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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VI Eyelid Surgery
33 Upper Eyelid Blepharoplasty
Ted Wojno
Abstract
Upper eyelid blepharoplasty is perhaps the most commonly per-
formed aesthetic surgery worldwide. This chapter will outline
the evaluation of patients for this procedure, discuss the relevant
anatomy, and describe the surgery in detail. Avoidance of com-
plications is stressed.
Keywords
blepharoplasty, ptosis, eyelid crease, eyelid fold, ptosis fi eld,
dermatochalasis, orbital septum
33.1 Indications and
Contraindications
33.1.1 Functional Upper Eyelid
Blepharoplasty
Patients who present for upper eyelid blepharoplasty can be
thought of as falling into two categories that often overlap. Many
older individuals are interested in functional improvement
to alleviate complaints of visual obstruction from redundant
upper eyelid tissues. Such patients complain of diffi culties with
activities of daily living such as driving and reading but will
often add comments related to tasks performed on their jobs
that are unique to their own situations. :hen severe, they may
complain of a frontal headache by day’s end due to constant use
of the frontalis muscle in an unconscious eff ort to open the eyes
to improve the superior and lateral fi elds of vision. Symptoms
are often vague, such as ´my eyes feel tired,µ ´I cannot seem
to get enough light in,µ or ´I have trouble reading.µ Patients
frequently state that the upper lids feel heavy, especially by the
end of the day. They will pull up on the eyebrow to demonstrate
how vision improves when the brow and forehead are lifted,
since they usually do not distinguish between upper eyelid skin
redundancy and brow ptosis (Fig. 33.1). Pointing this out to the
patient gives the physician the opportunity to explain the signif-
icant diff erence between upper eyelid blepharoplasty and brow
or forehead lifting. :hen patients realize that these are two
distinct but related procedures, they are sometimes confused
as to what is the best way to alleviate the functional problem.
Thus, it is the duty of the physician to help them to decide on
the best surgical option. This does not imply that patients who
seek functional improvement in their visual fi eld are not inter-
ested in cosmesis. Although the patient may state, ´I only want
to see better,µ the aesthetic appearance is usually a very close
second, if often unspoken, goal of the surgery. This is true even
for those individuals in their ninth or tenth decade of life. Simply
put, no one wants to look bad after eyelid or facial surgery.
Therefore, any cut placed on the face of the patient for any reason
has an aesthetic component.
Often patients are reluctant to express their desires for aes-
thetic surgery for fear of being labeled as vain by family mem-
bers or even the physician. Many have spent considerable time
searching the Internet to educate themselves as to exactly what
to say to communicate that their vision is functionally impaired,
in hopes of obtaining insurance coverage for the procedure. In
an age where one can easily access web-based data on any topic,
we should assume that patients have acquired at least a cursory
education in how to present themselves at the initial consultation.
A simple inquiry by the physician, such as ´How important is it to
you that the result look attractive"µ can open the discussion up
to the aesthetic component of surgery and reassure the patient
that the physician is also concerned that the patient experience
a favorable cosmetic outcome. I typically tell such patients that
I expect that, upon completion of surgery, not only will they will
see a signifi cant improvement in their visual function but they
should look better too.
33.1.2 Aesthetic Upper Eyelid
Blepharoplasty
The second group of patients are those who are primarily seeking
aesthetic improvement. On the whole, this is a younger group of
patients than those who come for functional improvement and
is predominantly female. I continue to be impressed by the fact
that this group often presents shortly after the conclusion of a
major negative life event such as severe illness or divorce. They
may be seeking cosmetic surgery to help lift their spirits, as a
reward for battling through medical problems, or as a prelude
to getting back into social dating. It is important to understand
Fig. 33.1 Patient demonstrating how vision is improved by pulling up
on the eyebrow.

33 Upper Eyelid Blepharoplasty
375
the underlying motivations of this group, since they are more
likely to be suffering emotional turmoil and are less likely to be
satisfied with results that they view as not achieving the desired
outcome. The desired outcome, of course, is sometimes not
totally related to the ultimate appearance after surgery.
-ust as functional patients may be secondarily interested in
aesthetic improvement, those patients who present for what they
regard as purely cosmetic interests often notice that their vision
has improved after upper eyelid blepharoplasty. It is important
to inform them prior to surgery that insurance coverage may be
possible.
33.1.3 General Considerations
I always ask my patients what type of work they do, since this
may have a bearing on how long it takes for them to recover and
return to full activity. A desk worker can often return to ´full
activityµ on the next day, whereas someone who performs heavy
manual labor may need to be off the job for two weeks or more.
The patients must realize that there will be a variable and unpre-
dictable period of bruising and swelling, during which they may
feel that they do not want to appear in public. The answer to the
question ´How bad will I look after surgery"µ is very different
from one person to the next, and the physician needs to have this
discussion with each patient.
I also inquire as to whether the patient is seeking surgery prior
to a major social event, such as a family wedding or class reunion.
The patient may not have allowed enough time between the
proposed date of surgery and the social event to permit adequate
healing. I caution patients to allow 2 weeks for bruising and 2
months for swelling to resolve. I tell them that we may need to
do additional ´touch-upsµ in the months that follow in order for
them to ´get as close to normal and symmetric as possibleµ and
that they should take all of this into consideration when planning
the timing of the procedure. This not infrequently results in
the patient deciding to wait until after the social event to have
surgery.
Some patients will plan a vacation immediately after surgery so
as to give themselves time to return to work or social engagements
without others noticing that they had surgery. They are often
surprised to find that they have significantly underestimated the
time needed to return to work. Some patients assume that the
surgeon will use ´those stitches that just fall out by themselves,µ
so this too needs to be discussed in the preoperative evaluation
and reiterated on the day of surgery. Some patients may travel a
long distance to have a procedure by a particular surgeon and will
ask, ´:hy can’t my doctor at home take out my stitches"µ This as
well should be discussed in advance of the procedure.
I caution all patients that upper eyelid blepharoplasty always
leaves a scar that will be noticeable to some degree. I advise
women that the incision in the upper eyelid frequently results in
a degree of numbness in the pretarsal skin and eyelashes for at
least 6 to 12 months, caused by cutting the sensory nerve fibers
that run vertically from below the brow inferiorly to the lash line.
Some women find that this temporary anesthesia is bothersome
when applying eye makeup due to the lack of tactile feedback
from the makeup brush.
There are few absolute contraindications to upper eyelid bleph-
aroplasty. Patients with disorders such as thyroid eye disease,
blepharochalasis syndrome (angioneurotic edema), rosacea, dry
eye syndrome, and essential blepharospasm may safely undergo
surgery if appropriately counseled and surgery is tailored to the
individual patient. Indeed, these can be some of the happiest
patients after surgery.
Likewise, patients with pre-existent lagophthalmos, for any
reason, should be carefully evaluated, since removal of additional
upper eyelid tissue would very likely exacerbate the problem.
Methods of lagophthalmos correction could be considered as an
adjunct to blepharoplasty surgery in such cases.
Perhaps the only absolute contraindications to upper bleph-
aroplasty are an uncontrolled coagulopathy or an inability to
discontinue anticlotting medications adequately for enough time
to minimize the risk of orbital hemorrhage. I caution patients
to discontinue all medications³prescription, over-the-counter,
or herbal³that can interfere with the coagulation system. For
prescribed medications, the patients must supply written docu-
mentation from their physician that the medications can be safely
discontinued and if so, for how long. If the patient’s physician is
unwilling to hold such medications for a sufficient length of time
to return the clotting status to normal, then the patient should
be informed of the relative risk of vision-threatening hemorrhage
depending on the individual circumstances. Obviously, the greater
the degree of anticoagulation, the greater the threat to vision.
:hen informed of this possibility, no matter how remote, some
patients will decide not to have the surgery.
As with any procedure, unreasonable expectations will
invariably lead to dissatisfaction with the results and the sur-
geon. Unfortunately, underlying psychopathology is not always
obvious in the preoperative period but becomes manifest only
postoperatively.
33.2 Pertinent Anatomy
33.2.1 Skin and Crease/Fold Complex
The eyelid skin is often the thinnest in the body, but this does
vary considerably amongst individuals and ancestries. :ith age,
the subcutaneous blood vessels are often noticeable and some-
times a source of dissatisfaction to patients. The upper eyelid fold
overlaps the upper eyelid crease. The crease is formed by elastin
fibers from the levator aponeurosis that penetrate through the
orbicularis oculi and insert into the underside of the dermis
(Fig. 33.2). In general, the fold is lowest in Asians, midrange
in Caucasians and highest in African populations (Fig. 33.3). A
lower fold generally gives the impression of having more skin,
while a higher fold gives the impression of less skin. The amount
of pretarsal show (the vertical height of visible skin below the
fold) preferred by the patient should be determined prior to
the surgery. The position and shape of the fold must always be
considered in surgery of the upper eyelid, since asymmetry of
the fold is quite noticeable.
33.2.2 Orbicularis Oculi Muscle
The orbicularis oculi muscle is divided into pretarsal, preseptal,
and orbital parts (Fig. 33.4a). The orbicularis is the protractor
muscle of the eyelids, functioning as a sphincter to blink for

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VI Eyelid Surgery
maintenance of the precorneal tear fi lm, close the eye for pro-
tection, and pump tears down the lacrimal system. The pretarsal
and preseptal parts of the orbicularis oculi insert medially into
the medial canthal tendon and then to the anterior and poste-
rior lacrimal crests, respectively. Laterally they insert into the
lateral canthal tendon and then into Whitnall’s orbital tubercle
(which most often is not a discernable structure) just inside the
orbital rim. The orbicularis oculi muscle interdigitates with
the frontalis muscle under the eyebrow and the corrugator and
procerus muscles in the medial brow. The motor innervation
to the orbicularis oculi comes from the frontal and zygomatic
branches of the facial nerve (Fig. 33.4b). Note that the buccal
branch separately innervates the medial aspect of the orbicularis
in the lower eyelid.
Any loss of function of the orbicularis oculi, whether due to
disease, injury or surgery, is signifi cantly debilitating. Despite
this fact, remarkable amounts of the orbicularis muscle can be
removed in upper eyelid surgery with no discernable loss of its
function. This is evidenced by the fact that patients who have
undergone orbicularis oculi myectomy for essential blepharo-
spasm have surprisingly few problems with lagophthalmos.
33.2.3 Tarsal Plate
The tarsal plates are composed of dense collagen and function
as the skeleton of the eyelids (Fig. 33.5). They contain the
Fig. 33.2 Cross-sectional view of the upper eyelid showing the elastin
fi bers given off by the levator to insert into the dermis thus forming
the upper eyelid crease. ROOF, retro–orbicularis oculi fat; SOOF,
sub–orbicularis oculi fat. (Reproduced from Nahai F, ed. The Art of
Aesthetic Surgery: Principles and Techniques, 2nd ed. New Thieme; 2011.)
Fig. 33.3 Variations in upper eyelid crease height with ancestral
group. (a) Asian, very low crease. (b) Caucasian, intermediate crease.
(c) African, relatively high crease.
a
b
c
Fig. 33.4 (a) The muscular anatomy of the periorbital region. (b) The motor innervation to the orbicularis oculi from the frontal and zygomatic
branches of the facial nerve. (Reproduced from Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques, 2nd ed. New 2011.)
a
b

33 Upper Eyelid Blepharoplasty
377
meibomian glands, which produce the outer, oily component of
the precorneal tear film, which prevents evaporation of the aque-
ous component of tears. Any incision through the tarsal plates can
decrease function of these glands and thus disrupt the tear film.
33.2.4 Orbital Septum and Lacrimal Gland
The orbital septum forms the anterior border of the orbit and con-
tains the two fat pockets of the upper eyelid. The medial pocket
is whiter and contains the medial palpebral artery, a terminal
branch of the ophthalmic artery. It is important to recognize this
artery when resecting this fat pocket, since if not adequately
cauterized, it can cause significant bleeding after retracting back
into the orbit. The lateral fat pad of the upper eyelid (referred to
by some authors as the middle pocket) is more yellow, due to
the greater amount of beta carotene compared with the medial
pocket. The significance of this difference is unclear (Fig. 33.6).
The lateralmost part of the upper eyelid contains the orbital
portion of the lacrimal gland, which with age can prolapse out
of the orbit from its attachment inside the superior orbital rim
and present as a distinct bulge in the lateral upper eyelid. Care
should be taken to avoid resection of the gland during surgery of
the upper eyelid. The palpebral lobe of the lacrimal gland lies just
under the lateral upper eyelid.
33.2.5 The Levator and Müller’s Muscle
Virtually all surgery performed on the upper eyelid must take
into account the levator palpebrae superioris muscle. This muscle
must be judiciously avoided in upper eyelid blepharoplasty
and carefully handled during ptosis repair. The levator muscle
arises from the lesser wing of the sphenoid bone superior to the
annulus of =inn. In the orbit it lies above, but is closely applied
to, the superior rectus muscle. It inserts into the medial canthal
tendon, the lateral canthal tendon (after dividing the orbital
and palpebral lobes of the lacrimal gland), the superior tarsal
border, the anterior face of the tarsus, the pretarsal orbicularis,
and overlying skin. The striated portion of the levator muscle is
40 mm long, while the aponeurotic component is 15 mm long,
although this varies considerably based on individual anatomy.
The levator muscle contains :hitnall’s superior transverse liga-
ment at the level of the equator of the globe (Fig. 33.7). This is a
condensation of fascia typically 15 to 20 mm above the superior
tarsal border that attaches to the trochlea, the levator horns, the
lacrimal gland, and the lateral orbital wall. Whitnall’s ligament
functions as a suspensory ligament of the upper eyelid and a
pulley or fulcrum around which the levator changes direction
Fig. 33.7 Whitnall’s superior transverse ligament (arrow).
Fig. 33.5 Detailed anatomy of the upper eyelid. (Reproduced from
Codner MA. Eyelid and Periorbital Surgery. New 2016.)
Levator aponeurosis
Gland of Wolfring
Gland of Moll
Gland of Zeis
Meibomian
gland
Crypts of Henle
Gland of Manz
Palpebral lobe
of lacrimal gland
Orbital lobe
of lacrimal gland
Gland of Krauss
Fig. 33.6 The medial and lateral preaponeurotic fat pockets in the left
upper eyelid. Note that the lateral pocket is distinctly more yellow in
color .

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VI Eyelid Surgery
from an anterior–posterior direction to a superior–inferior
direction.
The adrenergic Mller’s muscle arises from the posterior sur-
face of the levator muscle and inserts onto the superior border
of the tarsal plate. It is approximately 10 mm long. The plane
between the levator muscle and Mller’s muscle is relatively
easy to open surgically, while that between the conjunctiva and
Mller’s muscle is typically very tightly adherent and more diffi-
cult to separate.
33.2.6 The Conjunctiva
The conjunctiva is the inner, mucous membrane surface of the
eyelids (palpebral conjunctiva), which is reflected onto the sur-
face of the globe (bulbar conjunctiva) in the superior and inferior
fornices or culs-de-sac. The conjunctiva contains numerous
accessory lacrimal glands and mucin-producing glands, which
contribute to the precorneal tear film.
33.2.7 The Lacrimal Apparatus
The lacrimal puncta are found medially in the upper and lower
eyelid margins. They lead to the upper and lower canaliculi, each
being about 8 mm long. In 90 of patients, the upper and lower
canaliculi combine to form a 1- to 2-mm common canaliculus
that enters the upper part of the lacrimal sac just under the
medial canthal tendon. Care is necessary when any dissection is
performed medial to the puncta.
33.2.8 The Trochlea and Superior
Oblique Muscle
-ust medial to the supraorbital notch and 2 to 4 mm inside the
superior orbital rim is the trochlea. This is a U-shaped piece
of fibrocartilage that acts as a pulley to transmit the superior
oblique tendon, which passes inferiorly, posteriorly, and laterally
from the trochlea. The superior oblique passes under the superior
rectus muscle to insert on the posterior superior surface of the
globe. It functions to depress the globe in adduction and second-
arily to intort and abduct the globe. The tendon can be damaged
when dissecting through the nasal fat pocket (Fig. 33.8).
33.2.9 Blood and Lymphatic Supply to
the Upper Eyelid
The blood supply to the upper eyelid comes from the lacrimal
artery and the medial palpebral artery with anastomotic con-
tributions from the angular, supraorbital, and supratrochlear
arteries and the frontal branch of the superficial temporal artery.
The marginal arcades lie just under the orbicularis muscle 2 to 3
mm from the lid margin, while the superior branch (sometimes
just called the superior arcade) is 10 to 11 mm from the lid
margin. The upper branch lies between the levator aponeurosis
and Mller’s muscle at the superior tarsal border and can cause
bothersome bleeding when dissecting under the levator (Fig.
33.9). The lymphatic drainage from the upper eyelid is usually to
the preauricular nodes.
33.3 Preoperative Assessment
33.3.1 Past Medical and Ophthalmic
History
As stated in the ´Indications and Contraindicationsµ section,
the physician should determine the patient’s goals and expec-
tations for both cosmetic and functional improvement after
surgery. In addition to the usual medical history, it is necessary
to know about the presence of any ophthalmologic disease and
surgery in the patient’s past history. Patients often fail to men-
tion prior refractive surgery such as laser in situ keratomileusis
(LASI.) and radial keratotomy unless specifically asked. This
is important to know, since refractive and intraocular surgery
may weaken the globe and thus require extra caution during
Fig. 33.8 The superior oblique tendon just lateral to the medial fat
pocket (arrow).
Fig. 33.9 The superior arcade at the upper border of the tarsal plate
(arrow).

