Kỹ Thuật Bậc Thầy Trong Trẻ Hóa Khuôn Mặt

excellent result and patient acceptance. The highly pub-
licized issues with the open approach—alopecia,
numbness, scarring—have not been an issue in the senior
author’s practice for 25 years.54,56,57 Although a logical
argument can be made that these issues are serious, the
theory and reality diverge (unpublished data). In addition,
when one of the issues does arise, particularly numbness,
the patient does not see it as a priority and is generally so
pleased with the result that the issue fades. The patient is
also counseled about this preoperatively so that it is not
an unpleasant surprise if it does occur.
The most common troubling complication is that of
parasthesia. The patient must be aware, preoperatively,
that the forehead and scalp will be numb for several
months, and possibly permanently. When discussed exten-
sively in the preoperative phase this issue is managed
adequately. In our experience, this is of marginal impor-
tance to the patient. It usually resolves in the appropriate
time period and is almost always a nonissue when it has
been addressed preoperatively.
Hematomas are also, fortunately, rare with the tech-
nique. Despite the copious blood supply to this region,
hematomas are seldom seen. This is probably due to the
tense nature of the closure, edema, and the unyielding
cranium that tamponades any potential bleeding
complications. The complication profile for the open
browlift is excellent at 0.4% for hematoma formation,
permanent alopecia, and “nerve damage.”58 Others have
also found very acceptable complication rates.15
Alopecia is also a rare occurrence. In the coronal
approach, the beveling of the incision and a hair-to-hair
closure alleviate this concern. In the pretrichial lift, the
hair will grow either through the healing incision or over
it in the form of bangs. Rarely, a patient may not be a
candidate if he or she has a high hairline and prefers to
wear the hair back at all times or has hair growing in a
vector unfavorable for masking the incision. Scar
appearance is also greatly aided by meticulous attention
to detail in the operating room, especially during the
incision and closure.
One of the most noted complications of this procedure
is the creation of a “surprised look,” evidenced by a
widened, elevated medial brow complex.59 We minimize
this issue by judicious removal of tissue and an appro-
priate resection of the glabellar musculature. Relieved of
the need for overcorrection, as is needed in other
techniques, we have not found this to be an issue in our
practice.
An occasional issue that arises postoperatively is
pruritus that occurs along the incision line. The patient
may scratch and rub this area, causing a focal alopecia.
This can be avoided with patient education. If the
alopecia has already occurred, the patient is advised not
to disturb the area further, and the hair often returns. Any
undue scarring is very rare and can be treated with steroid
injections of Kenalog-10.
Future Considerations
The continuing evolution of technology will undoubtedly
benefit the patient in the long term. The surgeon must be
careful, however, to adhere to proven surgical principles.
We should expect that the patient’s demands and desires
will progress with these technologic advances, and we
must stay at the vanguard to offer our patients the
optimal care.
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2. Passot R: La churugie esthetique des rides du visage. Presse
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3. Hunt HL: Plastic Surgery of the Head, Face and Neck.
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4. Noel A: La Chirurgie Esthetique et son Role Socia. Paris:
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5. Joseph J: Nasenplastik und Sonstige Gesichtplastik Nebst
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11. Liang M, Narayanan K: Endoscopic ablation of the frontalis
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12. Vasconez LO, Gore GB, Gamboa-Bodadilla M, et al:
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13. Isse NG: Endoscopic facial rejuvenation. Endoforehead, the
functional lift: Case reports. Aesth Plast Surg 1994;18:21.
14. Ramirez OM: Endoscopic techniques in facial rejuvenation. An
overview: Part I. Aesth Plast Surg 1994;18:141.
15. Wojtanowski MH: Bicoronal forehead lift. Aesth Plast Surg
1994;18:33.
16. Ramirez OM: Endoscopic full facelift. Aesth Plast Surg
1994;18:363.
17. Chasan PE, Kupfer DM: Direct K-wire fixation technique
during endoscopic brow lifts. Aesth Plast Surg 1998;22:338.
18. Niazi ZBM, Salzberg CA: Endoscopic forehead lifts: The
postoperatively adjustable technique. Plast Reconstr Surg
1998;101:2006.
19. Pozner JN: Simplified fixation for endoscopic brow lifts:
Self-tapping, drill-free posts. Plast Reconstr Surg
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20. Loomis MG: Endoscopic brow fixation without bolsters or
miniscrews. Plast Reconstr Surg 1996;98:373.
21. Marchac D, Ascherman J, Arnaud E: Fibrin glue fixation in
forehead endoscopy: Evaluation of our experience with 206
cases. Plast Reconstr Surg 1997;100:704.
22. Mixter RC: Endoscopic forehead fixation with histocryl. Plast
Reconstr Surg 1998;101:2006.
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Mark R. Murphy • Calvin M. Johnson Jr.

23. Newman JP, La Ferriere KA, Koch RJ, et al: Transcalvarial
suture fixation for endoscopic brow and forehead lifts. Arch
Otolaryngol Head Neck Surg 1997;123:313.
24. Landecker A, Buck JB, Grotting JC: A new resorable tack
fixation technique for endoscopic browlifts. Plast Reconstr
Surg 2003;111:880.
25. Schnur PL, Don SA: Forehead and brow lift. In Weinzweig J
(ed): Plastic Surgery Secrets. Philadelphia: Hanley & Belfus,
1999.
