift and
neck lift. Her postoperative result shows significant improvement
in the lower lid–cheek junction, amelioration of the festoons, and
improved eyelid position.
The 40-year-old woman shown in Fig. 31.32 had prominent
eyes with a Hertel measurement of 23 mm, thus making her
a high-risk blepharoplasty patient. She underwent lower lid
blepharoplasty with fat redistribution and placement of a pri-
mary spacer graft with AlloDerm (Allergan, Dublin, Ireland) and
canthopexy and a short-scar facelift. Fig. 32.33 shows release of
the lower lid retractors, placement of an AlloDerm spacer, and
redistribution of fat. The split-face view of this patient, shown in
Fig. 32.34, demonstrates the postoperative improvement in the
lower lid–cheek junction, with normal lid position.
Fig. 32.32 This 40-year-old woman had prominent eyes with a Hertel
measurement of 23 mm, thus making her a high-risk blepharoplasty
patient. She underwent lower lid blepharoplasty with fat redistribution
and placement of a primary spacer graft with AlloDerm and cantho-
pexy and a short-scar facelift.
Fig. 32.30 This woman, who is in her 60s, had type III aging of the
lower lids, as well as lid laxity, tear-trough deformity, nasojugal
grooves, and early development of malar bags. Upper and lower
lid blepharoplasties with a transpalpebral midface lift, orbicularis
redraping, and canthopexy were performed. She also underwent
concomitant erbium laser resurfacing of the periorbital area. The
postoperative result shows improvement in the lid–cheek junction,
with amelioration of the malar mound and early festoons.
Fig. 32.31 This 60-year-old woman had type IV aging of the lower
eyelids. She had lid laxity; the lateral canthus was significantly lower
than the medial canthus. She also had malar mounds and festoons. To
address these problems, she underwent lower lid blepharoplasty with
a transpalpebral midface lift, horizontal lid shortening with cantholysis
and canthoplasty, and a facelift and neck lift. Her postoperative
result shows significant improvement in the lower lid–cheek junction,
amelioration of the festoons, and improved eyelid position.
Fig. 32.29 This woman in her late 40s had type II aging changes of the lower lids, midface, and jowls. She underwent a short-scar facelift, rhino-
plasty, and lower lid blepharoplasty, with fat redistribution and orbicularis redraping.

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32.4.2 Long-Term Results
The type II patient in Fig. 32.35 is shown 9 years after an
endoscopic brow lift, upper and lower blepharoplasty with fat
redistribution, orbicularis redraping, and canthopexy.
Another type II patient demonstrates a typical result; she is
shown 3 months, 5 months, and 5 years after a skin–muscle flap
blepharoplasty with fat redistribution, orbicularis redraping, and
canthal anchoring (Fig. 32.36).
32.5 Choosing the Best Option
Guidance for choosing the best option for the upper eyelid is
given in Fig. 32.37. Guidance for choosing the best option for the
lower eyelid is given in Fig. 32.38.
Fig. 32.34 This split-face view of the patient in Fig. 32.32
demonstrates the postoperative improvement in the lower lid–cheek
junction, with normal lid position.
Fig. 32.33 (a) Release of the lower lid retractors, (b) placement of the primary AlloDerm spacer, and (c) redistribution of the fat (right).
a
b
c
Fig. 32.35 This type II patient is shown (a,c) before and (b,d) 9 years
after an endoscopic brow lift, upper and lower blepharoplasty with fat
redistribution, orbicularis redraping, and canthopexy.
a
c
b
d

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VI Eyelid Surgery
Fig. 32.37 Options for upper eyelid blepharoplasty.
Fig. 32.36 Type II patient demonstrates a typical result; she is shown (a) before, 3 months after, (b) 5 months after, and 5 years after a
skin–muscle flap blepharoplasty with fat redistribution, orbicularis redraping, and canthal anchoring.
a
b