33 Upper Eyelid Blepharoplasty
379
subsequent periocular procedures. It is worth pointing out to
patients that any eyelid surgery may cause a few months of
blurred vision due to temporary changes in the refractive error
induced by eyelid edema. In rare cases, the refractive change
may be permanent.
Inquire as to whether the patient uses artificial tears or lubri-
cating ointment for dry eye, takes medications for ocular allergies,
or suffers from rosacea. Such conditions are notorious for worsen-
ing in the months after eyelid surgery. This seems to be especially
true for those patients with ocular rosacea manifestations such
as chalazia or posterior lid margin disease (meibomianitis). For
patients with severe dry eye (keratoconjunctivitis sicca), the
surgeon may consider performing a more conservative bleph-
aroplasty to minimize the risk of exposure in the postoperative
period. Likewise, when there is a history of severe rosacea, treat-
ment with low doses of an oral tetracycline (50 mg/day) before
and after surgery may be beneficial. Unfortunately, there are large
numbers of patients who are overdiagnosed and misdiagnosed
as having ´dry eyeµ or ´blepharitis.µ Such patients often show
up with a bag full of prescription and over-the-counter drops,
ointments, and lid hygiene products. If there is any doubt, an
ophthalmologic evaluation may be useful.
Does the patient use glaucoma medication, or has the patient
had glaucoma surgery" Topical glaucoma drops can cause consid-
erable ocular irritation, erythema, and contact dermatitis, which
may worsen in the postoperative period. Glaucoma filtering
procedures often have a noticeable ´blebµ at the limbus, or the
patient may have hardware in the subconjunctival space on the
superior part of the globe to facilitate lowering of intraocular
pressure. Likewise, scleral buckling procedures performed for ret-
inal detachment may have a noticeable, globe-encircling silicone
band at the equator of the eye. Obviously, caution is needed, since
these procedures may be associated with decreased thickness and
strength of the sclera. Fortunately, contemporary cataract surgery
involves very small incisions that are typically watertight and are
not prone to complications from the pressures exerted on the
eyelid during blepharoplasty.
33.3.2 Physical Examination
Evaluate the amount of redundant skin and fat in the upper
eyelid with the patient in a sitting position and looking straight
ahead. Prominent eyelid fat pockets are less obvious when the
patient is in a recumbent position. 1ote the position and level
of the eyelid crease and lid fold. Compare with the opposite eye
for symmetry. 1ote the position of the eyebrow and whether the
patient is using excessive frontalis force to lift the lids. :hen
necessary, encourage the patient to relax the frontalis muscle
to appreciate the full extent of any brow ptosis and redundant
upper eyelid skin. It may be necessary to push down gently on
the forehead and brow to nullify the effect of the frontalis.
1ext, measure the height of the palpebral fissure. This is the
distance from the lower eyelid to the upper eyelid at the center
of the pupil with the patient looking straight ahead (Fig. 33.10).
1ote the position of the upper eyelid relative to the pupil to detect
any ptosis. The normal upper eyelid rests 3 to 4 mm above the
center of the pupil and 2 mm below the superior limbus. Visually
significant ptosis is typically any lid that rests 2 mm or less above
the center of the pupil.
Measure the levator function. This is the excursion of the upper
eyelid from downgaze to upgaze with the brow fixated as mea-
sured at the center of the pupil (Fig. 33.11). 1ormal levator func-
tion is greater than 12 mm. If the levator function is less, suspect
that the patient may have had prior upper eyelid surgery (which
can restrict the motility of the upper eyelid) or has congenital
ptosis (wherein levator function is always decreased).
Look for upper eyelid retraction, which is most commonly
secondary to thyroid eye disease. Such patients often appear to
have greater skin excess than is actually the case. This is due to
the fact that the skin and orbicularis muscle become thicker in
thyroid eye disease, leading to the false perception of significant
redundancy. These patients are at risk for lagophthalmos in the
postoperative period from overzealous skin excision and relative
exophthalmos. If indicated, perform exophthalmometry readings.
A reading above 21 mm is indicative of exophthalmos in white
patients or above 25 mm in black patients.
Consider performing the basic secretion tear test to determine
whether there is a clinically significant dry eye. Instill a drop of
Fig. 33.10 Measurement of the palpebral fissure.
Fig. 33.11 Levator function is the change in millimeters of the upper
eyelid margin from (a) downgaze to (b) upgaze.
a
b

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VI Eyelid Surgery
topical ophthalmic anesthetic and then several seconds later
a drop of 1 to 4 lidocaine to obtain adequate anesthesia. The
topical ophthalmic anesthetic is placed first, since lidocaine is sig-
nificantly uncomfortable but does more thoroughly anesthetize
the eye. Insert a Schirmer tear strip at the lateral canthus for 5
minutes (Fig. 33.12). Any reading of less than 10 mm is considered
indicative of dry eye.
Examine the anterior segment of the eye and fornices with
a penlight. This is an easy way to spot any major ocular surface
pathology. Significant cataract is also easily visualized with a
penlight and is characterized by an opacity in the pupil. If there is
any doubt as to the health of the eye, ophthalmologic consultation
is appropriate.
Gently push on the upper and lower eyelids with a finger and
observe whether there is significant discharge from the meibo-
mian glands (Fig. 33.13). If noted, the patient is more likely to have
increased swelling and irritation after surgery and, as explained
previously, may require treatment with low dose, oral tetracycline.
:ith the patient looking in a mirror, I attempt to simulate the
postoperative appearance that the patient may have by elevating
the upper eyelid skin with a cotton-tipped applicator. I often speak
in terms of ´small,µ ´medium,µ and ´largeµ resections of upper
eyelid tissue in an attempt to determine what will make patients
happiest. Frequently, they have not considered the possibility that
the amount of skin and fat removal can, to a degree, be tailored
to their preference. This sometimes leads to confusion and might
end with the patient saying, ´-ust do what you think is best for
me.µ I typically respond by asking them to think about this after
our visit, simulate the skin excision in the mirror at home, and, if
available, consult with their spouse or partner. The vast majority
of patients will come to a ´small, medium, or largeµ decision on
their own.
Patients frequently bring old photos of themselves from their
youth. Many patients never had a significant amount of pretar-
sal skin visible between the lash line and the upper eyelid fold.
Although a full upper eyelid with a low fold may be perceived as
attractive when a person is in the 20s, a postoperative result in
which the upper eyelid fold rests just above the lash line will usu-
ally be judged by patients as an inadequate correction. Although
an old photo may represent an idealized result, I stress that we
simply cannot replicate the eyelid of youth. Instead we aim to
make the patient look better for their age, awake and refreshed.
Surgeons’ perceptions of an optimum postoperative result have
also evolved with time. A hollow superior sulcus was once the
norm. Fat preservation and fat grafting techniques now empha-
size fullness of the upper lid and orbital rim to emulate a youthful
appearance better. Despite this, many patients still want aggres-
sive skin and fat removal and desire the hollow superior sulcus.
Again, communication between patient and surgeon is essential.
As with any surgery, emphasize that secondary procedures or
´touch-upsµ may be needed to obtain desired results.
33.3.3 Documentation of Functional
vs. Cosmetic
If the dermatochalasis is severe enough, the surgery may be cov-
ered by insurance, and predetermination of benefits is usually
required. Insurance requirements differ significantly based on
the company, but some generalizations apply. A letter of medical
necessity accompanies a copy of the exam detailing the patient’s
specific complaint of visual field interference from the redun-
dant skin. Supply photographic documentation of the patient
in primary position and from each side. Some insurers require
this be done with flash to demonstrate the pupillary light reflex.
A visual field (automated Humphrey or manual Goldmann) is
required with taped and untapped eyelids, demonstrating the
improvement in the peripheral vision with taping (Fig. 33.14).
The exact visual field criteria needed to qualify vary from one
carrier to the next.
Fig. 33.12 Basic secretion tear test (Schirmer test).
Fig. 33.13 Digital pressure on the lower eyelid margin to check for
excessive meibomian gland discharge.
Fig. 33.14 Goldmann ptosis field of the right eye, indicating improve-
ment of 30° with taping of the upper eyelid.

33 Upper Eyelid Blepharoplasty
381
33.4 Preoperative Planning,
Including Markings
Mark the incision lines in the upper eyelid with the patient in the
recumbent position. There are no universally agreed-upon mea-
surements for the height and shape of the upper eyelid incision
line, but this typically varies between 8 and 12 mm above the
center of the eyelid margin. Most surgeons feel that the incision
line should be lower for male than for female patients to prevent
´feminizationµ of the male eyelid. I have not found this to be true
and use the same measurement on men and women. I typically
place the lower incision at 10 mm centrally, 9 mm above the lat-
eral canthus, and 8 mm above the punctum in Caucasian patients
(Fig. 33.15). Generally, this line will be significantly lower for
Asian blepharoplasty and higher in patients with relative exoph-
thalmos who already have a physiologically high eyelid crease.
:ith the patient gently closing the eyes, pinch the skin together
with a Green’s forceps or similar device centrally, medially, and
laterally to determine the excess and mark the upper edge of the
incision line (Fig. 33.16). :hile doing this, be certain that the eye
can still close. The degree of skin excision will have been agreed
upon by the patient and physician prior to the surgery based
on the desired result. An often-quoted rule of thumb is that the
upper edge of the skin excision should be at least 10 mm from
the lower edge of the eyebrow to allow for closure. This is not an
absolute rule, since some patients with low eyebrows and rela-
tive enophthalmos can have a slightly more aggressive removal,
while those with exophthalmos may need to have much more
than 10 mm of skin left between the upper edge of the incision
and the brow to prevent lagophthalmos.
The medial extent of the incision should go no further than
the medial canthus to prevent webbing or an epicanthal fold.
Laterally, however, it may have to go significantly further than the
lateral canthus to remove lateral hooding. :hen going beyond the
lateral canthus, angle the incision upward by 20 to 30ƒ following
a ´crow’s foot lineµ (Fig. 33.17a). Be certain that the upper eyelid
and lower eyelid incisions are separated by at least 10 mm from
each other to prevent a lateral web (Fig. 33.17b). Compare both
sides for symmetry in terms of skin removal and the horizontal
length of the incision. Scars that extend beyond the lateral orbital
rim are usually well tolerated, but the left and right must be
identical in terms of their length and position to be perceived as
aesthetically acceptable.
Fig. 33.15 Measurements for the lower edge of the incision.
Fig. 33.16 Determination of the amount of skin excision with a Green’s
forceps.
Fig. 33.17 (a) Outline of skin excision. (b) Lower eyelid blepharoplasty incision is 10 mm from the upper eyelid incision.
a
b

382
VI Eyelid Surgery
The choice of general anesthesia versus sedation versus
straight local is dependent upon the needs of the patient and the
preferences of the surgeon. Even with general anesthesia, local
infiltration with lidocaine and/or bupivacaine with epinephrine
is helpful in maintaining hemostasis and comfort after surgery.
The addition of hyaluronidase to the local greatly facilitates the
spread and duration of the anesthetic and decreases the swelling
of tissues during surgery, thus minimizing distortion.
33.5 Operative Technique
33.5.1 Skin, Orbicularis,
and Fat Resection
The choice of skin only versus skin/orbicularis excision versus
skin/orbicularis/fat excision is purely a choice of the surgeon
based on the desired result. Obviously, the more tissue removed,
the greater the magnitude of change. The following assumes that
all three are resected.
Incise the skin with a blade and remove with sharp scissors,
monopolar cautery, or laser or radiofrequency device as preferred
by the surgeon (Fig. 33.18). The exposed orbicularis muscle
may now be trimmed according to the surgeon’s judgment as to
whether it is better to debulk the eyelid or leave it to preserve
fullness (Fig. 33.19). A substantial amount of the upper eyelid
orbicularis can be removed if necessary without causing problems
with closure. Exercise caution at the lower edge of the incision to
prevent inadvertent resection of the levator aponeurosis, which
is in close proximity to the undersurface of the orbicularis at this
point.
If resecting preaponeurotic fat, now open the orbital septum.
:ith the fingers of one hand, push inferiorly on the upper eyelid
near the lid margin. :ith the other hand, retract the upper skin
edge superiorly while applying light pressure against the globe.
This maneuver pushes the globe posteriorly into the socket, dis-
placing the fat anteriorly, where it now visibly bulges out under
the septum. :hile still applying pressure as just described, cut
the septum, causing the fat to bulge through (Fig. 33.20). Cut
the septum across the eyelid to expose the remaining fat (Fig.
33.21). 1ext separate the fine fibrous attachments between
the fat and the levator (Fig. 33.22). Anteriorly, the fat can be
separated from the orbicularis up to the orbital rim if needed.
Resect the fat as planned and, if using scissors, clamp the fat
pockets with a small hemostat, cut the fat, and cauterize the
stump. Inspect for bleeding before releasing the fat. It is often
necessary to give a supplemental injection of local into the fat
pockets, especially the medial, to obtain complete anesthesia
(Fig. 33.23).
Do not resect fat above the level of the superior orbital rim.
Doing so can result in an adhesion between the levator muscle
and the bone, with resultant mechanical ptosis and restriction of
motility of the upper eyelid.
An alternative method to contour fat is simply to apply multi-
ple, small points of cautery across the orbital septum. This shrinks
and tightens the septum, thus pushing the fat posteriorly into the
orbit, decreasing its prominence (Fig. 33.24). Caution is advised
with this technique, since excessive septal contraction can lead to
lagophthalmos.
Fig. 33.18 Skin incision with a blade.
Fig. 33.19 Removal of additional orbicularis muscle.
Fig. 33.20 Retraction of the brow superiorly with one hand while
placing pressure on the upper lid margin to cause the fat to bulge
through the cut septum.

33 Upper Eyelid Blepharoplasty
383
33.5.2 Crease Fixation
1ow is the time to create an upper eyelid crease. Although a
crease will usually form spontaneously at the incision line,
crease fixation techniques reliably ensure this. Tissue excision
may be completely symmetric between right and left eyes, but if
the crease and fold do not match, the final result will not be even.
Historically, crease techniques have come from the Asian liter-
ature and so called ´double eyelidµ procedures. These practices
have been modified by numerous authors and are applicable to
:estern eyelids.
All crease fixation techniques work by establishing an adhesion
between the skin and the levator. :hen the upper eyelid opens,
the levator muscle pulls superiorly, invaginates the overlying
attached skin, and thus generates the upper eyelid fold from the
skin above the crease. Crease fixation is generally not required if
a hollow, deep superior sulcus is the goal. Crease fixation should
not be performed if the lower edge of the incision is more than 12
mm from the eyelid margin, since this usually leads to a mechani-
cal ptosis. This occurs because the crease essentially suspends the
skin and orbicularis muscle that is inferior to the point of fixation
to the levator. If performed above 12 mm from the lid margin, the
tissue is generally too heavy for the levator, resulting in ptosis.
The simplest way to form a crease is to close the skin with a
running, monofilament suture and incorporate a bite of the leva-
tor aponeurosis just above the lower skin edge with every other
throw (Fig. 33.25). The disadvantage of this method is that the
crease is sometimes lost after the suture is removed.
A more secure method of fixation is to use a 6–0 fast or 6–0
silk suture to take a bite of the lower skin edge, then a bite of the
levator aponeurosis, and then the upper skin edge (Fig. 33.26).
This is done in two or three locations across the upper eyelid. The
inflammatory nature of these sutures creates a ´spot weldµ and
thus forms the crease.
The most reliable technique for crease fixation is to use a 6–0
polyglactin or 6–0 polyester suture to take a bite of the levator
Fig. 33.21 Opening the orbital septum with scissors.
Fig. 33.22 Cutting the fine attachments between the orbital fat and
the levator.
Fig. 33.23 Additional injection of local anesthetic into the medial fat
pocket.
Fig. 33.24 Cautery to contract and tighten the orbital septum. Arrow
identifies the site of a spot of cautery.

384
VI Eyelid Surgery
aponeurosis just above the lower skin edge and then a bite of the
orbicularis on the underside of the lower skin edge (Fig. 33.27).
Again, this is done in two or three places across the incision (Fig.
33.28). Although a bit more time-consuming, this procedure
forms a crease that is reliable and long-lasting. The disadvantage
is that this suture may in time cause a reaction and need to be
removed. Removal of an occasional extruding suture is, however,
simpler than having to reform the crease in the months following
surgery, as may be needed with the other techniques.
33.5.3 Skin Closure
The skin is then closed according to the surgeon’s preference.
Running, monofilament suture can be removed as soon as the
fifth postoperative day and can be delayed for up to 2 weeks with
no problem.
33.6 Ancillary Procedures
Extensive brow procedures, fat grafting, and skin resurfacing can be
performed at the same time but are covered in separate chapters.
There is now considerable thought given to procedures that increase
rather than decrease the volume of the periocular tissues. This may
be as simple as preservation of the orbicularis oculi muscle, less
resection of orbital fat or the addition of hyaluronic acid fillers. Even
more extensive is concomitant fat grafting to the brows. All of these
modalities serve to give a fuller look to the periocular area, with
the thought that the result is more representative of the natural,
youthful state of these tissues. This is in contrast to an aggressive
removal of tissue, which leads to a very hollowed-out appearance
(sometimes referred to as ´the post-blepharoplasty lookµ) that for
so long was the goal of the procedure. Again, the surgeon needs to
educate patients in regards to the options available and help them
to make an informed decision so that they will be pleased with the
outcome. The concept of what is beautiful and pleasing continues
to evolve in the minds of both the physician and the patient.
33.6.1 Lacrimal Gland Resuspension
Prolapse of the orbital lobe of the lacrimal gland is seen as a
distinct bulge in the lateral part of the upper eyelid (Fig. 33.29).
If the prolapse is not severe, the application of bipolar or unipolar
Fig. 33.25 Creation of the eyelid crease by taking a bite of the levator
with every other throw of the running, monofilament skin suture.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A
Repair Manual. New Fig. 33.26 (a) Creation of the eyelid crease with an interrupted 6–0 silk suture passed between the lower skin edge, the levator aponeurosis, and the
upper skin edge. (b) Cross-sectional diagram of the suture placement. (Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair
Manual. New a
b

33 Upper Eyelid Blepharoplasty
385
cautery to the capsule of the gland will shrink it and eff ectively
reposit the gland back into the orbit. This will not aff ect the
function of the gland to any measurable degree.
If the prolapse is severe, it must be surgically repositioned.
Dissect anterior to the gland down to the level of the orbital rim
arcus marginalis. Take a bite of the lacrimal gland and then a bite
of the arcus marginalis with a nonabsorbable suture, and tie (Fig.
33.30). A second suture may be necessary to reposition the gland
adequately. This procedure does not aff ect the function of the gland.
33.6.2 Resection of Brow Fat
The brow fat, or ROOF (retro–orbicularis oculi fat) may some-
times need to be thinned if it is too prominent and has descended
into the upper eyelid. This is especially common in patients who
have had thyroid eye disease. This tissue is visible as a distinct
layer of fi rmer fat with smaller lobules just anterior and superior
to the preaponeurotic fat (Fig. 33.31a). This can be trimmed with
scissors or unipolar cautery to decrease the anterior projection
of the eyelid between the upper edge of the incision and the eye-
brow (Fig. 33.31b). Conservative resection is recommended, and
a thin layer of fat must remain between the skin and the orbital
rim. Excessive resection can result in a secondary lid crease due
to adhesion of the skin to the orbital rim.
Fig. 33.28 Frontal diagram of the suture placement. (Reproduced
from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual.
New Fig. 33.27 (a) Creation of the eyelid crease with a 6–0 polyester. First, the suture takes a bite of the levator aponeurosis. (b) Then the suture takes
a bite of the orbicularis at the lower edge of the incision. (c) Cross-sectional diagram of the suture placement. (All parts reproduced from Nahai F,
Wojno T. Problems in Periorbital Surgery: A Repair Manual. New a
b
c
Fig. 33.29 (a) Prolapse of the right lacrimal gland is visible as a distinct
bulge in the lateral upper eyelid. (b) A diff erent patient demonstrating
mild prolapse of the lacrimal gland inferior to the orbital rim (arrow).
a
b