26. Romo T III, Sclafani AP, Yung RT, et al: Endoscopic
foreheadplasty: A histologic comparision of subperiosteal
refixation after endoscopic versus bicoronal lift. Plast Reconstr
Surg 2000;105:1111.
27. Chiu ES, Baker DC: Endoscopic browlift: A retrospective
review of 628 consecutive cases over five years. Plast Reconstr
Surg 2003;112:628
28. Swift RW, Nolan WB, Aston SJ, et al: Endoscopic brow lift:
Objective result after one year. Aesth Surg J 1999;19:287
29. Troilus C: A comparison between subgaleal and subperisoteal
brow lifts. Plast Reconstr Surg 1999;104:1079
30. Yarenchuk MJ: Subperisoteal and full-thickness skin
rhytidectomy. Plast Reconstr Surg 2001;107:1045.
31. Hamra ST: A study of the long-term effect of malar fat
repositioning in face lift surgery: Short term success but
long-term failure. Plast Reconstr Surg 2002;110:940.
32. Elkwood A, Matarasso A, Rankin M, et al: National plastic
surgery survey: Brow lifting techniques and complications.
Plast Reconstr Surg 2001;108:2143.
33. Koch RJ: Endoscopic browlift is the preferred approach for
rejuvenation of the upper third of the face. Arch Otolaryngol
Head Neck Surg 2001;127:87
34. Murphy MR, Johnson CM: Unpublished data.
35. Godek CP, Buckey LP, Whitaker LA: Endoscopic versus open
coronal forehead surgery: Surgeon preference and patient
satisfaction. Plast Surg Forum 1999;22:182.
36. Guyuron B, Behmand RA, Green R: Shortening of the long
forehead. Plast Reconstr Surg 1999;103:218.
37. Marten TJ: Hairline lowering during foreheadplasty. Plast
Reconstr Surg 1999;103:224.
38. Michelow BJ, Guyuron B: Rejuvenation of the upper face: A
logical gamut of surgical options. Clin Plast Surg
1997;24:199.
39. Marten TJ: Hairline lowering during foreheadplasty. Plast
Reconstr Surg 1999;103:224.
40. McKinney P, Mossie RD, Zukowski ML: Criteria for the
forehead lift. Aesth Plast Surg 1991;15:141.
41. Knize D: An anatomically based study of the mechanism of
eyebrow ptosis. Plast Reconstr Surg 1996;97:1321.
42. Knize D: Limited-incision forehead lift for eyebrow elevation
to enhance upper blepharoplasty. Plast Reconstr Surg
1996;97:1334.
43. Romo T III, Jacono AA, Sclafani AP: Endoscopic forehead
lifting and countouring. Facial Plast Surg 2001;17:4.
44. Knize DM: A study of the supraorbital nerve. Plast Reconstr
Surg 1995;96:564.
45. Gunter J, Antrobus SD: Aesthetic analysis of the eyebrows.
Plast Reconstr Surg 1997;99:1808.
46. Whitaker LA, Morales L Jr, Farkas LG: Aesthetic surgery of
the supraorbital ridge and forehead structure. Plast Reconstr
Surg 1986;78:23.
47. Cook TA, Brownrigg AJ, Wang TD, et al: The versatile
midforehead browlift. Arch Otolaryngol Head Neck Surg
1989;115:163.
48. Matarasso A, Terino EO: Forehead-brow rhytidoplasty:
reassessing the goals. Plast Reconstr Surg 1994;93:1378.
49. McKinney P, Mossie RD, Zukowski ML: Criteria for the
forehead lift. Aesth Plast Surg 1991;15:141.
50. Freund RM, Nolan WB III: Correlation between brow lift
outcomes and aesthetic ideals for eyebrow height and shape in
females. Plast Reconstr Surg 1996;97:1343.
51. Ellenbogen R: Transcoronal eyebrow lift with concomittant
upper blepharoplasty. Plast Reconstr Surg 1983;71:490.
52. Roth JM, Metzinger SE: Quantifying the arch position of the
female eyebrow. Arch Facial Plast Surg 2003;5:235.
53. Rafety FM, Brennana HG: Current concepts of browpexy. Arch
Otolaryngol 1983;109:152.
54. Adamson PA, Johnson CM, Anderson JR, et al: The forehead
lift: A review. Arch Otolaryngol Head Neck Surg.
1985;111:325.
55. Romo T III, Sclafani AP, Yung RT, et al: Endoscopic
foreheadplasty: A histologic comparision of periosteal
refixation after endoscopic versus bicoronal lift. Plast Reconstr
Surg 2000;105:1111.
56. Adamson PA, Cormier R, McGraw BL: The coronal forehead
lift: Modifications and results. J Otolaryngol 1992;21:1
57. Kerth JD, Torimui DM: Management of the aging forehead.
Arch Otolaryngol Head Neck Surg 1990;116:1137.
58. Vinas JC, Caviglia C, Cortinas JL: Forehead rhytidoplasty and
brow lifting. Plast Reconstr Surg 1976;57:445.
59. Freund RM, Nolan WB III: Correlation between brow lift
outcomes and aesthetic ideals for eyebrow height and shape in
females. Plast Reconstr Surg 1997;99:1808.
CHAPTER 3
The Open Browlift
45

The aesthetic goal of foreheadplasty is to obtain a balanced
brow position, preserving the natural relationship
between the brow’s head, body, and tail, and to improve
wrinkles of the forehead and glabella. A minimally
invasive technique for foreheadplasty was first introduced
in 1992 and published in 1994.1 The endoscopic
foreheadplasty enables the correction of the brow position
by modifying the depressor muscles of the brow and
associated tissue while keeping the frontalis muscle intact
so it can exert an upward force, thereby repositioning the
brow. Since 1992, the technique has been enhanced by
the adoption of more precise methods of patient selection;
variations in tissue dissection, modification, and fixation;
and the introduction of associated techniques such as
chemical peeling, laser resurfacing, chemical denervation,
and soft tissue fillers.
HISTORY
The history of foreheadplasty can be traced back for
nearly 100 years. The very first description of fore-
headplasty was done by Passot in 1919.2 He described
several horizontal skin excisions on the higher portion of
the forehead to improve the horizontal wrinkles of the
forehead. Skin excision on the temporal area reduced the
crow’s-feet and hood of the lateral brow. Passot later
recommended direct skin excision above the brows with
undermining.3 In 1926, Hunt described the coronal,
anterior hairline, and direct skin excisions on the forehead.4
Claoue, in 1933, described undermining of the forehead.5
In 1939, Fomon described a subcutaneous undermining
with transection of the epicranium.6 Castanares recom-
mended modification of the frontalis muscle and
transection of the frontal branch of the facial nerve, in
addition to the forehead undermining and skin excision.7
In 1964, Marino and Gandolfo started to modify the
corrugator muscles in order to improve their results.8
In the 1960s and 1970s, Vinas described forehead lifts
utilizing the bicoronal or pretrichial incision, depending
on the patient’s forehead height.9,10 He also recommended
the subgaleal dissection with detachment of the fascial
adhesions to the glabella and supraorbital rim areas. He
widely dissected the region under the superficial temporal
fascia. In 1972, Regnault described a biplanar approach
on the temporal area to correct the crow’s-feet.11 Connell
and associates, in the 1980s, published techniques that
would modify the procerus and depressor supercilii
muscles in order to improve the results of the bicoronal
browlift.12 Flowers, in 1991, emphasized the need for
prioritizing the coronal browlift over the upper eyelids
excision to obtain better aesthetic results in the periorbital
area.13 He also recommended corrugator muscle modifi-
cation in the glabella and supraorbital rim area for
sustained brow elevation, with minimal skin excision on the
forehead area. In 1990, Tirkanis and Daniel introduced
the biplanar approach to the forehead, using subcutaneous
and subgaleal dissection.14 In 1992, Isse introduced a
minimally invasive technique for foreheadplasty using
endoscopic techniques.1 Since that time, the popularity of
endoscopic browlift has continued to grow significantly.
PERSONAL PHILOSOPHY
As a person ages, the soft tissues of the face and forehead
are drawn downward by a combination of static and
dynamic forces. Gravity and depressor muscles oppose the
elevators, leading to forehead wrinkles and malposi-
tioning of the eyebrows and upper eyelids. Until the
advent of minimally invasive surgical techniques, these
conditions could be corrected only through direct
incisions in the forehead or bicoronal incisions.
The technique for endoscopic rejuvenation of the
forehead aesthetic unit was first introduced at the 1992
meeting of the Los Angeles Society of Plastic Surgery and
published in 1994.1,15 Alternative improvements in the
technique have brought the procedure to the point at
which excellent and sustainable results can be obtained
with most patients. Moreover, advances in endoscopic
instrumentation and imaging technologies have facilitated
the adoption of this technique by a growing number of
plastic surgeons. The basic concept of the procedure,
however, remains unchanged: An endoscope is inserted
through small incisions in the scalp, a wide area of the
forehead is undermined, thereby releasing the soft tissue,
depressor muscles are modified, and fixation is performed.
The action of the frontalis muscle allows natural eyebrow
Endoscopic Foreheadplasty
Nicanor Isse, MD
47
C H A P T E R F O U R

elevation. Fixation is required to maintain the elevation
on the lateral or temporal portion of the brow.
The endoscopic foreheadplasty offers several advan-
tages over more invasive procedures. There is minimal
hair loss, reduced scarring, decreased bleeding, a low
incidence of prolonged or permanent numbness of the
scalp, and most important, rapid recovery. There is a high
rate of patient satisfaction for younger individuals, post-
menopausal women with very thin hair, and individuals
who object to a coronal incision.
This chapter presents a comprehensive review of the
surgical technique for the endoscopic foreheadplasty.
Factors that lend themselves toward successful outcome
are presented. Some of the key technical improvements
that have occurred as the procedure has evolved are
examined, including the development of patient selection
parameters and refinements in the techniques for
dissection, tissue modification, and fixation.
ANATOMY
The muscles of facial expression in the forehead and their
activity are described in Figure 4-1 and Table 4-1. From
a dynamic viewpoint, the eyebrow can be divided into
three parts: medial, central, and lateral (Fig. 4-2). The
medial third of the brow (the head) lies medial to the
supraorbital nerve in the glabella. This area is very rich in
muscular activity and is controlled by the balance
between the depressor and elevator muscles. The central
third of the brow (the body) is an area limited medially by
the supraorbital nerve and laterally by the superior
temporal crest. It is balanced by the action of the frontalis
muscle (elevator) and orbicularis oculi muscles (depressor).
The lateral third of the brow (the tail) is located lateral to
the superior temporal crest in the temporal region. This
region is the thinnest portion of the brow and its dynamic
activity is controlled mainly by depressor muscles (the
orbital portion of the orbicularis oculi muscle). The frontalis
muscle has little to no activity at this level and con-
sequently suspension of the soft tissue is always necessary
in the temporal area.