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VI Eyelid Surgery
33.6.3 Lateral Brow Pexy
If needed, the lateral brow can be fixated to the lateral orbital rim
via the upper eyelid incision (Fig. 33.32). Dissect below the orbicu-
laris under the lateral third of the brow to a point 2 cm above the
orbital rim. Place a 4–0 polyester suture full-thickness through
the skin at the inferior border of the brow. 1ext, take a bite of the
periosteum 1 cm superior to the orbital rim and then through the
tissue under the flap at the exit point of the original pass, which is
the lower border of the eyebrow. Adjust the placement upward or
downward for the desired effect and symmetry, pull the end of the
suture though from the skin side, and tie. Brow pexy performed
in this fashion will result in temporary, mild swelling and extra
discomfort in this area.
33.7 Postoperative Care
Patients are advised to avoid strenuous physical activity and
heavy lifting to prevent orbital hemorrhage and broken sutures.
Fig. 33.30 Repositioning of a prolapsed lacrimal gland. (a) First, take a bite of the gland (arrow) with a nonabsorbable suture. (b) Next, take a bite of
the arcus marginalis, and tie.
a
b
Fig. 33.31 (a) The retro–orbicularis oculi fat (ROOF, white arrow) is seen just superior to the orbital septum (black arrow). (b) Trimming excess ROOF
with scissors.
a
b

33 Upper Eyelid Blepharoplasty
387
Frequent use of cool compresses helps minimize swelling, bruis-
ing, and pain. Twice-daily application of a bland ophthalmic
ointment keeps the suture line clean and more comfortable.
Patients should be cautioned that even though the ointment is
applied to the sutures, some of it will melt, get into the eyes,
and cause some blurring of vision for 24 hours after the last
application. Any ophthalmic drops normally prescribed for
the patient are continued uninterrupted. The patients may get
the sutures wet and may read and watch television as desired.
They may return to work the following day if desired. They
are instructed to call immediately if they develop signifi cant,
uncontrolled bleeding or loss of vision. Acetaminophen usually
suffi ces for pain control, but a small minority will require the
addition of a mild narcotic. Patients are instructed as to when
to resume medications that interfere with the clotting system
on an individualized basis. Sutures are removed 5 to 7 days after
surgery, and the patient is seen 1 to 2 months later, after most of
the edema has resolved.
33.8 Outcomes
As with any other procedure, patients are generally satisfi ed
with the overall results and pleased with the improved fi eld of
vision. Touch-up procedures to remove small amounts of addi-
tional skin or fat for symmetry can be done as soon as 1 month
after surgery. Even 1 mm of asymmetry is very noticeable in the
upper eyelids and is not well accepted by most patients. In most
cases, patients should not require a repeat procedure for at least
10 years.
33.9 Results
Three patients are shown before and 2 months after upper eyelid
blepharoplasty. The patients, respectively, requested a ´smallµ
amount (Fig. 33.33), a ´moderateµ amount (Fig. 33.34), and a
´largeµ amount (Fig. 33.35) of skin and fat removal.
Fig. 33.32 Lateral brow pexy. (a) Dissection under the orbital orbicularis (arrow marks the orbital rim). (b) Placement of a 4–0 polyester suture
through the skin at the inferior border of the brow. (c) The needle of the 4–0 polyester suture emerging through the orbital orbicularis (arrow).
(d) Measuring 1 cm superior to the orbital rim. (e) Taking a bite of the periosteum 1 cm superior to the orbital rim (arrow). (f) The needle now taking
a bite of the orbital orbicularis at the point where the suture emerged at the lower border of the brow (arrow).
a
d
b
e
c
f
Fig. 33.33 Patient who requested a “small” amount of tissue removal.
(a) Before surgery. (b) Two months after surgery.
a
b

388
VI Eyelid Surgery
33.10 Concluding Thoughts
Functional and cosmetic blepharoplasties are some of the most
frequently performed aesthetic surgical procedures. Satisfi ed
patients become a source of referral for friends and associates
and a portal of entry for other aesthetic treatments. Results are
generally gratifying for the patient and surgeon. Careful consid-
eration of the underlying structures, individual diff erences in
anatomy and ethnicity, the patient’s medical condition, and the
patient’s desires will minimize postoperative problems.
Clinical Caveats
• No upper eyelid blepharoplasty is purely functional or purely
cosmetic.
• The surgeon needs to understand the patient’s expectations
and explain what can and cannot be accomplished.
• The surgeon must appreciate how individual diff erences in
anatomy and ethnicity will aff ect outcome.
• The major decisions are placement of the incision lines, how
much tissue is resected versus how much tissue is preserved,
and method of formation of the eyelid crease-fold complex.
• The notion that this is “simply a little tuck” must be avoided.
Suggested Reading
>1@ Cohen BD, Reiff el A-, Spinelli HM. Browpexy through the upper lid (BUL): a new
technique of lifting the brow with a standard blepharoplasty incision. Aesthet
Surg J 2011;31(2):163–169
>2@ Fagien S. Advanced rejuvenative upper blepharoplasty: enhancing aesthetics
of the upper periorbita. Plast Reconstr Surg 2002;110(1):278–291, discussion 292
>3@ Fagien S. The role of the orbicularis oculi muscle and the eyelid crease in
optimizing results in aesthetic upper blepharoplasty: a new look at the surgical
treatment of mild upper eyelid fi ssure and fold asymmetries. Plast Reconstr Surg
2010;125(2):653–666
>4@ Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty.
Clin Plast Surg 1993;20(2):193–207
>5@ Massry GG. 1asal fat preservation in upper eyelid blepharoplasty. Ophthal Plast
Reconstr Surg 2011;27(5):352–355
>6@ Mendelson BC, Luo D. Secondary upper lid blepharoplasty: a clinical series using
the tarsal fi xation technique. Plast Reconstr Surg 2015;135(3):508e–516e
>7@ Pang HG. Surgical formation of upper lid fold. Arch Ophthalmol 1961;65:783–784
>8@ Putterman AM. Treatment of upper eyelid dermatochalasis with reconstruction
of upper eyelid crease: skin-muscle fl ap approach. In: Fagien S. Putterman’s
Cosmetic Oculoplastic Surgery. 4th ed. Philadelphia, PA: Saunders Elsevi-
er;2008:79–86.
>9@ Sheen -H. Supratarsal fi xation in upper blepharoplasty. Plast Reconstr Surg
1974;54(4):424–431
Fig. 33.34 Patient who requested a “moderate” amount of tissue
removal. (a) Before surgery. (b) Two months after surgery.
a
b
Fig. 33.35 Patient who requested a “large” amount of tissue removal.
(a) Before surgery. (b) Two months after surgery
a
b

34 Upper Blepharoplasty in the Asian Patient
389
34 Upper Blepharoplasty in the Asian Patient
H. Joon Kim
Abstract
Asian blepharoplasty, or double-eyelid surgery, is one of the
most common cosmetic procedures performed in Asia. :hile it
encompasses the fundamental concepts of a traditional bleph-
aroplasty, the anatomical and aesthetic differences of Asian
eyelids necessitate a distinct procedure. A specialized preoper-
ative evaluation and understanding of patient expectations are
required for a successful outcome. Countless surgical techniques
exist, each with their set of advantages and disadvantages, that
are outlined in this chapter.
Keywords
Asian blepharoplasty, double-eyelid surgery, preoperative evalu-
ation, incisional techniques, nonincisional techniques
34.1 Background
Double-eyelid surgery can be dated back to -apan near the end
of the Edo period, when :estern influences prevailed. Although
the initial documented surgery was performed by Mikamo
during this time in 1896, the term Asian blepharoplasty was
popularized by :illiam Chen in 1987 to highlight the differences
in anatomy and technique from the traditional blepharoplasty.
Today, the procedure remains the most frequently performed
cosmetic procedure in Asia. It is important to note that while
the term Asian blepharoplasty has become nearly synonymous
with double-eyelid surgery, it can encompass the fundamental
concepts of skin and/or orbicularis excision and fat contouring
that define a traditional blepharoplasty.
34.2 Anatomy
Significant anatomical differences can exist between Asians and
Caucasians, even down to the bony anatomy. Anthropometric
studies have shown that Asian orbits tend to be more round,
whereas Caucasian orbits tend to be more square with a more
prominent superior orbital rim and deeper lateral orbital rim.
Despite the variation in the shape, the entrance height and width
remain similar.
The epicanthal fold, most notably epicanthus tarsalis, where
folds are most prominent from the upper lid to the medial canthus,
is another common feature of an Asian eyelid (Fig. 34.1). Several
traditionally accepted theories exist to explain this feature, which
include a combination of a low nasal bridge, Z-shaped kinking
of the orbicularis oculi muscle fibers, excess of orbicularis oculi
muscle, and an absence of dermal attachment to the medial can-
thal tendon. More recent cadaver studies by .akizaki showed that
the main etiologic factor for epicanthal tarsalis depends on the
fibers of the oblique direction of the preseptal orbicularis muscle
rather than those of the pretarsal orbicularis.
The most commonly referenced anatomical difference between
Asian and Caucasian lids is the point of fusion between the septum
and the levator palpebrae superioris aponeurosis. For Caucasian
lids, the fusion occurs between 5 and 10 mm above the superior
border of the tarsal plate, while for Asian eyelids the fusion occurs
below the superior tarsal border (Fig. 34.2). This difference, along
with the shorter tarsal height and an inferior displacement of
the preaponeurotic fat, give a fuller appearance of the eyelids in
Asians and a lower or absent lid crease. Additionally, the absence
of the terminal interdigitations of the levator aponeurosis to the
orbicularis and dermis have been described, which results in the
lack of a lid crease.
The upper eyelid crease in Asians exists about 50 of the time
and tends to be approximately 6 to 8 mm from the lid margin, as
compared to that in Caucasians, which often exists 9 to 11 mm
from the lid margin. Crease morphology can also vary, particularly
nasally, where it can be tapered or parallel (Fig. 34.3). A tapered
crease gradually converges to blend in with the medial epicanthal
fold, whereas a parallel crease will remain parallel medially and
remain above the epicanthal fold.
34.3 Preoperative Evaluation
As with any other cosmetic surgery, the initial consultation
is critical in arriving at a mutual understanding of desires and
expectations. For Asian blepharoplasty, understanding their
motive for surgery is important. Are they seeking surgery to just
obtain a double eyelid crease" Do they desire to make their eyes
look bigger" Do they just want to improve their vision" It is also
vital to understand whether they already have an ideal height
Fig. 34.1 An example of an epicanthal tarsalis with the prominent
folds from the upper lid to the medial canthus.

390
VI Eyelid Surgery
and shape of the crease in mind. It is often the case that they
desire to look natural but are unsure as to the details of what
this implies.
A comprehensive medical history should be obtained, with
special attention to the ocular history, including previous eye
and/or eyelid surgeries and injectables such as botulinum toxin
and fillers around the eyes, as these can impact the eyelid height
and shape. Also, asking about symptoms and conditions of dry
eye or ocular surface surgery such as laser in situ keratomileusis
(LASI.) is prudent. Safe discontinuation of anticoagulants is also
recommended to minimize intraoperative bleeding and to reduce
the risk of postoperative complications such as a retrobulbar
hemorrhage.
34.4 Physical Examination
A thorough examination of the periocular region and of the eyes
should be performed. Brow position and shape with associated
temporal hooding should be assessed. Determine any brow/fore-
head ptosis that may need to be corrected to augment the out-
come of the blepharoplasty. Measurement of the marginal reflex
distance (MRD1) is important (Fig. 34.4). This measurement in
millimeters is from the corneal light reflex in the center of the
pupil to the upper eyelid margin and will help to differentiate
true blepharoptosis from dermatochalasis. An average MRD1
in Caucasians is about 4 mm. For Asian patients the ´averageµ
MRD1 can vary slightly from 2 to 4 mm, presenting another
level of challenge to the necessary surgical procedure. Again,
the discussion of the desired outcome with the patient will be
critical. The presence or absence of a natural crease should be
noted along with its contour and shape, especially medial in
relation to the epicanthal fold. In addition to the natural fullness
of the Asian eyelid, older patients can also have fat prolapse that
can be simultaneously present with superior sulcus hollowing.
Fig. 34.3 Variations in crease morphology with (a) showing a tapered
crease and (b) showing a parallel crease.
a
b
Fig. 34.2 Comparison of (a) Caucasian and (b) Asian eyelid anatomy.
Orbicularis
oculi muscle
Orbital septum
Levator aponeurosis
Müller’s muscle
Superior tarsus
Conjunctiva
Inferior tarsus
Levator aponeurosis
Preaponeurotic fat
Orbital fat
Preaponeurotic fat
Orbital fat
Orbital septum
Terminal
interdigitations
Caucasian
Asian
a
b

34 Upper Blepharoplasty in the Asian Patient
391
Determination of how much fat to contour and/or excise while
maintaining the natural fullness of an Asian eyelid can add
another level of complexity to the surgery. A full eye exam
should be performed with close attention to visual acuity and
ocular surface changes to suggest dry eye or lagophthalmos.
To demonstrate the appearance of the patient’s lids with a
crease, a double-eyelid curved probe simulator (Fig. 34.5), or even
a straightened paper clip, could be used during the preoperative
consultation. Double-eyelid tape (Fig. 34.6), which has gained
popularity in Asia, can also be used to simulate a crease in the
office, with the caveat that the outcome could slightly vary.
34.5 Surgical Techniques
Asian blepharoplasty can be performed either in the office minor
room with local anesthesia or in the operating room under moni-
tored anesthesia care with intravenous sedation. In the office setting,
preoperative benzodiazepines can be prescribed as an anxiolytic.
Typical local anesthetic consists of 1 to 2 lidocaine with 1:100,000
dilution of epinephrine, either alone or in combination with a lon-
ger-lasting anesthetic, such as 0.5 to 0.75 bupivacaine in a 1:1 ratio.
Hyaluronidase can additionally be added to this local mixture for
rapid dispersion of the infiltrate with minimal turgor and distortion
of the tissue. Some surgeons also may add sodium bicarbonate to
minimize the burning sensation of the anesthetic. After instillation
of 0.5 proparacaine into both eyes, 5 povidone–iodine is often
used to prep the entire face prior to draping.
34.5.1 Nonincisional Techniques
Since there is no manipulation of the skin or fat in the noninci-
sional technique, it is ideal for young patients with minimal or no
redundant skin or fat seeking a double-eyelid crease. The nonin-
cisional suture technique has remained popular due to its short
operative time, minimal scarring, and quick recovery. Countless
variations in technique and suture preference have developed
over the years, to the extent that a comprehensive description
of every modification would prove challenging. Practically
speaking, this procedure can be subcategorized depending
on the suture placement: ´buriedµ versus ´nonburiedµ tech-
niques and ´continuousµ versus ´interruptedµ techniques. The
suture can then be passed full-thickness or near full-thickness
through the eyelid, either through the tarsal plate or through
Mller’s and levator muscle immediately superior to the tarsus.
Fig. 34.5 Double-eyelid curved probe simulators.
Fig. 34.6 Double-eyelid tape.
Fig. 34.4 Demonstration of the technique for measuring the marginal
reflex distance 1 (MRD1) from the corneal light reflex to the upper lid
margin for determining ptosis.

392
VI Eyelid Surgery
´Mini-incisionµ techniques also exist that serves as a hybrid
between the nonincisional and incisional techniques.
Interrupted Technique
Mikamo’s technique in 1896 was a nonburied, interrupted tech-
nique that required removal of the sutures 6 to 8 days postoper-
atively. He placed three 4–0 silk sutures full-thickness through
the eyelid medially, centrally, and laterally approximately 6 to 8
mm from the lashline (Fig. 34.7). The depth of the fold depended
on the day of the suture removal. Since then, buried techniques
have become increasingly favorable in an effort to minimize the
loss of the surgically created crease, one of the major failures
of the suture technique. One of the earliest buried techniques,
presented by Uchida in 1926, utilized the same three placements
of the sutures as Mikamo but instead used catgut. Song has also
utilized a similar technique but employed nylon sutures.
More recently, a single-suture technique has also been described
by Baek, which includes making a mark along the lid skin 6 to 8 mm
from the lash line (Fig. 34.8a). Two stab incisions are made with a
no. 11 blade along the marked line as points of entry for the sutures
(Fig. 34.8b). The eyelid is then everted, and one of the needles of a
double-armed 6–0 Prolene suture is passed through the conjunctiva
in the corresponding point of one of the stab incision sites and exits
through the conjunctiva corresponding to the second stab incision
site (Fig. 34.8c). Each of the two needles is then passed anteriorly
to exit through the skin where its stab incision was created (Fig.
34.8d). One needle is then passed subcutaneously to the other
stab incision site so that both needles are then exiting from the
same incision site (Fig. 34.8e). A knot is tied and buried beneath
the orbicularis. The stab incision sites are closed with interrupted
6–0 Prolene (Fig. 34.8f). :u describes a similar method but utilizes
four to seven sutures that are passed closer together.
Fig. 34.7 Artist’s rendition of the first reported double-eyelid surgery, performed by Mikamo in 1896.
6–8mm
Fig. 34.8 Artist’s rendition of a single-suture nonincisional technique by Baek. (a) Marking of the lid 6 to 8 mm from the lash line. (b) Two stab
incisions on the marked line serve as (c) entry and exit points for double-armed suture. (d) Each needle is passed back out through its incision. (e)
One suture is led subcutaneously to the other stab incision site. (f) The sutures are joined with a buried knot, and the stab incisions are closed.
A
6–8mm
B
C
D
a
e
b
c
d
f