Three sets of muscles are involved in the mechanism
of “human facial expression” around the brows, namely the
elevators, depressors, and corrugators (see Table 4-1).16,17
The endoscopic foreheadplasty procedure has the
ability to modify the frontalis, corrugator, orbicularis,
procerus, and depressor supercilii muscles as needed.18
PREOPERATIVE ASSESSMENT
Endoscopic foreheadplasty is indicated when improve-
ment of the brow position and shape is desired, or when
the rhytids of the forehead, glabella, and periorbital areas
need to be softened. These conditions may arise due to the
following:
■Brow ptosis and malposition
■Glabellar rhytids (frown lines)
■Tissue sagging (root of nose)
■Pseudoptosis of upper eyelids
■Mild to moderate dermatochalasia (upper eyelids)
■Minimal ptosis of the upper eyelids
■Downward slanting of the lateral canthus
■Periorbital wrinkles (crow’s-feet)
ENDOSCOPIC EQUIPMENT
Endoscopic browlift requires the use of a complete
endoscopic unit: medical video camera, camera control
unit, light source, monitor, and a fiberoptic cable.
DVD, VCR, or printer mounted on a movable stand
may also be used. One-chip cameras are generally adequate
for facial procedures. However, if crisp documentation of
a specific case is required for publication or teaching
purposes, the surgeon may wish to utilize a three-chip
48
Nicanor Isse
a
c
b
e
d
f
g
Figure 4-1 Muscles of the forehead. a, The frontalis muscle is the main
elevator of the eyebrows. This muscle produces the horizontal rhytids on
the forehead. b, The orbital portion of the orbicularis oculi muscle (OOM)
is the main depressor muscle of the entire brow. Its activity forms the radial
horizontal lines around the orbit. c, Deep head, the septal part of the OOM,
produces further depression of the brow, resulting in forceful closure of the
eyes and squinting. This muscle is generally mistaken for the corrugator
muscle. d, The depressor supercilii muscle depresses the head of the brow
and is responsible for the “reverse parenthesis line” around the medial head
of the brow. Its action results in an “angry” facial expression. e, The
procerus muscle depresses the head of the brow producing horizontal
rhytids at the root of the nose. Its action is synergistic with the levator nasi.
f, The corrugator supercilii muscle has a dual action of elevating the head of
the brow (synergistic with the frontalis muscle at this level) and depressing
the tail of the brow (synergistic with the OOM at this level). The corrugator
produces flattening of the glabellar area, midforehead wrinkles, and
notching of the brow at the level of the supraorbital nerve. g, The superficial
or medial branch of the supraorbital nerve (SON) gives the sensory
innervations of the forehead. The lateral branch of the SON innervates the
scalp and is located under the periosteum in a more lateral position.

camera, which will provide superior resolution, detail,
and definition.
An improved soft tissue endodissector/retractor with
a downward curved tip can increase the visual field
during the dissection. The retractor provides more control
during tissue handling and avoids the creation of a false
surgical plane, reducing surgical trauma and limiting tissue
damage. Periosteal and soft tissue elevators are used, as
well as a tissue “spreader” for the temporal and midface
areas.
SURGICAL TECHNIQUE
A combination of intravenous sedation and local
anesthesia is adequate, although general anesthesia can
be used. Intravenous sedation is performed using 0.5%
lidocaine (Xylocaine) with epinephrine (1:200,000) for
the forehead, temporal area, eyelids, and scalp infiltration.
The following standard surgical steps are performed
during an endoscopic foreheadplasty:
■Preoperative marking (Box 4-1)
■Incisions
■Creation of an optical cavity
■Dissection of the forehead and temporal areas
■Release of tissue attachment to bone and deep fascia
■Tissue modifications
■Fixation
THE INCISIONS
A central forehead incision and two paramedial incisions
(right and left) approximately 4.5 to 5.0 cm lateral to the
central incision are made behind the hairline (Fig. 4-3).
These incisions measure about 1.2 to 1.5 cm in length.
An incision is then made in the temporal region 2.0 cm
behind the hairline and about 1.0 cm lateral to the
temporal crest, measuring 1.5 to 2.0 cm in length.
CREATION OF AN OPTICAL CAVITY
A blind subperiosteal dissection is performed in the
forehead area down to the midforehead line, and 1.2 to
2.4 cm posterior to the incisions, using a curved periosteal
elevator (see Fig. 4-3). Using a blunt dissector, the
temporal area is “blindly dissected” between the
superficial (tempoparietalis fascia) and the deep temporal
CHAPTER 4
Endoscopic Foreheadplasty
49
Table 4-1
Muscles of Facial Expression in the Forehead and
Their Activity
Muscle
Muscle
Facial
Movement
Name
Action
Expression
Elevators
Frontalis
Elevation
Attention
of brow
Depressors
Orbicularis
Depresses
Reflection
oculi
entire brow
Procerus
Depresses
Aggression
medial brow
Depressor
Depresses
Anger
supercilii
head
Corrugators
Corrugator
Elevates and
Pain
supercilii
adducts head
Depresses
lateral brow
a
c
b
Sup. temporal crest
Supraorbital n.
Figure 4-2 Segments of the brow. a, The head of the brow is located
medial to the supraorbital nerve (SON) and contains most of the muscles of
facial expression in the forehead (glabella). The repositioning of the brow in
this area depends mainly on decreasing the muscle activity. “Tissue
modification” is the best way to deal with the muscles via myotomy,
myectomy, neurotomy “block,” or chemical denervation. b, The body of
the brow is limited medially by the SON and laterally by the superior
temporal crest (STC). This region contains two muscles: frontalis as an
elevator and orbicularis oculi muscle (OOM) as a depressor. Brow
repositioning at this level occurs secondarily to the elevation of the medial
and lateral brow. If the medial brow does not achieve the desired height,
direct brow fixation is done at the paramedial location. Medial brow ptosis
occurs secondary to OOM action and dermatochalasia (most commonly
seen in older patients). c, The tail of the brow is located lateral to the STC in
the temporal region. The pars orbitalis of the OOM produces an active
depression of the tail of the brow, which could be exaggerated, depending
on the degree of dermatochalasia. In this area, weakening pars orbitalis of
OOM as well as fixation is necessary because the frontalis muscle does not
exert any significant elevation of the brow at this level.
Box 4-1
Preoperative Markings
1. Incisions (see description)
2. Temporal crest line
3. Posterior edge of lateral orbital rim
4. Superior edge of the zygomatic arch
5. Midforehead line: horizontal line marking the midpoint
between the hairline and the brows
6. The trajectory of the temporofrontal branch of the
facial nerve: a line drawn from the lowest portion of
the tragus to an area about 1.5 cm cephalad to the
superior edge of the brow at the level of the temporal
crest

fascia for a distance of 2 cm anterior and posterior to the
temporal incision.
DISSECTION OF THE FOREHEAD AND
TEMPORAL AREA
“Blind dissection” is done initially to allow the instru-
ments to be located under the periosteum in the frontal
area (see Fig. 4-3). The endoscopic dissection is then
performed in the forehead area. The endoscope is inserted
through one of the forehead incisions while the periosteal
elevator is inserted in another incision. The distal end of
the endoscopic sheath has a curved elevator/dissector that
creates an optical cavity when the very tip of the
endoscope is tilted upward approximately 15 to 30
degrees. A magnified view of the regions is created.
In the temporal area, the dissection is initially
performed using a blunt dissector and Metzenbaum
scissors. “Vertical spreading” of the scissors maintains the
correct plane of dissection. It is important to alternate the
dissections between the frontal and temporal areas in
order to avoid creating and working in a “tight tunnel.”
Working in a widely dissected area allows better
visualization of the surrounding structures and better
control of bleeding vessels.
RELEASE OF TISSUE ATTACHMENTS TO BONE
AND DEEP FASCIA
Tissue attachments to bone and deep fascia are released
in order to achieve mobilization and gliding of the
superficial tissue over the deeper structures (Fig. 4-4).
Several regions will require release, including both
periosteal attachments and galea.
The periosteum is released at level of the glabella,
supraorbital rim, and superior temporal crest. Horizontal
and vertical periosteal release at the glabella improves the
vertical wrinkles of the forehead. Horizontal release of
the supraorbital rim will allow access to the deep galea
of the orbicularis muscle and the suborbicularis planes.
The vertical release of the periosteum will assist on the
repositioning of the body and tail of the brow. Periosteal
release of superior temporal crest together with the release
of the temporal crest ligament and the superior orbicularis
ligament will allow elevation of the body and tail of the
brow, as well as improve the pseudoptosis of the upper
eyelids.
50
Nicanor Isse
a
b
c
b
d
Figure 4-3 Incisions and dissection. a, The central incision is located at
the center of the forehead, behind the hairline, measuring about 1.2 to
1.5 cm. b, Paramedial incisions are located 5 cm lateral to the central
incision and are also about 1.2 to 1.5 cm. c, Temporal incisions are located
in the temporal area, about 2 cm behind the hairline, and about 1.0 cm
lateral to the temporal crest (TC). d, The trajectory of the frontal branch of
the facial nerve is marked, starting at the level of the lower portion of the
tragus heading toward a point 1.5 cm superior to the upper edge of the
brow at the level of the TC. The light pink shaded area represents the initial
nonendoscopic subperiosteal dissection, which extends down to the
midportion of forehead laterally and close to the glabella medially. In the
temporal area, the “blind” dissection is limited to the anterior hairline
between the superficial and deep temporal fascia. The dark pink shaded
area represents the “endoscopic dissection.”
Figure 4-4 Release of tissue attachments. a, The temporal crest (TC)
separates the frontal and temporal area during the subperiosteal or
subgaleal dissection. The TC is thinner in the cephalad region near the scalp
and thicker caudally toward the brow, where it is referred to as “superior
orbital ligament.” b, Superior palpebral ligament separates the pars orbitalis
and preseptal regions of the orbicularis oculi muscle (OOM). c, The
precanthal ligament is the thickening between the periosteum of the lateral
orbital rim and the deep galea of the OOM. d, The orbicularis temporal
ligament (temporal line of fusion) attaches directly onto the deep temporal
fascia because the area does not have the superficial temporal fascia.
a
c
d
b

A sustained long-term elevation of the brow cannot
been maintained without the release of the deep galeal
ligaments and the myotomies of the lateral orbital pars of
the orbicularis muscle. The deep galea is released at the
level of glabella, superior palpebral ligament, superior
orbital ligament (conjoined tendon), superior temporal
crest ligament, orbicularis temporal ligament (temporal
line of fusion), and precanthal ligament. Glabellar release
(galea of procerus, depressors, and corrugators) stretches
the soft tissue of the area, thereby smoothing out the
glabellar wrinkles. The release of the superior palpebral
ligament (deep galea of orbicularis oculi muscle attach-
ment to the superior orbital rim) repositions the body and
tail of the brow as well as improves the pseudoptosis of
the upper eyelids by unfolding the preseptal orbicularis
“festoon.” Superior orbital ligament (conjoined tendon) is
the most caudal portion of the temporal crest ligament at
the junction of temporal crest and lateral orbital rim. Its
release allows elevation of the body and tail of the brow.