34 Upper Blepharoplasty in the Asian Patient
393
Continuous Technique
In an effort to create a more durable crease, numerous con-
tinuous methods have also been described. One of the initial
techniques was described by Maruo in 1929 as a two-way
continuous buried-suture method that has been illustrated
by Chen, .im, Song, :ong, and more recently in a modified
version by Fan. In both Maruo’s and Fan’s methods, seven to
nine stab incisions are created along the designated crease
starting from about 5 mm lateral to the medial canthus and
ending 10 mm medial to the lateral canthus (Fig. 34.9a).
Modifying Maruo’s technique in a way first reported by .im et
al in 2000, Fan excises an approximately 1-mm-long piece of
skin through each incision. A 7–0 nylon suture is then passed
from the lateralmost stab incision and advanced medially,
alternating between dermis bites and partial-thickness tarsal
bites (Fig. 34.9b). The suture is then reversed from medial
to lateral, again alternating between dermal and tarsal bites
in the opposite intervening segments (Fig. 34.9c), and tied
buried within the incision laterally. It is important to note,
as :ong emphasized in his report, that with each intratarsal
bite, the lid should be everted to ensure that the suture does
not pass full-thickness through the tarsal plate where it may
cause corneal damage. Most authors believe that continuous
techniques result in a longer-lasting crease because of the
numerous points of fixation to the underlying tissue, but some
argue that it is more difficult to control the crease contour and
deal with revisions, still making the interrupted techniques
more superior.
34.5.2 Incisional Techniques
The traditional incision methods were described by Maruo in
1929 and popularized during the 1950s and 1960s by Sayoc,
Fernandez, and Boo-Chai. .ey points from their methods include
marking the crease approximately 5 to 8 mm from the lid
margin, followed by conservative excision of ellipse of skin and/
or orbicularis oculi with dissection down to expose the levator
aponeurosis. Usually minimal or no fat resection is performed.
Crease fixation differs between authors: some will separately
form the crease and close the skin independently, while others
will incorporate tarsal or levator bites with skin closure, usually
in an interrupted fashion. One or more sutures are then passed
from either the levator or the tarsal plate (depending on the
desired crease height) and through the dermis of the inferior skin
edge (Fig. 34.10). The skin is closed with a nonabsorbable suture
that is typically removed within 3 to 10 days. Results are shown
in Fig. 34.11 and Fig. 34.12.
Upper eyelid skin
Levator palpebrae
superioris
Conjunctiva
Cornea
Superior tarsal
plate
Orbicularis oculi
muscle
Orbital septum
Preaponeurotic
fat
Fig. 34.10 An artist’s rendition of the crease fixation suture placed via
an incisional technique reported by Boo-Chai.
Stab incisions
6–8mm
1
2
3
4
5
6
7
Medial
Lateral
1
2
3
4
5
6
7
Skin
Fat
Orbicularis
Aponeurosis
Tarsus
Conjunctiva
Cornea
1
2
3
4
5
6
7
Fig. 34.9 Artist’s rendition of a continuous nonincisional technique by
Fan. (a ) Seven to nine stab incisions are made along the marked line.
(b ) A 7–0 nylon suture is passed from incision to incision from lateral
to medial, alternating between dermis bites and tarsal bites. (c) Suture
is passed back from medial to lateral, taking dermis bites and tarsal
bites opposite to those in the first pass.
a
b
c

394
VI Eyelid Surgery
Due to the prolonged edema and hypertrophic scarring
that can be associated with Asian eyelids, the classic methods
have evolved to ´mini-incisionµ techniques that in theory yield
minimal scarring and fast recovery associated with the suture
techniques and also with the longevity of the open methods (Fig.
34.13, Fig. 34.14). Lam reported 1,500 cases in which he utilized
a 1- to 1.8-cm incision along the desired crease height with
resection of the septum and preaponeurotic fat. He then placed
five to seven interrupted 7–0 nylon sutures from the levator apo-
neurosis to the inferior edge of the incision. Chen illustrates a
technique that adopts a single 1-cm incision centrally along the
desired crease height, with or without fat removal, and utilizes
three 6–0 Prolene sutures to secure the crease from the levator
aponeurosis to the dermis along the inferior incision. His method
also allowed for simultaneous ptosis correction by adjusting the
suture placement on the levator. Ma describes making two 2- to
3-mm incisions along the marked crease, debulking the pretar-
sal tissue, and fixating the crease by passing a 7–0 nylon suture
from the pretarsal levator to the dermis along the inferior edge
of the incision.
34.6 Complications
Problems with the crease are undoubtedly the most frequently
encountered complications. They can include an incomplete crease,
an asymmetric crease, multiple creases, or an excessively high
or low crease (Fig. 34.15), and various corrective methods have
been described. Aggressive fat excision can result in a ´sunken
upper eyelidµ or a superior sulcus deformity that can be difficult
to restore. Due to the thicker dermis and a more exuberant fibro-
blastic response during wound healing, persistent erythema and
hypertrophic scarring have also been an anticipated problem in
Asian patients, and thus it would be prudent to have a postoperative
algorithm for managing the scar. Excessive skin removal can result
in an ectropion (lid margin turning outward) and/or lagophthalmos
(incomplete closure of the eyelid). These complications are not
unique to Asian eyelids but can occur in any eyelid where the skin
has been aggressively resected. Additional surgery is often neces-
sary to correct these issues. Although Asian blepharoplasty can be a
straightforward procedure to perform, it can be riddled with com-
plications and should be approached with appropriate planning and
strategies for managing the common postoperative problems.
Fig. 34.11 Results of an incisional technique with a natural-appearing
“medium” crease. (a) Preoperative photo. (b) Three-month postoper-
ative photo.
a
b
Fig. 34.12 Results of an incisional technique with a minimally visible
“low” crease. (a) Preoperative photo. (b) Three-month postoperative
photo.
a
b

34 Upper Blepharoplasty in the Asian Patient
395
Fig. 34.15 A patient showing a high crease with a “sunken” appear-
ance of both upper lids after an Asian blepharoplasty. The left upper lid
has an additional complication of having multiple creases
Fig. 34.14 Results of “mini-incision” technique with a natural
appearing “medium” crease. (a) Preoperative photo. (b) Three-month
postoperative photo.
a
b
Fig. 34.13 An example of a “mini-incision” technique. (a) A 1- to 2-cm incision is marked. (b,c) Dissection is carried down to the superior border of
the tarsal plate. (d) A 5–0 polyester suture is passed partial-thickness along the superior border of the tarsal plate. (e) The lid is everted to ensure that
the polyester has not passed full-thickness through the tarsal plate. (f) The polyester is then passed through the inferior cut edge of the orbicularis
oris muscle from deep to superficial, then (g) reversed and passed superficial to deep in a horizontal mattress fashion, then (h) tied down securely. (i)
The resulting invagination of the lid forms the lid crease.
a
d
g
b
e
h
c
f
i

396
VI Eyelid Surgery
34.7 Concluding Thoughts
:hile Asian blepharoplasty can be a challenging operation, the
exponentially growing demand for a double eyelid necessitates
its inclusion in the fundamental armamentarium of surgeries
for a plastic surgeon. A thorough understanding of the distinct
anatomy and subtle nuances of the various techniques can make
this a very rewarding and successful procedure.
Clinical Caveats
• Absence of the eyelid crease in individuals of Asian ancestry
stems from a subtle yet significant difference in anatomy, with
a lower fusion point of the septum with inferiorly displaced
preaponeurotic fat.
• Be aware of the various crease heights and morphology and
reach a mutual understanding with patients preoperatively
regarding their expectations.
• Distinguish brow ptosis, blepharoptosis, and dermatochalasis
to determine the appropriate surgery.
• Be familiar with the numerous techniques that exist for an
Asian blepharoplasty, each with its unique pros and cons.
• Anticipate and prepare for potential complications, such
as asymmetry, high “sunken” crease, multiple creases, and
hypertrophic scarring.
Suggested Reading
>1@ Baek SM, .im SS, Tokunaga S, Bindiger A. Oriental blepharoplasty: single-stitch,
nonincision technique. Plast Reconstr Surg 1989;83(2):236–242
>2@ Boo-Chai .. Plastic construction of the superior palpebral fold. Plast Reconstr
Surg 1963;31:74–78
>3@ Chen :P, Park -D. Asian upper lid blepharoplasty: an update on indications and
technique. Facial Plast Surg 2013;29(1):26–31
>4@ Chen :. Suture ligation methods. In: Chen :PC, ed. Asian Blepharoplasty and the
Eyelid Crease, 2nd ed. London, U.: Butterworth Heinemann Elsevier; 2006:39–50
>5@ Chen B, Song H, Gao 4, et al. Measuring satisfaction with appearance: Validation
of the FACE-4 scales for double-eyelid blepharoplasty with minor incision in
young Asians–retrospective study of 200 cases. J Plast Reconstr Aesthet Surg
2017;70(8):1129–1135
>6@ Chen SHT, Mardini S, Chen HC, et al. Strategies for a successful corrective
Asian blepharoplasty after previously failed revisions. Plast Reconstr Surg
2004;114(5):1270–1277, discussion 1278–1279
>7@ Duke-Elder S. The eyelids. In: System of Ophthalmology. Vol II. London, U.: Henry
.impton; 1961:504–505
>8@ Fan -, Low D:. A two-way continuous buried-suture approach to the creation of
the long-lasting double eyelid: surgical technique and long-term follow-up in 51
patients. Aesthetic Plast Surg 2009;33(3):421–425
>9@ Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr
Surg Transplant Bull 1960;25:257–264
>10@ -eong S, Lemke B1, Dortzbach R., Park an anatomical study with comparison to the Caucasian eyelid. Arch Ophthalmol
1999;117(7):907–912
>11@ -ordan DR, Anderson RL. Epicanthal folds. A deep tissue approach. Arch Ophthal-
mol 1989;107(10):1532–1535
>12@ .akizaki H, Ichinose A, 1akano T, Asamoto ., Ikeda H. Anatomy of the epicanthal
fold. Plast Reconstr Surg 2012;130(3):494e–495e
>13@ Goold LA, Casson R-, Selva D, .akizaki H. Tarsal height. Ophthalmology
2009;116(9):1831–1831.e2
>14@ .im BG. Multiple suture technique. In: Park -I, Toriumi DM, eds. Asian Facial
Cosmetic Surgery. Philadelphia, PA: Saunders Elsevier; 2006:24–32
>15@ .im <., .wan -D, Oh .S. Double eyelid operation with three tiny incisions. Arch
Plast Surg 2000;27(3):195–198
>16@ .im <:, Park H-, .im S. Secondary correction of unsatisfactory blepharoplasty:
removing multilaminated septal structures and grafting of preaponeurotic fat.
Plast Reconstr Surg 2000;106(6):1399–1404, discussion 1405–1406
>17@ .im S, Choi TH, Liu :, Ogawa R, Suh -S, Mustoe TA. Update on scar man-
agement: guidelines for treating Asian patients. Plast Reconstr Surg
2013;132(6):1580–1589
>18@ Lam SM, .im <.. Partial-incision technique for creation of the double eyelid.
Aesthet Surg J 2003;23(3):170–176
>19@ Lee <, .won S, Hwang .. Correction of sunken and/or multiply folded upper
eyelid by fascia-fat graft. Plast Reconstr Surg 2001;107(1):15–19
>20@ Lee :, .won SB, Oh S., orbital fat transposition flap and dermofat graft. J Plast Reconstr Aesthet Surg
2017;70(12):1768–1775
>21@ Ma F<, Cheng MS. Mini-incision double eyelidplasty. Aesthet Surg J
2010;30(3):329–334
>22@ Maruo M. Plastic construction of a ´double-eyelid.µ Jpn Rev Clin Ophthalmol
1929;24:393–406
>23@ Mikamo .. A technique in the double-eyelid operation. J Chugaishinpo 1896
>24@ Saonanon P. Update on Asian eyelid anatomy and clinical relevance. Curr Opin
Ophthalmol 2014;25(5):436–442
>25@ Sayoc BT. Plastic construction of the superior palpebral fold. Am J Ophthalmol
1954;38(4):556–559
>26@ Shirakabe <, .inugasa T, .awata M, .ishimoto T, Shirakabe T. The double-eyelid
operation in -apan: its evolution as related to cultural changes. Ann Plast Surg
1985;15(3):224–241
>27@ Song R<, Song 1985;9(3):173–180
>28@ Song R<. Further discussion on the improved suturing technique for double
eyelid operation (intradermal and intratarsal suturing technique). Chin J Plast
Burn Surg 1990;6:96–97
>29@ :ong -.. A method in creation of the superior palpebral fold in Asians using a
continuous tarsal stitch. Facial Plast Surg Clin N Am 2007;15:337–341e3
>30@ :u :. A two-way continuous buried-suture approach. Aesthetic Plast Surg
2009;33(3):426–429

35 Ptosis Surgery in the Blepharoplasty Patient
397
35 Ptosis Surgery in the Blepharoplasty Patient
Ted Wojno
Abstract
Ptosis repair may be an integral part of upper eyelid blepharo-
plasty. If ptosis goes unrecognized and untreated during upper
eyelid blepharoplasty, secondary surgery will likely be needed. If
the surgeon is familiar with the anatomy, this is a straightforward
addition to the procedure. The evaluation of the ptosis patient is
discussed, as is the surgical repair in both patients under local
and general anesthesia. Management of complications of ptosis
repair is reviewed.
Keywords
levator muscle, levator aponeurosis, mllerectomy, acquired
ptosis, congenital ptosis
35.1 Indications and
Contraindications
Ptosis repair is easily combined with upper eyelid blepharoplasty,
since the levator palpebrae superioris aponeurosis and muscle
are already exposed in the surgery. The addition of functional
ptosis repair should be considered when the upper eyelid margin
rests 2 mm or less above the center of the pupil, which is gener-
ally considered to be the point at which ptosis is visually signif-
icant. Ptosis repair should also be considered if there is greater
than 1 mm difference in the upper eyelid position between the
two eyes in primary position. This magnitude of asymmetry,
although seemingly small, is surprisingly noticeable. Such a
difference may not, however, be discerned by patients if they are
focused on the redundant skin and fat of the upper eyelid. Often,
pre-existent ptosis is only noticed by patients after the swelling
from upper eyelid blepharoplasty has resolved.
There is no absolute contraindication to ptosis repair at the
time of upper eyelid blepharoplasty in an otherwise normal
patient. If, however, the patient has preoperative lagophthalmos
from any etiology, then ptosis repair would exacerbate symptoms
of exposure and thus should be carefully considered. As with
upper eyelid blepharoplasty, the only real contraindication is a
patient who has an uncontrolled coagulopathy or one who cannot
discontinue anticoagulant medication for a sufficient length of
time to return the clotting system to a level that minimizes the
risk of vision-threatening orbital hemorrhage.
35.2 Pertinent Anatomy
The anatomy of the upper eyelid was discussed at length in
the chapter on upper eyelid blepharoplasty, and the reader is
referred there for this discussion.
35.3 Preoperative Assessment
Examine the eyes with the patient sitting in front of and level
to the examiner. Have the patient look straight ahead over the
examiner’s shoulder to the end of the room. Be certain that the
frontalis muscle is relaxed. It may be necessary to gently push the
brow and forehead down to the normal position to achieve this.
35.3.1 Palpebral Fissure
The palpebral fissure (PF) is the vertical gap in millimeters
between the upper and lower eyelid margins as measured at
midpupil (Fig. 35.1). Again, the patient should have the frontalis
muscle relaxed and looking toward the end of the room. This
measure will vary depending on the position of both the upper
and lower eyelids but is usually between 8 and 10 mm.
:hen measuring the palpebral fissures, remember the influ-
ence of Hering’s law of equal innervation (also known as Hering’s
law of motor correspondence of yoked muscles). The two levator
muscles receive their motor innervation from a single, unpaired
nucleus in the brain. This means that both levator muscles receive
the same amount of neural stimulation no matter what the
anatomic state of either muscle may be. If the patient attempts to
compensate for a unilateral ptosis or an asymmetric ptosis (either
consciously or unconsciously), there will be an equal increase
in the innervation to both levator muscles. If the patient has a
bilateral, asymmetric ptosis, the more ptotic eye may appear to
have only a mild ptosis while the opposite eye appears to rest at a
normal level. In such a case, a unilateral ptosis repair of the more
severely ptotic eye will result in the opposite eye displaying ptosis
postoperatively, since the neurologic stimulation of both muscles
is now lessened somewhat. Also, in some cases of unilateral ptosis,
the ptotic eye may appear normal while the opposite (normal eye)
may actually appear retracted.
Fig. 35.1 Measurement of the palpebral fissure.

398
VI Eyelid Surgery
To detect whether this exists, the examiner should elevate the
ptotic (or more ptotic) eyelid with a fingertip (thus decreasing the
need for excessive stimulation of the levator muscles) and observe
any drop in the resting level of the opposite upper eyelid. If the
opposite upper eyelid is now ptotic, both eyelids will require
ptosis repair in conjunction with blepharoplasty (although the
amount of repair will likely differ).
Although not 100 reliable, the demonstration of Hering’s law
will apply in the vast majority of ptosis cases. There will still be an
occasional patient who will not exhibit ptosis of the opposite eye
until sometime in the postoperative period.
35.3.2 0DrginDO 5eÁe[ 'iVWDnFe
:ith a penlight centered on the cornea, the marginal reflex
distance (MRD) is the vertical gap between the pupillary light
reflex and the upper eyelid margin (Fig. 35.2). This is typically
3 to 4 mm. This measurement is independent of the position of
the lower eyelid and is thus a more accurate gauge than the pal-
pebral fissure for the presence and degree of ptosis. By conven-
tion, 1 to 2 mm of ptosis is considered mild, 3 mm is moderate,
and 4 mm or greater is severe.
35.3.3 Levator Function
The levator function is the vertical excursion of the upper eyelid
as measured at midpupil from downgaze to upgaze (Fig. 35.3).
The examiner should hold a finger over the eyebrow to nullify
any contribution from the frontalis muscle. 1ormal levator func-
tion is 12 mm or greater.
35.3.4 Acquired (Age-Related) Ptosis
The vast majority of patients who present with both upper eyelid
dermatochalasis and ptosis will have acquired, age-related
ptosis. This is also referred to as aponeurotic ptosis, since it is
best conceptualized as a thinning and/or stretching of the levator
aponeurosis. Although many authors assert that the aponeurosis
is disinserted from its attachment to the tarsus, careful inspec-
tion at the time of surgery will almost always reveal an intact,
albeit thinned, aponeurosis (Fig. 35.4). Most cases of aponeurotic
disinsertion found at surgery are most likely iatrogenic, having
been caused by inadvertent excision of the diaphanous inferior
aponeurosis during removal of skin and orbicularis or after
opening the orbital septum.
Age-related, acquired ptosis is due to degenerative changes and
thinning of the levator aponeurosis. It can be exacerbated by or
unmasked by prior intraocular surgery, an episode of lid edema/
swelling, long-term contact lens wear, or direct trauma. These
patients will have excellent levator function (! 12 mm), a higher
than normal or absent eyelid crease (due to loss of the fibrous
attachments from the levator to the underside of the skin), and,
in severe cases, visibility of the iris through the thinned eyelid
tissues (Fig. 35.5). Such ptosis is characteristically worse in the
evening as the levator, Mller’s, and frontalis muscles tire of sup-
porting the drooping eyelids. Since this is best conceptualized as a
´stretched-outµ levator aponeurosis, if unilateral, the involved lid
will descend to a lower level than the opposite lid on downgaze.
Often the thinning of the levator is more remarkable medially,
and in some instances the aponeurosis and muscle are essentially
non-existent here (Fig. 35.6). This nasal atrophy is responsible
for the frequently noted observation that acquired ptosis may be
much worse medially.
Fig. 35.2 Measurement of the marginal reflex distance.
Fig. 35.3 Measurement of levator function from (a) downgaze to (b)
upgaze. In this example it is 14 mm.
a
b

35 Ptosis Surgery in the Blepharoplasty Patient
399
There also exists a much less common form of age-related,
acquired ptosis that is characterized not by thinning but rather by
thickening of both the levator aponeurosis and muscle (Fig. 35.7).
These changes are quite obvious at surgery, and pathology reveals
that the tissues display fat infi ltration and fi brosis. Although
sometimes unilateral, most cases are bilateral. This variant is
poorly understood and underappreciated as a cause of ptosis. It is
perhaps best conceptualized as an adult onset dystrophy specifi c
to the levator. Some cases display a remarkable family history
of signifi cant ptosis that develops in the age range of 20 to 40
years. For all purposes, it behaves as, and can be treated just like,
´aponeuroticµ ptosis in terms of surgery. Repeat surgery is often
necessary over a period of years, since in some patients the degen-
erative process seems to continue.
35.3.5 Other Causes of Acquired Ptosis
Myasthenia Gravis
An infrequent cause of ptosis is the neuromuscular disorder
myasthenia gravis. A classic symptom in myasthenia is worsen-
ing by day’s end, which, although present in most other cases
of ptosis, is typically much more dramatic in this disorder. It
is sometimes accompanied by diplopia, as other extraocular
muscles may be involved. Although an intravenous injection of
edrophonium is the classic way of making the diagnosis, this test
is inconvenient and has signifi cant side eff ects. A much simpler
and very reliable test is the ´ice test,µ whereby the examiner
places an ice cube (usually in a disposable exam glove) over the
Fig. 35.4 Intact levator aponeurosis demonstrating extreme thinning
at the time of ptosis repair.
Fig. 35.5 The dark iris can be subtly visualized through the thinned
upper eyelid tissues in this patient with ptosis.
Fig. 35.6 Photo of the left upper eyelid demonstrating almost
complete atrophy of the nasal portion of the levator muscle and
aponeurosis in the medial region.
Fig. 35.7 Grossly thickened levator muscle with fi bro-fatty infi ltration.

400
VI Eyelid Surgery
patient’s closed upper eyelid for 2 minutes. In myasthenia, the
ptosis (and diplopia if present) will reverse for about 30 seconds
after removal of the ice (Fig. 35.8). The test may have some
false positives but rarely has false negatives. Alternatively, the
examiner can have the patient look repetitively from extreme
downgaze to upgaze for 1 minute. In myasthenia, the ptosis will
become much worse. If myasthenia is suspected, referral to a
neurologist is appropriate. It is important to know that if myas-
thenia gravis is isolated in the levator muscle, antibody testing
will usually be negative.
Horner’s Syndrome
Acquired Horner’s syndrome is also very uncommon and is
characterized by 1 to 2 mm of ptosis accompanied by the very
distinctive sign of a miotic pupil (Fig. 35.9). The pupillary asym-
metry is worse in dim light than in regular light. There is also a
1- to 2-mm elevation of the lower eyelid (upside-down ptosis)
compared with the opposite side due to the lack of sympathetic
innervation to the adrenergic muscle of the lower eyelid.
Ipsilateral facial anhidrosis may also be noted. If suspected, the
patient should be referred to a neuro-ophthalmologist or neurol-
ogist for additional testing, since Horner’s syndrome has many
causes, many of which have signifi cant consequences.
Chronic Progressive External Ophthalmoplegia
Very uncommon as a cause of ptosis is chronic progressive
external ophthalmoplegia (CPEO). This is a bilateral disorder of
the levator and all the extraocular muscles that begins in ado-
lescence and is characterized by severe ptosis and limitation of
ocular motility (Fig. 35.10). The .earns-Sayre form of the disease
is a mitochondrial myopathy accompanied by a retinal pigmen-
tary dystrophy and cardiac conduction abnormalities.
Oculopharyngeal Muscular Dystrophy
Oculopharyngeal muscular dystrophy is a progressive disorder
of bilateral, severe ptosis and diffi culty swallowing that most
often arises in patients with French-Canadian ancestry (Fig.
35.11). The symptoms of dysphagia are usually quite marked. If
suspected, a referral to a neurologist is indicated.
Mechanical Ptosis
Mechanical ptosis is due to any lesion that weighs down the
upper eyelid. The cause of such cases is typically obvious on
exam (Fig. 35.12). The notable exception is the rare case of a
´lostµ contact lens that becomes embedded in the eyelid tissues
of the superior fornix. Treatment of mechanical ptosis is aimed
at correction of the underlying pathology, which often must be
combined with levator surgery.
Acquired Third-Nerve Palsy
Acquired third-cranial-nerve palsy is easily diagnosed given that
the ptosis is usually complete and accompanied by severe exo-
tropia of the involved eye (Fig. 35.13). Repair requires a frontalis
sling procedure and extensive strabismus surgery. Results are
most often unsatisfying since diplopia is rarely alleviated.
Traumatic Ptosis
Traumatic ptosis is any that is due to injury to the levator muscle
or its innervation. Repair of traumatic ptosis is best delayed for
at least 6 months after the injury, since many cases will sponta-
neously improve (Fig. 35.14). Many instances of traumatic ptosis
Fig. 35.9 Patient with ptosis of the right upper eyelid in Horner’s
syndrome.
Fig. 35.10 Patient with chronic progressive external ophthalmoplegia.
Fig. 35.8 (a) Patient with ptosis of left upper eyelid due to myasthenia
gravis. (b) Patient immediately after the ice test demonstrating
complete resolution of ptosis.
a
b

35 Ptosis Surgery in the Blepharoplasty Patient
401
are simply thinning of the levator aponeurosis due to eyelid
edema from the injury and behave as acquired, aponeurotic
ptosis of aging.
Orbital Pathology
Acquired ptosis is rarely due to orbital pathology such as a neo-
plasm or infl ammation. Look for subtle signs of proptosis, globe
dystopia, and strabismus. An inexplicable decrease in levator
function should arouse suspicion of orbital pathology.
Pseudoptosis
Pseudoptosis may be due to contralateral lid retraction and is
most frequently seen with thyroid eye disease. It is common for
such patients to present complaining of unilateral ptosis, since
the lower of the two lids is often perceived as the ´abnormalµ
one (Fig. 35.15). Look for other signs of thyroid eye disease such
as eyelid and conjunctival edema, injection over the medial and
lateral recti, and exophthalmos. Pseudoptosis is also seen with
unilateral enophthalmos caused by orbital disease, injury, or a
microphthalmic globe (Fig. 35.16). Unilateral hypotropia (down-
ward deviation of the globe) may also give the appearance of
ptosis. This is because the upper eyelid follows the movement of
the globe and thus simply appears to be lower than the opposite
side.
35.3.6 Congenital Ptosis
:hile the correction of congenital ptosis is not covered in this
chapter, the surgeon should be familiar with its diagnosis, since
it is not uncommon to encounter such patients in adulthood.
Although the vast majority of patients with congenital ptosis
will be appropriately diagnosed and managed in childhood,
the occasional patient may be unrecognized and then present
as an adult seeking repair in conjunction with blepharoplasty.
Since the repair is distinctly diff erent, surgeons must be able to
distinguish it from the more common adult, aponeurotic ptosis.
If a congenital ptosis is treated as an acquired ptosis, the result
will almost always be a signifi cant undercorrection.
Approximately 75 of congenital ptosis cases are unilateral
and will, of course, have a history that dates from infancy. About
30 of patients with congenital ptosis have an accompanying
amblyopia, strabismus, and/or anisometropia. Pathological exam
of the levator reveals replacement of muscle with fi brofatty tissue.
In general, the greater the degree of congenital ptosis, the more
severe the dystrophic changes and the lower is the measured
levator function.
:hen severe and with the appropriate history, the identifi ca-
tion is obvious. The problem arises in those cases that are mild and
were never diagnosed. Patients may talk in terms of always having
had ´bedroom eyesµ or inaccurately describe their condition as
Fig. 35.11 Patient with oculopharyngeal muscular dystrophy.
Fig. 35.12 Patient with mechanical ptosis secondary to
neurofi bromatosis.
Fig. 35.13 (a) Patient with complete ptosis secondary to a
third-cranial-nerve palsy. (b) The severe exotropia due to medial rectus
paralysis in third-cranial-nerve palsy.
b
a
Fig. 35.14 (a) Patient with traumatic ptosis 1 month after injury. (b)
The same patient 6 months later, with spontaneous resolution of
ptosis.
b
a

402
VI Eyelid Surgery
´lazy eye.µ If unilateral or asymmetric, it is easy to distinguish
congenital ptosis from acquired ptosis. Simply have the patient
look from primary position to extreme downgaze while holding
the head straight. :ith congenital ptosis, the involved lid will not
descend as low as the opposite lid on downgaze, while in acquired
ptosis the involved lid descends to a lower level than the opposite
lid (Fig. 35.17, Fig. 35.18). This occurs because the levator muscle
in congenital ptosis is best conceptualized as a ´tightµ muscle, so
it will hang up a bit on downgaze. Contrarily, the lid in acquired
ptosis can be thought of as being ´stretched outµ and thus drop
to a lower level on downgaze. This fi nding can be relied upon to
diff erentiate most congenital from acquired cases.
If congenital ptosis is bilateral and symmetric, the only clue
other than the history may be a decrease in the measured levator
function. As a rule, the greater the ptosis, the lower the levator
function. Any levator function of 10mm or less is strongly suspi-
cious for a congenital etiology.
The surgical repair of congenital ptosis is usually referred to
as ´levator resectionµ and often involves the combined, en bloc
shortening of both the levator and Mller’s muscle. Unlike the
surgery of aponeurotic ptosis, which involves muscle shortening
on the order of 2 to 10 mm, levator resection typically involves
shortening of the muscles by 12 to 20 mm. Cases with poor levator
function (4 mm or less) will require a frontalis sling procedure
utilizing autogenous fascia lata, banked tissue, or alloplastic mate-
rials. :hen performing surgery for acquired, adult ptosis, lagoph-
thalmos should be strictly avoided, whereas the full correction of
congenital ptosis usually results in some degree of lagophthalmos
given the relatively large resections that are required. If performed
before the age of 10 years, the corneal exposure that results is well
Fig. 35.16 Patient referred for ptosis of the left upper eyelid who
actually has enophthalmos due to an old orbital fl oor fracture.
Fig. 35.15 (a) Patient referred for “ptosis” of the right upper eyelid
who actually has unrecognized retraction of the left upper eyelid
secondary to thyroid eye disease. (b) By pulling down on the retracted
left upper eyelid, the “ptotic” lid is now in normal position.
b
a
Fig. 35.17 (a) A patient with congenital ptosis of the left upper eyelid
in primary position. (b) The same patient in downgaze. Note that
the ptotic left upper eyelid appears higher than the opposite lid in
downgaze. (Reproduced from Nahai F, Wojno T. Problems in Periorbital
Surgery: A Repair Manual. New b
a
Fig. 35.18 (a) A patient with acquired ptosis of the left upper eyelid
in primary position. (b) The same patient in downgaze. Note that the
ptotic left upper eyelid descends lower than the right upper eyelid in
downgaze. (Reproduced from Nahai F, Wojno T. Problems in Periorbital
Surgery: A Repair Manual. New b
a

35 Ptosis Surgery in the Blepharoplasty Patient
403
tolerated for life. If the age of initial surgery for congenital ptosis
progresses beyond this point, corneal decompensation becomes
increasingly problematic.
When doing repair of congenital ptosis in adulthood, whether
combined with blepharoplasty or in isolation, some degree of pur-
poseful undercorrection is necessary to avoid exposure problems.
35.4 Preoperative Planning,
Including Markings
The addition of ptosis repair changes nothing in terms of
planning and marking from pure upper eyelid blepharoplasty.
The reader is therefore referred to the chapter on upper eyelid
blepharoplasty for a thorough discussion.
35.5 Operative Technique
Ptosis repair can be performed by either an anterior, skin
approach or a posterior approach through the conjunctiva.
Posterior approaches include the tarsoconjunctivomllerectomy
(Fasanella-Servat procedure) or Putterman’s mllerectomy
procedure. The addition of a second incision, which would be
required for a posterior approach, seems unnecessary if the sur-
geon is already performing a blepharoplasty, so the techniques
discussed here will focus on the anterior approach.
35.5.1 Surgery in the Awake Patient
1ote the level of the eyelid(s) with the patient lying down and
prior to local anesthetic injection and any intravenous sedation.
This observation is important in the awake patient because the
resting lid level may be affected by epinephrine, local anesthesia,
patient anxiety, and level of consciousness. The eyelid level will
be reassessed prior to suture placement in the levator.
Skin, orbicularis, and fat management are first performed as
detailed in the chapter on upper eyelid blepharoplasty. At this
point, the levator muscle must be disinserted centrally from the
tarsal plate. This is accomplished by lifting up the lower edge of
skin and orbicularis and cutting with a sharp scissors straight
down onto the superior border of the tarsal plate in the center
of the incision (Fig. 35.19). Extend this incision medially and
laterally for a 1-cm opening (Fig. 35.20). The superior tarsal
arcade is usually visible in the underlying Mller’s muscle (Fig.
35.21). Care should be taken to avoid cutting these vessels, since
they can bleed substantially and the application of cautery can be
painful in the awake patient. The surgeon can usually determine
the degree of natural adhesion between the levator and Mller’s
muscle by pulling up on the levator and inspecting under it. In
some cases the bond is quite minimal, and the muscles separate
easily from each other for several millimeters superiorly. If so, no
further dissection is needed. If the muscles are firmly attached,
then dissect superiorly between them for 5 to 6 mm (Fig. 35.22).
At this point, ask the patient to open the eyes; reassess the level
of the eyelid(s), comparing to what was observed before anesthetic
injection. Occasionally, the lid level will now be much higher due
to the effect of epinephrine on Mller’s muscle. If, for example,
the eyelid has artificially elevated by 3 mm compared to the start
of surgery, it will fall by that same amount after the epinephrine
wears off. Thus the surgeon should set the eyelid 3 mm higher
than the ideal level at this point, knowing that the epinephrine
effect is temporary.
Determine the exact location for suture placement by pulling
with a forceps on the superior border of the tarsal plate and
observing the contour of the lid margin to determine whether it
looks natural. This is usually between the pupil and the lateral
limbus of the eye. At this point, take a partial thickness bite with a
double-armed 5–0 or 6–0 polyester or polyglactin suture parallel
to and in the superior border of the tarsal plate (Fig. 35.23). Evert
the lid and inspect below to be certain that the needle did not
penetrate the conjunctival surface (Fig. 35.24). If the bite is secure,
pull the needle the rest of the way through the tarsus. 1ow pass
both arms of the suture through the levator from the posterior to
anterior surface about 2 to 3 mm apart (Fig. 35.25). There is no
accurate formula to determine how high in the levator to place
these bites, given the variability of the levator aponeurosis length
and muscle strength, but a good starting point is as follows:
Fig. 35.19 To disinsert the levator, cut straight down onto the tarsus in
the center of the upper eyelid.
Fig. 35.20 The levator disinsertion is carried medially and laterally for
a total of 1 cm. The arrow marks the superior border of the tarsal plate.

404
VI Eyelid Surgery
• For 1 to 2 mm of ptosis correction, place the sutures 4 to 5 mm
above the cut edge.
• For 4 to 5 mm of ptosis correction, place the suture 8 to 10 mm
above the cut edge.
In general, it is only infrequently necessary to go significantly
higher than the musculoaponeurotic junction of the levator. Place
a slip knot in the suture (Fig. 35.26). Move the overhead lights off
the field and ask the patient to open the eyes. Observe the height
and contour of the eyelid to determine whether it is acceptable.
It is sometimes helpful to sit the patient up to observe the eyes
better (Fig. 35.27). If the height is wrong, untie the slip knot and
replace the suture arms either higher or lower in the levator as
required. If the contour is wrong, untie the slip knot, remove both
arms of the suture from both levator and tarsus, and replace the
tarsal bite more medially or laterally as needed. Observe the lid
height and contour again. These adjustments should ensure the
desired ptosis correction (Fig. 35.28).
Although one suture will suffice under most circumstances,
there are some cases in which two or three sutures will be
needed to obtain a proper contour of the eyelid margin. This is
required when an unnatural peak is observed that is not corrected
by moving the initial suture either medially or laterally in the
tarsal plate. The reason for this occurrence is unclear but may be
related to the tarsal plate’s being more slack than normal. In this
circumstance, it will be necessary to disinsert the levator aponeu-
rosis more medially and laterally, exposing the entire horizontal
expanse of the tarsal plate. 1ow place one suture more medially
and the second suture more laterally in the tarsal plate, or place
three sutures evenly spaced across the tarsus centrally, medially
and laterally. Pass the sutures through the levator, tie slip knots,
and again observe the lid contour and height.
Ask the patient to close the eyes so as to check for lagophthal-
mos. Depending on the amount of levator shortening and the
degree of orbicularis paralysis imparted by the local anesthetic
infiltration, 2 to 3 mm of lagophthalmos may be noted. Gently
push the upper lid closed to determine whether this can be done
easily and without resistance. If the eyelid closes easily, there
should be no permanent lagophthalmos as a result. If, however,
the eyelid feels very tight or will not close, then the suture should
Fig. 35.23 Taking a bite of the superior border of the tarsal plate with
a 5–0 polyester suture.
Fig. 35.24 Everting the upper eyelid to be certain that the suture does
not penetrate the posterior surface of the tarsal plate.
Fig. 35.21 The superior arcade is visible on the anterior surface of
Müller’s muscle just above the superior border of the tarsal plate.
Fig. 35.22 With the cut edge of the levator aponeurosis elevated with
a forceps, dissect between it and Müller’s muscle for 5 to 6 mm.