Superior temporal crest ligament (tempoparietalis fascia
and deep galea of frontalis muscle attached to superior
temporal crest) release allows elevation of the body and
tail of the brow. The precanthal ligament is the
attachment of the deep galea of the orbicularis muscle to
the periosteum at the level of the lateral canthal raphe.
Release of this ligament produces a tilt at the lateral
canthal raphe as well as a more sustained elevation of the
tail of the brow. The orbicularis temporal ligament
(temporal line of fusion) is the attachment of the
superficial fibroadipose tissue to the deep temporalis
fascia. By releasing this ligament, the lateral brow is
mobilized, adding to the long-term elevation of the tail of
the brow.
An anatomically important area of concern is a series
of vessels and sensory nerves that are present between the
fibers of the orbicularis temporal ligament and are known
as “the telephone formation” (Fig. 4-5). The medial
zygomatic temporal vein (sentinel vein) is located lateral
to the posterior edge of the lateral orbital rim and signals
the trajectory of the temporal branch of the facial nerve.
Transection of this vein further rotates the tail of the brow
and lateral canthal region. This maneuver, however, might
produce a long-standing or permanent postoperative
venous congestion in the temporal area (varicosity). The
lateral zygomatic temporal vein and artery, known as “the
pointers,” aim directly to the temporal branch of the facial
nerve as it traverses the superior edge of the zygomatic arch.
The medial and lateral zygomatic temporal nerves provide
the sensory innervation to the temporal area (branches of
the trigeminal nerve, V2). These vessels and sensory
nerves are aligned from the temporal crest to the superior
edge of the zygomatic arch. The temporal branch of
the facial nerve crosses superficial to this formation in the
temporal area. This formation is also known as “the
telephone pole.”
CHAPTER 4
Endoscopic Foreheadplasty
51
TISSUE MODIFICATIONS
“Tissue modification” refers to the weakening of the
depressor muscles of the brow via myotomy and neurotomy.
These maneuvers can be used to achieve specific aesthetic
outcomes in all of the major area of the forehead (Fig.
4-6).18,19 The glabella is the focus of the majority of the
tissue modifications. Myotomy of the procerus produces
elevation of the head of the brow and improvement of the
horizontal rhytids at the root of the nose. The myotomy is
B C
A
D
E
F
Figure 4-6 Internal view of the glabella and supraorbital area showing
the periosteum release as well as myotomies. Periosteum release at the
glabella (A). Myotomy of procerus muscle (B). Myotomy of depressor
supercilii muscle (C). Myotomy of vertical-medial orbicularis oculi muscle
(OOM) (D). Myotomy of corrugator/OOM decussation (E). Lateral
myotomy of pars orbitalis OOM and neurotomy of the corrugator nerve (F).
Figure 4-5 Endoscopic view of the temporal area. Deep temporal
fascia (A). Lateral orbital rim (B). Orbicularis oculi muscle (C). Tempo-
parietalis fascia (D). Zygomatic arch (E). Medial zygomatic temporal vein
(sentinel vein) (1). Medial zygomatic temporal nerve (sensory branch of V2)
(2). Lateral zygomatic temporal neurovascular bundle (3). Frontal branch of
the facial nerve (4).

carried out by incising the muscle transverse to its fibers
using Metzenbaum scissors. Depressor supercilii myotomy
produces elevation and slight separation of the head of the
brow, reducing the “frown lines.” This maneuver is done
by avulsing the muscle with a tip of a closed Metzenbaum
scissors. Myotomy of the corrugator supercilii muscle
produces moderate separation of the head of the brow,
correcting the vertical wrinkles of the glabella. This is
accomplished by using electrofulguration to partially
“coagulate” and remove the most superficial fibers of the
muscle without transecting the muscle completely.
At the level of the supraorbital rim, the myotomy of
the orbicularis oculi muscle (pars orbitalis) and neurotomy
of the corrugator nerve provide further improvements in
the aesthetic outcome of the endoscopic browlift. Medial
to the supraorbital nerve, a single myotomy of the
orbicularis oculi muscle is performed at the level of the
decussating fibers of the corrugator and orbicularis
muscle. This maneuver is carried out right under the
eyebrow using a thin Metzenbaum scissors. The myotomy
produces elevation and moderate separation of the head
of brow. Lateral to the supraorbital nerve, multiple
myotomies of orbicularis oculi muscle are performed,
spanning a distance of approximately 2 cm. This elevates
and rotates the body and tail of the brow. The pars
orbitalis of the orbicularis oculi muscle is the strongest
depressor of the brow, and its myotomy produces
sustained and long-lasting elevation of the brow.
Neurotomy of the nerve to the corrugator muscle is done
incidentally at these two levels. This neurotomy produces
mild separation of the head of brow.
FIXATION
Fixation is performed in order to “keep” the released
tissue repositioned in the desired higher position (Fig.
4-7). Fixation should not be done forcefully to elevate the
tissue without tissue release. In this situation, chronic
action of the depressor muscle will drive the tissue
downward, tearing the soft tissue and returning the brow
to its original position. The three types of fixations are
paramedian, bitemporal, and temporal.
Paramedian fixation is performed at the level of the
paramedian incisions bilaterally. The periosteum and
frontalis muscle are grasped at the caudal end of the
incision with a 3-0 PDS and tunneled 10 cm posteriorly
under the periosteum onto a “stab” incision. The
periosteum and occipitalis tissue are then grasped with
the suture (distance of 1 cm) and the suture is brought
back anteriorly through the same tunnel. With the single
skin hook the assistant will exert posterior tension as the
surgeon ties a knot. This fixation is indicated for patients
with severe brow ptosis and severe dermatochalasia.
Fixation can also be utilized in patients who desire the
“arched brow” by producing maximum brow elevation at
the level of the “midbrow.”
Bitemporal fixation is routinely used for all cases. It
produces an even elevation of the tail of the brows. The
browlift is symmetrical because both lateral brows are
elevated and suspended with the same suture (3-0 PDS).
The suture is applied from the superficial temporal fascia
at the medial end of the temporal incision, passing under
the periosteum of the forehead to the opposite side,
grasping the medial end of the contralateral superficial
temporal fascia and temporal incision. This fixation method
works well owing to the wide release of the temporal
region and because the medial brow is elevated mainly by
the action of the frontalis muscle after the depressor
muscles are myotomized. The central brow (body of the
brow) does not usually require fixation because it follows
the new position of the medial and lateral brow.
Temporal fixation is performed to elevate and
reposition the temporal area, as well as the lateral
orbicularis muscle, producing slight slanting of the lateral
canthal raphe. This maneuver is maximized when the
medial zygomatic vein (sentinel vein) and precanthal
ligaments are released. This fixation is done by suturing
the temporoparietalis fascia (1.0 cm anterior to the
temporal incision) to the deep temporal fascia as far
posteriorly possible with a 3-0 or 4-0 nylon. Fixation
sutures are utilized in the upper and lower part of the
temporal incisions bilaterally. Figures 4-8 to 4-11 are
preoperative and postoperative photographs of patients
who have undergone endoscopic foreheadplasty.
52
Nicanor Isse
a
c
b
Figure 4-7 Fixation: temporal fixation (a), paramedial fixation (b),
bitemporal fixation (c).

CHAPTER 4
Endoscopic Foreheadplasty
53
A
B
C
D
E
F
Figure 4-8 Preoperative (A, C, E, G, I, and K) and postoperative (B, D, F, H, J, and L) photographs of a 41-year-old patient following endoscopic
foreheadplasty.

54
Nicanor Isse
G
H
I
J
K
L
Figure 4-8 Continued.

CHAPTER 4
Endoscopic Foreheadplasty
55
A
B
Figure 4-9 Preoperative photo showing wrinkles on the forehead secondary to frontalis muscle hyperactivity attempting to overcome the action of the
depressors muscle (A). Postoperative view after endoscopic foreheadplasty (B). The horizontal wrinkles have almost disappeared. The tissue release plus the
myotomies of the depressor muscles have diminished frontalis muscle activity.
A
B
Figure 4-10 Preoperative view of a female patient with low positioning of the lateral brow as well as pseudoptosis of the upper eyelids (A).
Postoperative photo after endoscopic foreheadplasty shows repositioning of the brow and improvement of the pseudoptosis of the upper eyelids without
the need for “upper blepharoplasty” (B).
A
B
Figure 4-11 Preoperative photo of a patient with brow ptosis as well as rhytids in the forehead, glabella, and root of the nose (A). Postoperative photo
following endoscopic foreheadplasty (B).

Special Considerations
Frontalis Plication
The endoscopic dissection is done routinely for all cases.
Clinical circumstances will dictate additional maneuvers. If
the patients have brow asymmetry, unilateral fixation is
performed only on the ptotic brow, and unilateral
myotomy of the orbicularis oculi muscle is performed on
the lowermost brow. Furthermore, frontalis plication is
applied to the more ptotic brow. Frontalis plication involves
a horizontal incision behind the hairline measuring
approximately 4 cm. Anteriorly and posteriorly, sub-
cutaneous dissection is performed over the frontalis
muscle for a distance of 2 cm. The frontalis muscle fibers
are then split (1.5 cm) in the longitudinal fashion to allow
subperiosteal undermining of the rest of the forehead as
discussed previously. The frontalis muscle is then folded
over and plicated with 4-0 vicryl (creating a fold of
approximately 0.5 to 1.0 cm). Overlapping skin edges
are trimmed and two-layered closure is performed
(2 mm of skin overlapping is maintained to decrease scar
widening postoperatively). Bilateral frontalis plication is
performed in patients with severe bilateral brow ptosis,
dermatochalasia, and horizontal rhytids of forehead.
Receding Hairlines and Baldness
Special attention to the incision must be made in patients
who have receding hairlines or male-pattern baldness.
The incisions are typically made about 7 cm superior to
the brows and measure about 0.7 to 1.0 cm. The
uppermost forehead rhytid can also be utilized. A small
endoscopic elevator (sheath) is subsequently used. The
forehead incisions are closed in multiple layers in order
to minimize scarring.
Glabellar Endoscopic Foreheadplasty
Glabellar endoscopic foreheadplasty is recommended for
the correction of the isolated ptotic medial brow and
glabellar muscle hyperactivity. The dissection is limited to
the glabellar area and may be performed through a
frontal upper eyelid and nasal approach. The surgeon
must take care not to break the balance of the brow;
otherwise, the resulting medial brow will be in a higher
position in comparison to the lateral brow.