35 Ptosis Surgery in the Blepharoplasty Patient
405
be replaced lower in the levator. A slight undercorrection of ptosis
is preferable to lagophthalmos.
If reinforcement of the eyelid crease is desired, use the levator
suture(s) to create the crease as described in the chapter on upper
eyelid blepharoplasty and then close the skin (Fig. 35.29).
35.5.2 Surgery in a Patient under
General Anesthesia
It may be necessary to perform ptosis repair under general
anesthesia due to the need for more extensive concomitant pro-
cedures or as a matter of physician and patient preference. Under
these circumstances, it is not possible to utilize the assessments
outlined in the preceding section. The following describes two
techniques that can be utilized under these circumstances.
The Anatomic Method
Clinton McCord has developed what he referred to as an ´ana-
tomic methodµ to be used in cases of bilateral ptosis requiring
heavy sedation or general anesthesia. In this technique, the
preaponeurotic fat is retracted to expose the musculoaponeu-
rotic junction. The levator itself is dissected centrally off the
underlying Mller’s muscle up to the level of the junction. As
with an awake patient, a double-armed suture is placed centrally
in the tarsal plate and then into the levator at the musculoapo-
neurotic junction in both eyes. It is important to place the sutures
in both eyes at precisely the same point in the tarsal plate and
levator. Place the first throw of a knot in each with exactly the
same tension and observe the gapping between the upper and
lower eyelids. Tighten or loosen the sutures until the gapping is
the same on both eyes.
For the last step in this technique, perform what McCord called
the ´spring back test.µ Grasp the center of both upper eyelid
margins with forceps, pull the lids closed, and then release them.
Fig. 35.26 A slip knot is placed into the suture to assess the eyelid
position.
Fig. 35.28 After the sutures are repositioned lower in the levator
muscle, the level of the eyelid is now correct.
Fig. 35.27 When this patient sits up and opens her eyes, it is obvious
that the lid is too high. The double-armed suture will be repositioned
slightly lower in the levator.
Fig. 35.25 (a) The first arm of the suture is passed from the underside of the levator through the muscle. (b) The second arm emerges 2 to 3 mm
from the first.
a
b

406
VI Eyelid Surgery
Observe the speed with which the lids spring back to the gapped
position. If uneven, adjust the tension on one or both lids until
the spring back is symmetric. Complete the knot and, if desired,
re-form the crease.
This technique is best suited to patients with bilateral ptosis.
For those with unilateral ptosis who undergo bilateral upper
blepharoplasty, the surgeon should employ the method previ-
ously outlined for awake patients or perform a mllerectomy as
described next.
Müllerectomy
Although the levator muscle is the main upper eyelid retractor,
a significant minority of surgeons prefer to treat acquired ptosis
with a mllerectomy utilizing a specially designed clamp as
originally described by Allen Putterman. In addition to its ability
to be used on a sedated patient, the appeal of the procedure is its
simplicity if one is comfortable working from the conjunctival
side of the eyelid. It is best utilized for relatively small degrees
of ptosis, 1 to 2 mm. There is some question as to exactly how
the procedure works, since there is evidence that it may actually
incorporate a resection or plication of the levator aponeurosis.
There are numerous variations described in the literature that
have attempted to fine-tune the results, but a discussion of these
many modifications well exceeds the scope of this chapter.
Most mllerectomy procedures are based on the response of
the eyelid to topically applied 2.5 ophthalmic phenylephrine
drops to determine the relative integrity of Mller’s muscle.
Originally, a 10 solution was used, but this may have significant
cardiovascular effects from systemic absorption and should be
avoided. Phenylephrine is an alpha-adrenergic agonist and will
stimulate the sympathetically innervated Mller’s muscle. A pos-
itive response, lid elevation, predicts the suitability of the muscle
for this procedure.
For the phenylephrine test, first note the position of the upper
eyelids. Place a drop of topical ophthalmic anesthetic into the
eye(s). 1ext, place a drop of the 2.5 phenylephrine into the ptotic
eye(s) every 15 seconds, for a total of four drops. :ait 5 minutes
and observe again. Elevation of 2 to 3 mm predicts that the pro-
cedure will be effective. If evaluating a unilateral ptosis, recheck
the lid level of the opposite eye after observing elevation of the
involved eye. It may now be ptotic due to the effect of Hering’s
law, an indication that the problem is indeed bilateral and needs
bilateral repair. For repair of 1 mm of ptosis, plan to resect a total
of 4 mm of tissue. For 2 mm of ptosis, resect 8 mm. For 3 mm of
ptosis, resect a total of 10 mm of tissue.
For surgical repair of ptosis in combination with blepharoplasty,
perform skin, orbicularis, and fat removal in the standard fashion.
1ext, place a traction suture through the central margin of the
upper eyelid and evert over a Desmarres retractor. If desired, mark
the superior border of the tarsus as visualized through the con-
junctiva with a marking pen or cautery. 1ext, mark one-half of the
planned resection amount on the conjunctiva centrally, medially,
and laterally as measured from the superior border of the tarsal
plate (Fig. 35.30). 1ext, place a running 6–0 silk suture through
these three marks. Exert traction with the suture by pulling it away
from the eyelid, tenting up the conjunctiva and Mller’s muscle
and thus (in theory) separating them from the overlying levator
fibers (Fig. 35.31). While maintaining traction, place a Putterman
clamp at the superior border of the tarsus, thus sandwiching the
elevated tissue in the center and securing the conjunctiva and
Mller’s muscle to be resected (Fig. 35.32). 1ow remove the
Desmarres retractor to aid visualization. Inspect to be certain that
no portion of the tarsal plate has been incorporated into the clamp.
Return the lid to its normal position and pull the lid skin and/or
lid margin superiorly while pulling the sutures inferiorly (Fig.
35.33). If the lid margin contour is peaked, tarsus may have been
incorporated into the clamp. If so, remove and replace the clamp.
Likewise, if the skin feels very tight, the levator may have been
incorporated. If so, remove and replace the clamp. 1ext, place a
6–0 plain gut suture through the anterior surface of the eyelid just
above the superior border of the tarsal plate in the lateral aspect of
the blepharoplasty incision to emerge on the conjunctival surface.
:eave this suture back and forth under the clamp to its medial end
and then return in a similar fashion back to the lateral end. Pass
the suture back through the conjunctiva to the anterior surface of
the blepharoplasty incision and tie it to the other end in the open
wound. 1ext, use a blade or scissors to cut the conjunctiva and
Mller’s muscle tissue between the clamp and the running suture,
being certain not to cut the suture (Fig. 35.34). Inspect the edges
of the conjunctiva. If separated by more than 2 mm, consider an
interrupted, buried suture of 6–0 plain gut to approximate the
edges better. Close the skin to complete the procedure.
35.6 Ancillary Procedures
:ith the exception of overcorrection and undercorrection of
ptosis, the ancillary procedures for ptosis repair performed in
conjunction with upper eyelid blepharoplasty are identical to
those outlined in the chapter on upper eyelid blepharoplasty, and
the reader is referred to that chapter. :hen the postoperative
lid level differs from the desired level, a secondary procedure
Fig. 35.29 The crease is reformed using the same suture to take a
bite of the orbicularis at the lower edge of the incision and tying.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A
Repair Manual. New

35 Ptosis Surgery in the Blepharoplasty Patient
407
may be warranted. In general, asymmetry equal to or greater
than 1 mm is easily noticed by patients. Likewise, a contour
diff erence between the two lid margins (which is essentially a
focal undercorrection or overcorrection) is also quite apparent to
most patients. Bilateral undercorrection or overcorrection that is
symmetrical is usually much less noticeable and better tolerated
if relatively small.
35.6.1 Overcorrection of Ptosis
Overcorrection is often easier to handle than undercorrection.
1onsurgical treatment can begin as soon as 1 week after surgery
and can still be eff ective if begun in the month following the
procedure. Instruct the patient to massage the closed eyelid with
a fi nger over the underlying globe for 5 minutes, four times daily.
This can loosen the sutures attaching the levator aponeurosis to
the tarsus (or the sutures securing Mller’s muscle if a mllerec-
tomy was performed) and stretch the fi bers of both the aponeuro-
sis and Mller’s muscle. Another technique is to have the patient
grasp the upper eyelid lashes and look repetitively upward. If
Fig. 35.30 The superior border of the tarsal plate is denoted by the
downward arrows. One-half of the proposed resection of tissue is
marked centrally, medially, and laterally (upward arrows).
Fig. 35.32 The Putterman clamp is placed on the tissue to be
resected.
Fig. 35.34 Excision of the conjunctiva and Müller’s muscle between
the running suture and the clamp, performed with a scissors.
Fig. 35.31 A 6–0 silk traction suture is placed through the three marks
that denote one-half of the proposed tissue resection.
Fig. 35.33 After removal of the Desmarres retractor, the sutures are
pulled inferiorly while the lid margin is pulled superiorly to ascertain
whether any tarsus or levator has been incorporated into the tissue
clamped tissue.

408
VI Eyelid Surgery
eff ective, improvement should be seen within a week and contin-
ued for up to 1 month until the desired lid level is obtained.
If conservative treatment is not eff ective, a surgical adjustment
is necessary and can usually be performed in the offi ce. An ideal
time to do this is at least 1 month after the surgery, when edema
has subsided (Fig. 35.35a). Inject a small amount of local anesthetic
into the old incision and open it with a blade or scissors. Typically
it is necessary to open no more than 10 mm of the incision line
in the center of the lid (or the area of the focal overcorrection, as
the case may be). :hile retracting the lower edge of the incision,
undermine beneath the orbicularis at the upper edge for a few
millimeters superiorly to identify the levator aponeurosis (Fig.
35.35b). :ith scissors, disinsert the levator from the superior
border of the tarsal plate by cutting the suture(s) if still present,
and observe the lid level to see whether the desired lowering was
obtained. If not, dissect between the levator and on top of Mller’s
muscle to further divide adhesions that have formed since the
original surgery (Fig. 35.35c). If needed, extend the separation of
the levator medially and laterally until the lid is at the appropriate
level and the contour is satisfactory. It is not necessary to resuture
the levator, since the adhesions of the surrounding tissue will
be suffi cient to hold the eyelid in place. Suture the skin closed
(Fig. 35.35d). This technique is applicable to both patients who
have had a prior levator shortening and those who have had a
mllerectomy.
35.6.2 Undercorrection of Ptosis
It is best to wait for 1 month before attempting to repair an under-
correction of ptosis. Eyelid edema and ecchymosis always cause
some degree of mechanical ptosis in the postoperative period, so
it can be diffi cult to assess the accuracy of an adjustment if per-
formed too early. The only way to remedy an undercorrection is
with additional surgery, which most often is easily accomplished
in the offi ce. As in the technique just described for overcorrec-
tion, anesthetize and open approximately 10 mm of the incision
in the applicable area of the eyelid and disinsert the levator from
the tarsal plate. Place a new double-armed 5–0 or 6–0 polyester
or polyglactin suture in the superior border of the tarsus and then
into the levator more superiorly than the original suture. Place
a slip knot and observe the lid position to be certain that it is
satisfactory. If so, complete the knot and close the skin. For those
patients who have had a previous mllerectomy resulting in
undercorrection, a repeat mllerectomy is usually unsuccessful;
therefore, they too will require a shortening of the levator.
Fig. 35.35 (a) A patient 2 months after bilateral upper eyelid blepharoplasty and ptosis repair. The patient desires that the left upper lid be lowered.
(b) The central incision is opened, exposing the levator on the anterior surface of the tarsal plate (arrow). (c) The levator was disinserted centrally,
exposing the superior border of the tarsal plate (arrow). (d) The patient immediately afterward, showing improved symmetry of the eyelid levels.
a
c
d
b

35 Ptosis Surgery in the Blepharoplasty Patient
409
35.7 Postoperative Care
Postoperative care is identical to those steps described in the
chapter on upper eyelid blepharoplasty. If the patient has had a
mllerectomy procedure, it is helpful to apply a small amount of
the ophthalmic antibiotic ointment into the eye to lubricate the
posterior surface of the eyelid at the incision line. This is done
as needed for comfort. The patient should be cautioned that this
will blur the vision signifi cantly for the 24-hour period after the
application.
35.8 Outcomes
The addition of ptosis repair to upper eyelid blepharoplasty will
certainly increase the frequency of postoperative adjustments
compared with that of blepharoplasty alone. The surgeon should
anticipate and plan for this. If the patient is appropriately coun-
seled during the preoperative evaluation, this should create little
diffi culty for the physician and patient.
35.9 Results
Two patients are shown before and 2 months after combined
blepharoplasty and ptosis repair in Fig. 35.36 and Fig. 35.37.
35.10 Concluding Thoughts
The addition of ptosis repair to upper lid blepharoplasty is often
necessary and well within the area of expertise of surgeons
comfortable with upper eyelid surgery. The guidelines are
straightforward and if followed will lead to successful outcomes
in the vast majority of cases.
Clinical Caveats
• Since ptosis repair involves shortening of the eyelid retractor
muscles, lagophthalmos can occur with greater frequency
than with upper eyelid blepharoplasty alone.
• Wait until eyelid edema has subsided to evaluate the postop-
erative eyelid position critically.
• Even a small amount of eyelid level asymmetry (1 mm) is
easily perceived by the patient and others.
• Although the vast majority of acquired ptosis is due to
age-related changes in the levator, be suspicious for signs and
symptoms that indicate an underlying cause representative
of systemic disorders or orbital pathology.
• Congenital ptosis is more diffi cult to correct than acquired,
age-related ptosis and will necessitate larger amounts of
muscle tightening, with an increased risk of lagophthalmos.
• Ptosis with less than 5 mm of levator function cannot be
adequately corrected with the techniques presented here
and will require a frontalis sling procedure.
Suggested Reading
>1@ Anderson RL. Age of aponeurotic awareness. Ophthal Plast Reconstr Surg
1985;1(1):77–79
>2@ Dresner SC. Further modifi cations of the Mller’s muscle-conjunctival resection
procedure for blepharoptosis. Ophthal Plast Reconstr Surg 1991;7(2):114–122
>3@ Perry -D, .adakia A, Foster -A. A new algorithm for ptosis repair using conjunc-
tival Mllerectomy with or without tarsectomy. Ophthal Plast Reconstr Surg
2002;18(6):426–429
>4@ Putterman AM, Urist M-. Mller muscle–conjunctiva resection. Technique for
treatment of blepharoptosis. Arch Ophthalmol 1975;93(8):619–623
Fig. 35.36 (a) A patient before combined blepharoplasty and ptosis
repair. (b) The patient 2 months after combined blepharoplasty and
ptosis repair.
b
a
Fig. 35.37 (a) A patient before combined blepharoplasty and ptosis
repair. (b) The patient 2 months after combined blepharoplasty and
ptosis repair.
b
a

410
VI Eyelid Surgery
36 Lower Eyelid Blepharoplasty
Mark A. Codner and Juan Diego Mejia
Abstract
Lower eyelid blepharoplasty is one of the most complex and
challenging procedures in aesthetic surgery. Achieving optimal
results requires careful preoperative planning and meticulous
intraoperative technique. In the preoperative evaluation, besides
evaluating the eyelids, the midface must also be assessed. Both
of these areas have a profound effect on periorbital aging and
should be managed as one aesthetic unit. Emphasis on routine
lower lid support (lateral canthal anchoring), transpalpebral
elevation of the midface, and fat preservation and repositioning
are key to achieving good results and avoiding complications.
Keywords
lower blepharoplasty, canthal anchoring, canthopexy, canthop-
lasty, midface lift
36.1 Introduction
Despite the frequency with which lower blepharoplasty is
performed, the procedure remains a complex, challenging, and
technically demanding one that should not be considered rou-
tine. Minimizing complications and maximizing postoperative
results depend on careful preoperative planning and meticulous
intraoperative technique. In addition to evaluating the eyelids,
the surgeon must carefully assess the periorbital anatomy,
including the midface, because midfacial aging can have a pro-
found effect on the appearance of the lower lid. The lower lid and
midface compose an aesthetic unit that is best treated together,
and the standard lower lid approach provides an easy entry for
midface rejuvenation. However, it is important to individualize
the operative plan to address individual patient needs.
It is essential to identify risk factors and concomitant medical
conditions that could contribute to postoperative complications.
Excellent blepharoplasty results can be achieved through the
combination of careful preoperative assessment and meticulous
surgical technique using an anatomic approach to the aesthetic
correction of aging changes of the eyelids and periorbital region.
Traditional blepharoplasty techniques placed little emphasis on
lower lid support or the correction of acquired anatomic changes
of the surrounding periorbital region. 1ewer techniques empha-
size lower lid support, such as routine canthopexy or canthop-
lasty, as well as transpalpebral elevation of the midface and fat
preservation and repositioning. In our patients, routine canthal
anchoring has been the key to achieving good, predictable results
and avoiding complications.
36.2 Indications
Candidates for lower blepharoplasty are individuals with valid
complaints in conjunction with physical findings that are amenable
to surgical improvement. Typical complaints include a tired look,
puffy lower eyelids, malar bags, wrinkled skin, an accentuated
lid–cheek junction, and a deep nasojugal groove. Patients must
understand the importance of treating the lower lid and midface
as an aesthetic unit. In most cases, treatment of one area without
the other will produce unsatisfactory results (Fig. 36.1).
36.3 Preoperative Assessment
36.3.1 Medical History and Evaluation
The first step in a thorough evaluation includes taking a history
to identify specific conditions, including inflammatory eyelid
disorders, Graves’ disease, benign essential blepharospasm, and
dry-eye syndrome. All of these increase the risk of complications
after blepharoplasty and should be screened before surgery.
Medical Conditions That Might Increase the
Risk of Complications
• Blepharochalasis
• Rosacea
• Pemphigus
• Graves’ disease
• Benign essential blepharospasm
• Dry-eye syndrome
• Sarcoidosis
• Menopause
Fig. 36.1 Aging changes.

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411
36.3.2 Physical Examination
To produce a result that will be aesthetically pleasing to the
patient, the surgeon must take time to understand the patient’s
complaints and concerns, and these should be confirmed by the
physical examination. For example, patients complaining of
lower eyelid bags may actually have midfacial aging or malar
bags, which would not be improved with standard lower bleph-
aroplasty techniques. Therefore the surgeon must be diligent
in evaluating both the patient’s complaints and the underlying
anatomic findings to improve the aesthetic appearance of the
periorbital region and provide the best possible outcome. The
physical examination should proceed sequentially to ensure
complete assessment of the periorbital anatomy. A Snellen
eye chart is used to document preoperative visual acuity in all
patients before blepharoplasty.
Eye Protection Mechanisms
Patients should be evaluated for the presence of Bell’s phenom-
enon, since the combination of dry eyes with a poor Bell’s phe-
nomenon may lead to significant postoperative corneal dryness
(Fig. 36.2).
These patients should be further evaluated with Schirmer’s
test. The conjunctiva is anesthetized in the inferior lateral fornix
with tetracaine eye drops. Then the excess tear film is blotted
with a cotton-tipped applicator, and a Schirmer’s strip is placed
in the lateral fornix while the patient maintains a forward gaze.
Decreased tear production is present when less than 10 mm of the
Schirmer’s strip is wet after 5 minutes.
Eye Prominence
The globe should be examined to evaluate its position relative
to the bony orbit. Patients with prominent eyes have a negative
vector, which is visible on the lateral view of the orbit when the
anterior aspect of the globe is anterior to the underlying soft
tissue of the infraorbital rim. Patients with deep-set eyes have
a positive vector, where the globe is posterior to the infraorbital
rim and overlying soft tissues (Fig. 36.3).
A more detailed analysis can be performed with a Hertel
exophthalmometer, which measures the position of the globe
relative to the lateral orbital rim. 1ormal globe prominence is
in the range of 16 to 18 mm; patients with enophthalmos have
measurements less than 16 mm, and those with exophthalmos
have measurements greater than 18 mm. Patients with deep-set
eyes or prominent eyes are at increased risk for complications, and
the degree of prominence influences the level at which the lateral
canthus will be anchored during lateral canthoplasty (Fig. 36.4).
In patients with a standard eye position (16–18 mm), the lateral
canthal fixation should be in line with the inferior edge of the pupil
to produce a normal eye fissure. Patients with prominent eyes (19
Fig. 36.3 Evaluation of the position of the globe relative to the bony
orbit.
Fig. 36.4 Analysis with a Hertel exophthalmometer.
Fig. 36.2 (a) Test for Bell’s phenomenon and (b) Schirmer’s test.
a
b

412
VI Eyelid Surgery
mm or more) exhibit a tendency for downward migration of the
eyelid margin with lateral tightening, which will produce postop-
erative scleral show. Canthal anchoring in a standard position will
´clotheslineµ the lid margin underneath the eye. In patients with
mild prominence, supraplacement of the lateral canthal tendon is
needed at the level of the midpupil. However, canthal anchoring
in a higher position will impair upper lid closure. Therefore, with
increasingly prominent eyes (as in patients with Graves’ disease),
canthal anchoring should not surpass the midpupillary line; other
techniques are needed, such as recession of the inferior retractors,
insertion of primary spacers, or crisscross anchoring of the upper
and lower lids. Patients with deep-set eyes (15 mm or less) need
lower and deeper lateral canthal anchoring, because a standard
canthal position can cause upward clotheslining of the lower
lid, narrowing the eye fissure and reducing the size of the lateral
scleral triangle.
Lower Lid Evaluation
The lower eyelid should be evaluated for lateral canthal descent,
lower lid laxity, and the presence of scleral show as well as
excess skin and muscle, orbital fat, and malar bags. The presence
of scleral show should be a red flag to the surgeon; this is often
caused by a combination of a prominent eye, lower lid laxity,
and poor infraorbital support. Adjunctive procedures should be
considered, such as lateral canthal support, a possible midface
lift, or orbital rim augmentation.
The eyelid should be evaluated for both shape and function. The
lateral canthal position is normally 2 mm superior to the medial
canthal position; an imaginary line should be drawn from the
medial to the lateral canthus to indicate the canthal tilt (Fig. 36.5).
A positive lateral canthal tilt is present when the lateral canthus
is superior to the medial canthus; a negative lateral canthal tilt
is present when the lateral canthus is inferior to the horizontal
position of the medial canthus. A negative canthal tilt may indi-
cate descent of the lateral canthus from disinsertion, laxity, or the
presence of a prominent eye. These last patients are at increased
risk for lid malposition and require lateral canthal support during
blepharoplasty procedures (Fig. 36.6).
The lid snapback test may indicate the presence of lower lid
laxity; however, this is a fairly subjective test, and conclusions
drawn from it may be inaccurate (Fig. 36.7a). More precise eval-
uation can be obtained by lid distraction. Anterior lid distraction
should be less than 3 mm from the globe. Anything greater indi-
cates lid laxity and postoperative risk for scleral show, ectropion,
or corneal exposure. Appropriate lateral canthal anchoring can
help reduce the risk in these cases (Fig. 36.7b).
Herniated Fat Pads
Progressive weakening of the overlying septum as individuals age
has been an accepted theory for the protrusion of the fat pads.
Descent of the midface with aging also contributes to the unmask-
ing of the lower eyelid bags as the interface between the lid and
Fig. 36.5 The eyelid should be evaluated for both shape and
function. Drawing an imaginary line from the medial to the lat-
eral canthus indicates the canthal tilt. The lateral canthal position
is normally 2 mm superior to the medial canthal position.
Fig. 36.6 Positive and negative lateral canthal tilt. A negative canthal tilt
may indicate descent of the lateral canthus from disinsertion, laxity, or the
presence of a prominent eye.
Fig. 36.7 (a) Testing for lid laxity using the lid snapback test and (b) lid distraction.
a
b

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cheek becomes more apparent, leading to a ´double-bubbleµ
appearance. The lower lid has medial, central, and lateral fat
prominences. The volume of these fat pads varies among patients.
The surgeon should mark and document the most prominent
fat pads preoperatively, because this can be difficult to do when
the patient is on the operating table. The lateral fat pad is the
most commonly overlooked pad in lower lid blepharoplasty, yet
it generally contains the greatest volume and contributes most
significantly to the lower lid bags. The options for managing the
fat of the lower lid depend mostly on the amount of fat and on
the characteristics of the lid–cheek junction. :ith this in mind,
the fat pads can be preserved, removed, redistributed, or even
augmented with autologous fat grafting (Fig. 36.8).
Tear Trough Deformity
The tear trough is a midfacial hollow that begins at the inner
canthus and travels obliquely toward the lid–cheek junction. The
orbitomalar ligament, along with the origin of the levator labii
superioris and levator labii alaeque nasi muscles, contributes to
its formation. Release of the orbitomalar ligament in the preperi-
osteal plane and fat transpositioning or grafting are effective for
adding volume and improving this concavity (Fig. 36.9).
Skin Pigmentation
Sometimes dark circles around the eyes are shadows produced
by the convexity of the herniated fat, and these can be improved
with blepharoplasty. However, many patients have pigmentation
of the skin that will remain even after surgery, and it is important
that the patient be told this. Use of hydroquinone may be effec-
tive for lightening dark circles caused by hyperpigmentation.
Midface
Aging changes in the midface are characterized by descent of
the tissues, exposing the inferior orbital rim and allowing the
postseptal fat to become more visible. Recognition of these
changes is essential as the surgeon chooses the proper proce-
dure. Transconjunctival fat removal alone without correction of
Fig. 36.8 Usual areas of fat herniation and protuberance.
Fig. 36.9 The tear trough is a midfacial hollow that begins at the inner canthus and travels obliquely toward the lid–cheek junction. The orbitomalar
ligament, along with the origin of the levator labii superioris and levator labii alaeque nasi muscles, contributes to its formation. Release of the
orbitomalar ligament in the preperiosteal plane and fat transpositioning or grafting are effective for adding volume and improving this concavity.

414
VI Eyelid Surgery
vertical midface descent in these patients will lead to a skele-
tonized appearance of the lid–cheek junction. Patients with
mild midface descent can benefit from extended blepharoplasty
with release of the orbitomalar ligament with fat repositioning
to produce a smoother lid–cheek junction. Those with more
advanced aging changes and midface descent require a lower lid
blepharoplasty combined with a midface lift.
Malar Eminence
Fat should be removed conservatively in patients with prominent
cheekbones, because excessive resection will create a sunken
lower lid appearance, accentuate the malar eminence, and dis-
turb the balance of the lid–cheek junction. Patients with a lack
of projection of the malar eminence are at greater risk for lower
lid malposition after blepharoplasty. These patients can present
with preexisting scleral show and prominent eyes. Canthal
anchoring and lower lid release procedures are especially
important in these cases to decrease the risk of complications.
36.3.3 Patient Education
All of the potential risks of surgery should be discussed with
patients before blepharoplasty surgery. Common complications
may include swelling, ecchymosis, chemosis, and lagophthal-
mos. Other possible complications include infection, hematoma,
hypertrophic scarring, dry eye, epiphora, asymmetry, lid
malposition, ectropion, entropion, and the rare risk of vision
loss. Informed consent should include a detailed preoperative
discussion of these risks with the patient.
36.4 Preoperative Planning
36.4.1 &ODVViÀFDWiRn RI 3eriRrEiWDO Aging
A classification system of periorbital aging may aid in selecting
the appropriate surgical procedure for correction. The classifi-
cation described in Table 36.1 is based on the anatomic findings
associated with aging of the eyelids as well as midface descent,
including the presence of tear trough deformity, nasolabial folds,
and bags under the lower lids. This classification system focuses
on the relationship between the lower lid and the midface using
an anatomic approach to develop a specific surgical plan.
Type I patients (Fig. 36.10) demonstrate the earliest changes of
periorbital aging, with findings confined to the lower eyelid. The
presence of dermatochalasis includes acquired age-related folds of
excess skin and muscle, along with apparent fat excess. However,
the volume of orbital fat remains relatively unchanged from youth
to middle age and is resistant to volume loss even in cachectic
patients. In contrast, facial fat, including the malar fat pad and
jowl, undergoes redistribution with age; that is, deflation and
descent. The perception of increased orbital fat volume is often
affected by the presence of edema. In type I patients, the focus is
to improve the appearance of the eyelids by means of upper and
lower blepharoplasty, including fat resection by a transconjunc-
tival or transcutaneous approach and possible skin resection or
resurfacing. Alternative procedures are also appropriate, including
resetting or tightening the orbital septum and repositioning and
retaining intraorbital fat.
Type II patients (Fig. 36.11) have a combination of lower lid
aging and early evidence of midfacial descent. As the malar fat pad
descends, the lid–cheek junction is more evident, with the infe-
rior orbital rim becoming visible through attenuated soft tissue.
Midfacial descent is often associated with loss of upper malar
fullness, which contributes significantly to the loss of lower lid
support. These patients require augmentation of the infraorbital
rim, either through arcus marginalis release and fat repositioning
or through elevation of the sub–orbicularis oculi fat (SOOF) to
camouflage the infraorbital rim. Modified superficial midface lift
techniques with dissection in the supraperiosteal plane may be
considered.
Type III patients (Fig. 36.12) display more advanced midfa-
cial aging, with further descent of the lid–cheek junction and
deepening of the nasolabial folds. Descent of the malar fat pad
contributes to the formation of the nasolabial fold and requires
elevation, either with a subperiosteal midface lift or combined
face lift procedures that elevate the malar fat pad.
Type IV patients (Fig. 36.13) have extensive midfacial aging
changes, including malar bags, and often demonstrate lower lid
malposition with lid laxity. Subperiosteal dissection is required,
with release of the orbitomalar ligament, orbital retaining liga-
ments, and the subzygomatic space to elevate the midface, along
with lateral canthal support to correct lower lid laxity.
36.4.2 Patient Preparation
Preoperatively the patient is instructed to stop taking all medi-
cations that increase the risk of bruising and swelling, including
aspirin, ibuprofen, and vitamin E. Homeopathic herbs such
as Arnica montana and bromelain may reduce postoperative
edema and ecchymosis and have been used routinely for sur-
gery patients for more than 15 years. Patients are instructed to
carefully remove all makeup, particularly mascara residue, and
to wash the face the morning of surgery. Lower blepharoplasty
can be performed with a general anesthetic or with intravenous
conscious sedation.
The patient should be placed in a reverse Trendelenburg posi-
tion to decrease venous pressure. Surgical preparation includes
application of a dilute povidone–iodine (Betadine) solution to the
eyelids and face, taking care to avoid exposure of the conjunctiva;
the eyes are irrigated with balanced saline solution before corneal
protectors are placed.
Table 36.1 Classification of periorbital aging
Type
Age-related changes
Appropriate procedure
I
Excess fat, no skin excess
Transconjunctival
blepharoplasty
II
Excess skin, muscle, and fat
Transcutaneous blepharoplasty
Changes above intraorbital rim
Preperiosteal cheek lift
Minimal lower lid laxity
Lateral canthopexy
III
Excess skin, muscle, and fat
Transcutaneous blepharoplasty
Descent of malar fat pad
Subperiosteal cheek lift
IV
Malar bags
Subperiosteal cheek lift
Significant lower lid laxity
Lateral canthoplasty

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415
36.5 Operative Technique
36.5.1 Anesthesia
Adequate intravenous or general anesthesia is obtained; preop-
erative antibiotic administration is recommended. Local anes-
thetic, consisting of lidocaine 1 with epinephrine 1:100,000, is
injected with a 27-gauge needle into the lateral canthus, lower
eyelid, and inferior orbital rim, avoiding the marginal arcades
and the deep orbital structures to reduce the risk of eyelid or
retrobulbar hematoma.
36.5.2 Markings
The lower lid incision is initially marked with a single point at
the level of the lateral canthus. Markings should extend approxi-
mately 6 to 10 mm inferolaterally in a prominent crow’s-feet skin
line. Approximately 10 mm of skin should be preserved between
the lateral extension of the upper and lower blepharoplasty
incisions. Postoperative webbing or distortion can occur if these
incisions are placed too close together. The remainder of the
marking parallels the lid margin approximately 1 mm below the
eyelashes (Fig. 36.14).
36.5.3 Lower Lid Blepharoplasty
The lower lid skin is incised with a scalpel lateral to the canthus,
exposing the underlying orbicularis oculi muscle, which is
then divided with electrocautery into the submuscular space
(Fig. 36.15).
With the lower lid on stretch, scissors are used to dissect a sub-
cutaneous tunnel over the pretarsal muscle just below the lashes,
and with the same instrument the skin is incised, stopping 4 mm
inferior to the punctum (Fig. 36.16).
Through the lateral incision, the scissors are used once again
to dissect a submuscular tunnel, and a second parallel incision
is made through the orbicularis, preserving a 5-mm strip of
pretarsal orbicularis muscle (Fig. 36.17). Electromyographic
Fig. 36.10 Periorbital aging: type I.
Fig. 36.11 Periorbital aging: type II.
Fig. 36.12 Periorbital aging: type III.
Fig. 36.13 Periorbital aging: type IV.

416
VI Eyelid Surgery
analysis has revealed normal function to the pretarsal muscle
strip with minimal risk of denervation. The skin–muscle flap is
then dissected anterior to the septum with a Bovie cutting needle
to the level of the infraorbital rim. Dissection continues past the
infraorbital rim just superficial to the periosteum, releasing the
orbitomalar ligament to improve the appearance of the lid–cheek
junction.
Submuscular dissection continues over the septum down to
the orbital rim. The orbitomalar ligament is divided along the
entire infraorbital rim. A tear trough deformity requires release
of the medial origins of the orbicularis oculi, levator labii supe-
rioris, and levator labii superioris alaeque nasi muscles from the
inferior orbital rim. Once the orbitomalar ligament is released, the
sub–orbicularis oculi fat (SOOF) becomes visible, and dissection
superficial to the periosteum is continued approximately 10
mm below the orbital rim, preserving the zygomaticofacial and
zygomaticotemporal nerves (Fig. 36.18). Release of the orbitoma-
lar ligament allows elevation of the SOOF with the skin–muscle
flap. Elevation of the SOOF with orbicularis muscle redraping
camouflages the inferior orbital rim, giving the lid–cheek junction
a smoother appearance.
Fat can be removed conservatively with the Bovie from all three
lower lid compartments, and the orbital septum is resected along
with excess fat (Fig. 36.19). Removal of the septum may reduce
the risk of subsequent septal scar formation. If fat resection is
planned, the arcuate expansion of Lockwood’s ligament between
the central and lateral fat pad should be preserved for additional
support to prevent further herniation of periorbital fat. :hen fat
transposition is the objective, Lockwood’s ligament should be
divided to allow adequate release and redraping of the fat pads.
Care should be taken to avoid injury to the inferior oblique
muscle between the nasal and central fat pads (Fig. 36.20).
The inferior oblique muscle is reportedly the most common
extraocular muscle injured during blepharoplasty, usually from
indiscriminate cauterization. The lateral fat pocket should be
Fig. 36.14 The lower lid incision is initially marked with a single point
at the level of the lateral canthus.
Fig. 36.15 (a) The lower lid skin is incised with a scalpel lateral to the
canthus, exposing the underlying orbicularis oculi muscle, (b) which is
then divided with electrocautery into the submuscular space.
a
b
Fig. 36.17 (a) Through the lateral incision, the scissors are used
once again to dissect a submuscular tunnel, and (b) a second parallel
incision is made through the orbicularis, preserving a 5-mm strip of
pretarsal orbicularis muscle.
a
b
Fig. 36.16 (a) With the lower lid on stretch, scissors are used to dissect
a subcutaneous tunnel over the pretarsal muscle just below the lashes,
and (b) with the same instrument the skin is incised, stopping 4 mm
inferior to the punctum.
a
b
Fig. 36.18 (a) Submuscular dissection continues over the septum
down to the orbital rim. (b) Once the orbitomalar ligament is released,
the sub–orbicularis oculi fat (SOOF) becomes visible, and dissection
superficial to the periosteum is continued approximately 10 mm below
the orbital rim, preserving the zygomaticofacial and zygomaticotem-
poral nerves.
a
b

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417
reevaluated after lateral canthopexy, because lateral tension will
cause additional herniation.
Alternative procedures might also be considered: arcus mar-
ginalis release, septal reset, or septal tightening. Septal reset, as
described by Hamra, involves suturing the septum orbitale over
the inferior orbital rim to produce a youthful convex contour to
the lower eyelid–cheek complex. Septal tightening, as described
by de la Plaza and Mendelson, encompasses suture tightening
of the septum after partial resection or septal plication with-
out resection. These procedures are designed to improve the
pseudoherniation of the orbital fat through the septum. As in
an upper blepharoplasty, the lower lid should be irrigated with
normal saline solution after resection of the orbital fat pads.
Lateral Canthal Support
The degree of lower lid laxity should be evaluated intraopera-
tively by placing anterior traction on the lower eyelid away from
the globe and measuring the amount of lid distraction with cal-
ipers (Fig. 36.21). Lid distraction of 1 to 2 mm indicates minimal
lid laxity; 3 to 6 mm indicates moderate laxity; more than 6 mm
indicates significant lid laxity.
Routine lateral canthal anchoring is performed as part of all of
our lower blepharoplasties. A lateral canthopexy is indicated in
patients with minimal or moderate lid laxity. :hen lid distrac-
tion is more than 6 mm from the globe or when persistent intra-
operative lid laxity is seen after a routine canthopexy, horizontal
shortening of the lid is performed with a lateral canthotomy and
canthoplasty. Regardless of the type of anchoring used (cantho-
pexy or canthoplasty), the internal vector of fixation is essential.
The canthus should be anchored inside the orbital rim to enable
the lid to conform to the globe (Fig. 36.22).
The vertical position at which the lateral canthal fixation
suture will be placed depends on the degree of eye prominence,
the amount of lower lid laxity, and the preoperative shape of the
lower eyelid. The preoperative shape of the lower eyelid must
be carefully maintained, avoiding overcorrection or alteration of
the preoperative canthal position. In patients who have normal
eye prominence, the position of the lateral canthal suture is most
commonly at the inferior edge of the pupil. However, patients with
prominent eyes require supraplacement of the canthal support
suture at the level of the midpupillary line, with overcorrection
and minimal tightening to avoid downward clotheslining of the
lower lid below the inferior limbus, which can cause scleral show.
The release of the inferior retinaculum and lower lid retractors
facilitates the supraplacement of the canthus. The downward
force of the prominent globe on the lower lid will cause descent
of the lid margin after lateral canthal anchoring. However, this
force does not exist in patients who have deep-set eyes. Patients
with deep-set eyes require more inferior and posterior placement
of the canthal suture to avoid upward clotheslining, with care to
avoid overcorrection (Fig. 36.23).
Fig. 36.20 Care should be taken to avoid injury to the inferior oblique
muscle between the nasal and central fat pads.
Fig. 36.21 The degree of lower lid laxity should be evaluated intraop-
eratively by placing anterior traction on the lower eyelid away from the
globe and measuring the amount of lid distraction with calipers.
Fig. 36.22 Routine lateral canthal anchoring is performed as part of all
of our lower blepharoplasties. The internal vector of fixation is essential
to enable the lid to conform to the globe.
Fig. 36.19 (a) Conservative removal of fat with the Bovie from lower
lid compartment; (b) resection of orbital septum along with excess fat.
a
b

418
VI Eyelid Surgery
The objective of lateral canthopexy is to suture the tarsal plate
and lateral retinaculum to the periosteum of the lateral orbital
rim, thereby tightening the lower lid tarsoligamentous sling.
Through the blepharoplasty incision, a horizontal mattress suture
of 4–0 polyester fiber suture (Mersilene, -ohnson -ohnson, 1ew
Brunswick, 1-) is used to incorporate the tarsal plate and lateral
retinaculum. To prevent dehiscence of the Mersilene through the
tarsus, an interlocking 6–0 polyglactin (Vicryl, -ohnson -ohnson,
1ew Brunswick, 1-) suture is placed around the 4–0 Mersilene.
The Mersilene suture is then placed inside the lateral orbital rim
periosteum from deep to superficial, which allows the lateral
canthus and lower lid to be tightened posteriorly and superiorly
to maintain the position of the lower lid margin against the globe
(Fig. 36.24).
A single tie is placed on the lateral canthal suture to set the cor-
rect tension as the lower lid assumes its desired position. Before
completing the knot, lower lid laxity is once again evaluated with
a pair of fine pickups. At this point, the lower lid should have a
normal distraction of 1 to 2 mm, and it should allow some upper
and lower displacement without restriction. If this is the case, the
canthopexy knot is completed. If the lid is too tight and does not
permit displacement above the lower limbus with the pickups,
the knot should be loosened (Fig. 36.25).
Patients who have significant lid laxity with lid distraction
greater than 6 mm, or those with persistent intraoperative lid
laxity after canthopexy, require lateral canthotomy and can-
thoplasty. Lateral canthoplasty is performed after canthotomy
of the inferior limb of the lateral canthal tendon, followed by
cantholysis, which allows mobilization of the lower lid (Fig.
36.26). Before the lid is transposed over the lateral orbital rim, 2
to 3 mm of full-thickness horizontal lid shortening is performed
to correct significant lid laxity. A 4–0 Mersilene suture is used for
lateral canthoplasty and is placed through the edge of the tarsal
plate from inferior to superior, ensuring vertical alignment while
controlling lash rotation. The mattress suture is then placed along
the posterior aspect of the lateral orbital rim periosteum at the
appropriate level according to eye prominence and is tied in a
surgeon’s knot. The desired amount of tension created by the
lateral canthoplasty should allow 1 to 2 mm of lid distraction
away from the globe, and the lid should be easily mobilized over
the cornea. Overtightening of the lateral canthoplasty should be
avoided to minimize lid malposition. The lateral commissure is
then reconstructed with a 6–0 plain catgut suture placed in the
gray line to prevent postoperative lateral canthal webbing. To rec-
reate a normal-appearing lateral commissure, the suture is placed
Fig. 36.23 Vertical position of lateral canthal fixation suture depends
in part on the degree of eye prominence.
Fig. 36.24 Objective of lateral canthopexy: to suture the tarsal plate
and lateral retinaculum to the periosteum of the lateral orbital rim,
thereby tightening the lower lid tarsoligamentous sling.
Fig. 36.26 Lateral canthotomy and canthoplasty.
Fig. 36.25 (a) Placement of a single tie on the lateral canthal suture
to set the correct tension as the lower lid assumes its desired position.
(b) Before completing the knot, lower lid laxity is once again evaluated
with a pair of fine pickups.
a
b

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419
in the posterior aspect of the upper lid gray line and the anterior
aspect of the lower lid gray line to allow the upper lid to overlap
the lower lid slightly in a normal anatomic relationship.
After lateral canthal support is achieved, the skin–muscle flap
is redraped in a superior lateral vector. A triangle of excess skin
and muscle is resected according to the amount that overlaps the
lateral extent of the lower blepharoplasty incision (Fig. 36.27).
The orbicularis muscle flap is then resuspended to the lateral
orbital rim at the level of the lateral canthus using a 4–0 Vicryl
suture, which is placed as a three-point quilting suture from the
incised edges of skin and muscle to the periosteum along the inner
aspect of the lateral orbital rim to recreate the normal concavity
associated with the lateral orbital raphe. Similarly, interrupted
absorbable sutures are placed in the lateral cut edge of the orbi-
cularis flap to the lateral orbital rim periosteum and temporalis
fascia to resuspend the orbicularis under appropriate tension.
Resuspension of the orbicularis provides additional lower lid
support as well as elevation of the SOOF over the inferior orbital
rim, anatomically blending the lid–cheek junction and giving it a
smoother look.
Minimal skin and muscle are resected parallel to the lower
lid margin to minimize the risk of lid malposition. A small strip
of orbicularis is removed from the skin–muscle flap to avoid a
redundant layer overlying the preserved pretarsal orbicularis.
Tension-free closure is then performed in the skin–muscle edges
with a 6–0 fast-absorbing catgut suture (Fig. 36.28).
36.5.4 Adjunctive Techniques
Treatment of the Tear Trough Deformity
The tear trough hollow can be corrected during a standard lower
blepharoplasty (Fig. 36.29). When releasing the orbitomalar
ligament along the infraorbital rim, the surgeon performs addi-
tional preperiosteal dissection and release of the tear trough.
This dissection is performed with low-power electrocautery and
should be limited to prevent injury to the buccal branch of the
facial nerve, which is located medial to the tear trough at the
level of the angular artery. If the levator labii superioris alaeque
nasi muscle twitches with the electrocautery, this may be a sign
of overdissection near the buccal branch. After release of the tear
trough, the nasal fat pad is transposed and secured with a 6–0
Vicryl suture into the periosteum. It is important to remember
that aggressive transposition of the nasal and central pads can
impair inferior oblique function and result in diplopia. Fat graft-
ing from excised orbital fat can also be used to fill this space.
36.6 Postoperative Care
At the end of the procedure, a 6–0 nylon suture can be placed as a
temporary tarsorrhaphy along the gray line lateral to the limbus.
Another option is to place a temporary Frost suture in the lower
lid margin lateral to the lateral limbus and either suturing to the
eyebrow or suspending to a Steri-Strip (3M, St. Paul, M1) above
the eyebrow. These techniques will reduce corneal exposure in
the immediate postoperative period and minimize chemosis.
These sutures are removed at the first postoperative visit 5 to 7
days after surgery (Fig. 36.30).
Postoperatively the patient’s head should remain elevated
to reduce edema and ophthalmic pressure. An ice pack or cold
compresses should be applied to the eyelids for 48 hours. The eyes
should remain lubricated at all times, using saline drops during
the day and lubricating ointment at night. Lagophthalmos can
be caused by periorbital edema; if this occurs, it resolves spon-
taneously in 1 to 2 weeks. In these cases eye drops and ointment
are essential to prevent corneal abrasions and exposure problems.
Before discharge the patient’s vision should be evaluated and
documented. Any signs of corneal irritation or decreased visual
acuity require careful ophthalmologic evaluation, including
slit-lamp examination with the use of fluorescein eye drops to
evaluate the cornea. Patients are asked to avoid the use of contact
lenses and any eyelid makeup on the suture lines for 2 weeks after
blepharoplasty.
Persistent postoperative chemosis can be treated with liberal
application of ophthalmic ointments and steroid eye drops. Use
of these eye drops should be limited to 2 weeks to avoid the
risks associated with prolonged treatment. Severe chemosis that
herniates through the palpebral fissure requires more aggressive
management with liberal use of ophthalmic ointment, topical ste-
roids, patching the eye closed for 24 to 48 hours, conjunctivotomy,
or tarsorrhaphy.
Mild lid malposition may contribute to lagophthalmos and
corneal exposure, which may require bandage contact lenses
to protect the cornea and conservative massage of the lower lid
Fig. 36.27 (a) After lateral canthal support is achieved, the skin-mus-
cle flap is redraped in a superior lateral vector. (b) A triangle of excess
skin and muscle is resected according to the amount that overlaps the
lateral extent of the lower blepharoplasty incision.
a
b
Fig. 36.28 (a) Minimal skin and muscle are resected parallel to the
lower lid margin to minimize the risk of lid malposition. (b) A small
strip of orbicularis is removed from the skin–muscle flap to avoid a
redundant layer overlying the preserved pretarsal orbicularis.
(c) Tension-free closure is then performed in the skin–muscle edges
with a 6–0 fast-absorbing catgut suture.
a
b
c

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VI Eyelid Surgery
margin until the patient has passed the critical 6-week postopera-
tive period, which corresponds with the peak inflammatory phase
of healing. Lower lid ectropion or persistent lid malposition after a
6-week period of conservative management may require surgical
intervention, including placement of a posterior lamella spacer
graft and lateral canthoplasty.
36.7 Outcomes
Lower blepharoplasty can no longer be considered a routine
operation. Surgical techniques have evolved and are today sig-
nificantly more sophisticated than in previous decades. Careful
preoperative evaluation is the initial step toward creating a spe-
cific and comprehensive treatment plan for each patient based
on individual findings and desired outcome. Patients who have
medical or anatomic characteristics known to be factors pre-
dictive of poor outcome should be considered high-risk patients
who require alternative procedures to minimize complications.
Once assessment and planning are complete, blepharoplasty
procedures should be performed with precision. Emphasis is
placed on maintaining the preoperative shape of the palpebral
fissure, with particular attention to maintaining lower eyelid
position. Lateral canthal support, most commonly with lateral
canthopexy, represents a very important step in the technique to
maintain lid shape and reduce the risk of lower lid malposition or
postoperative round-eye syndrome. The tradeoff, which should
be discussed with the patient before surgery, is that the lower lid
may appear tight, and this could last 2 to 3 weeks after surgery.
The natural S-shaped curve of the lower lid and the palpebral
aperture are preserved after healing is complete.
Complications associated with lateral canthoplasty have been
minor and primarily include canthal angle webbing or asymme-
try that requires surgical revision. The risk of frank ectropion is
significantly minimized with the use of lateral canthal support.
In addition to minimizing the risk of complications, maximizing
the aesthetic result is directly related to management of both
periorbital fat compartments, the orbicularis muscle, and SOOF.
Elevation of the skin muscle flap and release of the orbitomalar
ligament mobilize the SOOF, which is elevated with the orbicu-
laris muscle. Using the orbicularis muscle as a sling with secure
lateral orbital fixation is the key to maximizing the aesthetic
appearance of the infraorbital region. This can be performed
safely based on the anatomy of the lower eyelid. The posterior
lamella (tarsoligamentous sling) has a separate point of periosteal
fixation from the anterior lamella (skin–muscle flap). These basic
principles, founded on anatomy, are the two key points in max-
imizing surgical outcome after lower blepharoplasty. Adherence
to these basic principles significantly contributes to achieving the
overall goal.
36.8 Complications
36.8.1 Lower Lid Malposition
Lower lid malposition is the most common surgical compli-
cation after transcutaneous lower lid blepharoplasty and
includes lid retraction, scleral show, and ectropion (Fig. 36.31).
The incidence of this complication varies from 5 to 30 in the
literature. Lower lid malposition not only detracts from the
aesthetic results but can also lead to functional problems such
as exposure keratopathy. The most common etiologic factor
is vertical deficiency of the anterior or posterior lamella in
patients with preexisting tarsoligamentous laxity. Care should
be taken to avoid excessive skin and muscle resection. Patients
associated with increased risk include those with lower lid
laxity, prominent eyes, negative vector, negative canthal tilt,
and preoperative scleral show. To avoid this complication, some
have suggested less invasive approaches to the lower lid, such
as the transconjunctival lower blepharoplasty. Although more
conservative, this technique does not eliminate the risk of lower
lid malposition. In addition, most patients who consult for
lower lid rejuvenation need removal of excess skin and muscle,
which is a limitation of the transconjunctival approach. The
treatment of postoperative mild lower lid malposition is con-
servative, with postoperative massage, the use of tape to hold
the lower lid in position, and eye lubrication. If conservative
treatment fails to improve the position of the lower lid after 6
weeks, surgical revision with canthopexy or canthoplasty with
or without the use of spacers is recommended. Drill-hole can-
thal anchoring is often needed, because there might be a lack of
Fig. 36.29 Treatment of the tear trough deformity.
Fig. 36.30 A 6–0 nylon suture can be placed as a temporary tarsorrha-
phy along the gray line lateral to the limbus.

 /RZer (yeOid %OeSKDrRSODVWy
421
adequate periosteum for suture fixation. Severe postoperative
lower lid malposition, causing functional problems or corneal
exposure, requires immediate correction to avoid exposure
keratopathy.
The addition of routine lateral canthal anchoring provides an
anatomic solution for decreasing the risk of lower lid malposition
after transcutaneous blepharoplasty. In a review of our 10-year
experience with routine lateral canthal support in 264 primary
cosmetic transcutaneous lower lid blepharoplasties, we reported
ectropion in 0.8, lower lid retraction requiring revision in 2.7,
and mild lower lid retraction (1 mm or less) that resolved with
massage in 6.1. Patients who needed revision were treated with
secondary canthoplasty; three patients required posterior lamella
spacer grafts.
Causes of Postblepharoplasty Lower Lid
Malposition
• Lower lid laxity
• High-risk patients
• Excessive skin removal
• Excessive muscle removal
• Middle lamellar scarring
• Posterior lamellar scarring
• Damage to pretarsal orbicularis muscle
• Untreated hematoma
36.8.2 Chemosis
Chemosis is the most common nonsurgical complication after
lower blepharoplasty, occurring in up to 12 of patients under-
going the procedure. It is a transudative edema of the bulbar or
fornical conjunctiva and is characterized by visible swelling of
the conjunctiva (Fig. 36.32).
Patients may experience epiphora, irritation, foreign body
sensation, and mild visual alteration. In a lower blepharoplasty,
the causes include conjunctival desiccation from exposure,
regional edema, and lymphatic stasis resulting from local trauma.
Chemosis usually presents in the first postoperative week. The
median duration is approximately 4 weeks and can range from 1
week to 3 months.
Prevention is the most important treatment in chemosis man-
agement, and it starts in the operating room. The use of lubricated
corneal protectors, preventing prolonged eye exposure and
dryness with frequent moisturizing of the eyes, and minimizing
trauma can all help reduce its incidence. If significant chemosis
is seen intraoperatively, it can be treated with an immediate
conjunctivotomy using a pair of small scissors. A temporary
tarsorrhaphy suture can be placed lateral to the lateral limbus to
reduce postoperative chemosis.
Postoperative treatment of chemosis starts by keeping the
eyes lubricated with wetting drops and ophthalmic lubricants.
Ophthalmic steroid drops (tobramycin/dexamethasone >Tobradex;
Alcon, Fort :orth, TX@) are also helpful. If the irritation does not
resolve, an eye patch to the affected eye with the use of an Ace
bandage at night can be used. In more severe cases (lasting more
than 2 weeks), especially if lagophthalmos is present, a conjunc-
tivotomy or tarsorrhaphy should be considered.
The patient in Fig. 36.33 presented with postoperative chemosis
that prolapsed through the eyelids during closure, causing lagoph-
thalmos. A conjunctivotomy of the prolapsed conjunctiva with the
patient under local anesthesia was performed in an office setting.
The patient in Fig. 36.34, seen before and immediately after a
conjunctivotomy with the use of a local anesthetic in the office,
shows an almost complete resolution of her chemosis.
36.8.3 Visual Changes
Visual changes such as diplopia are generally temporary and
can be attributed to edema. The most common extraocular
muscle damaged in lower blepharoplasty is the inferior oblique
muscle, which is located between the nasal and central fat
pads and can be inadvertently injured during fat manipulation.
Conservative treatment is recommended; normal vision is
usually regained when the muscle edema subsides. Vision loss
can also occur; it is discussed in the chapter on upper eyelid
blepharoplasty.
Fig. 36.31 Lower lid malposition.
Fig. 36.32 Chemosis is a transudative edema of the bulbar or fornical
conjunctiva and is characterized by visible swelling of the conjunctiva.

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VI Eyelid Surgery
36.8.4 Other Complications
Epiphora is usually a transient problem that can resolve sponta-
neously in days; it is most commonly caused by edema distorting
the lacrimal canaliculi. If persistent, punctal eversion can be cor-
rected by excising and closing an ellipse of conjunctiva below the
canaliculus, producing inversion. The same effect can be obtained
by applying cautery below the lacrimal canaliculus on the conjunc-
tival side to produce contraction and inversion of the punctum.
Corneal abrasions can be prevented by constant corneal lubrica-
tion, the use of ocular protectors, and avoiding prolonged exposure of
the cornea. Dry-eye syndrome, infection, and hematoma may occur;
these are discussed in the chapter on upper eyelid blepharoplasty.
36.9 Results
The following cases represent a variety and continuum of
patients who demonstrate age-related changes of the eyelids and
periorbital region.
Fig. 36.35 shows a patient preoperatively and after an extended
lower blepharoplasty and correction of a tear trough deformity.
The patient shown in Fig. 36.36 had herniated fat compart-
ments, worse nasally, and a prominent tear trough deformity. She
underwent a lower lid blepharoplasty and a lateral canthopexy.
The patient shown in Fig. 36.37 similarly had herniated fat
compartments, worse nasally, and a prominent tear trough defor-
mity. He also received a lower lid blepharoplasty and a lateral
canthopexy.
The patient shown in Fig. 36.38 presented with herniated fat
compartments and tear trough deformity and mild ptosis of his
right upper lid. He desired only a lower blepharoplasty with
canthopexy, with the results shown.
The patient shown in Fig. 36.39 had dermatochalasis and malar
bags. Treatment involved preperiosteal dissection to the inferior
extent of the malar bags.
36.10 Concluding Thoughts
As concepts of aging evolve and new techniques are developed,
operative approaches to blepharoplasty continue to be refined,
thereby producing a more natural, youthful eyelid appearance.
The stigmata of surgery can be minimized, along with the
risk of complications, by proper preoperative assessment and
meticulous surgical technique. Appreciation of the underlying
anatomy, along with the indications and limitations of tech-
niques used to correct the anatomic changes that occur with
aging, form the basis of a sound surgical approach that ensures
favorable results.
Fig. 36.33 This patient presented with postoperative chemosis that
prolapsed through the eyelids during closure, causing lagophthalmos.
A conjunctivotomy of the prolapsed conjunctiva with the patient under
local anesthesia was performed in an office setting.
Fig. 36.34 This patient, seen before and immediately after a
conjunctivotomy with the use of a local anesthetic in the office, shows
an almost complete resolution of her chemosis.
Fig. 36.35 This patient is shown (a) preoperatively and (b) after
an extended lower blepharoplasty and correction of a tear trough
deformity
a
b
Fig. 36.36 (a) This patient had herniated fat compartments, worse
nasally, and a prominent tear trough deformity. (b) She is shown after
a lower lid blepharoplasty and a lateral canthopexy.
a
b