Temporal/Lateral Frontal Endoscopic Foreheadplasty
Temporal/lateral frontal endoscopic foreheadplasty is
recommended when the medial brow does not require
improvement. This procedure allows for the elevation of
the brow’s tail, modification of the brow’s contour,
improvement of crow’s–feet, or elevation of the lateral
canthal raphe. Paramedian and temporal incisions are
made. Subperiosteal dissection in the lateral portion of
the forehead (lateral to the supraorbital nerve) is
extended caudally down to the tarsal plate under the
orbicularis muscle. Temporal dissection is done under
the temporoparietalis fascia, down to the superior edge
of the zygomatic arch, and medially over the periosteum
of the lateral orbital rim.
56
Nicanor Isse
POSTOPERATIVE CARE
Immediately after the operation the patient’s forehead is
taped and a head dressing (turban) is applied to decrease
swelling. The drains and dressing are removed after 24 to
48 hours. The patients are encouraged to sleep with the
head elevated for about a week. One week later the
“tapes” and stitches are removed. Special attention is
given to the hair around or inside the wound in order to
prevent wound infection. Female patients can have their
hair tinted after 2 weeks, assuming that all the wounds
are completely closed.
COMPLICATIONS
The most common complications associated with endo-
scopic browlift are numbness of the scalp and temporary
alopecia due to inflammation or edema. Paresis of the
frontal branch of the facial nerve occurs less frequently
(about 5%). These complications are all transient and
none require additional surgery. Total recurrence of brow
ptosis is rare, occurring in less than 2% of the cases. The
usual cause of recurrent brow ptosis is severe bossing of
the frontal bone (it is advisable to reshape the bony
prominence during the procedure). Partial recurrence is
about 1.2% in the author’s experience.
REFERENCES
1. Isse NG: Endoscopic facial rejuvenation: Endoforehead, the
functional lift. Case reports. Aesth Plast Surg 1994;18:21-29.
2. Passot R: La chururgie esthetique des rides du visage. Presse
Med 1919;27: 258.
3. Passot R: Chirurgie Esthetique Pure: Techniques et Resultats.
Paris: Gaston Doin & Cie, 1930.
4. Hunt HL: Plastic Surgery of the Head, Face, and Neck.
Philadelphia: Lea & Febiger, 1926.
5. Claoue G: La ridectomie cervico-faciale par accrochage
parieto-temporo-occipital et resection cutanée. Bull Acad Med
(Paris) 1933;109:257.
6. Fomon S: Surgery of Injury and Plastic Repair. Baltimore:
Williams & Wilkins, 1939.
7. Castanares S: Forehead wrinkles, glabellar frown and ptosis
of eyebrow. Plast Reconstr Surg 1964;34:406.
8. Marino H, Gandolfo E: Treatment of forehead wrinkles.
Prensa Med Argent 1964;51:1368.
9. Vinas JC: Plan general de la ritidoplastia y zona tabu. In
Transactions of the 4th Brazilian Congress on Plastic Surgery,
Porto Alegre, October 5-8, 1965, p 32.
10. Vinas JC, Caviglia C, Cortinas JL: Forehead rhytidoplasty and
brow lifting. Plast Reconstr Surg 1976;57:445.
11. Regnault P: Complete face and forehead lifting, with double
traction on “crow’s feet.” Plast Reconstr Surg 1972;49:123.
12. Connell BF, Lambros VS, Neurohr GH: The forehead lift:
Techniques to avoid complications and produce optimal
results. Aesth Plast Surg 1989;13:217.

13. Flowers RS: Periorbital aesthetic surgery for men: Eyelids and
related structures. Clin Plast Surg 1991;18:689.
14. Tirkanis B, Daniel RK: The “biplanar” forehead lift. Aesth
Plast Surg 1990;14:111.
15. Fodor PB: Editorial: Endoscopic plastic surgery, a new
milestone in plastic surgery. Aesth Plast Surg 1994;18:31-32.
16. Sobotta J, Figge FHJ (eds): Atlas of Human Anatomy, 9th ed.
Baltimore-Munich: Urban and Schwarzenberg, 1977, p 180.
17. Isse NG: The corrugator supercilii muscle revisited. Aesth
Surg 2001;21:3, 293.
18. Isse NG: Endoforeheadplasty: The functional approach with
emphasis on myotomies and myectomies. Fac Plast Surg Clin
North Am 1997;4:2.
19. Isse NG: Endoscopic facial rejuvenation: Clin Plast Surg
1997;24:2.
CHAPTER 4
Endoscopic Foreheadplasty
57

HISTORY
The history of eyelid surgery dates back to approximately
AD 25, when Aulus Cornelius Celsus, a first century
Roman philosopher, described the excision of upper eyelid
skin for the “relaxed eyelid” in his De re Medicina. It is
not known whether he was describing a true ptosis or an
excess of skin. The first medical illustration of the aging
eyelid was published in 1817 by Beer. A year later, Von
Graefe first used the term “blepharoplasty” to describe a
case of eyelid reconstruction following a cancer resection.
It was during this period that many in Europe first began
to advocate the removal of the upper eyelid skin to correct
associated functional problems.
In 1844 Sichel described “ptosis adiposa” as a con-
dition by which the excessive upper eyelid skinfold was
filled with fat. He theorized that the disproportionate
adipose tissue caused the skin to hang down over the lid.
However, it was Fuchs who later correctly recognized the
role of the fascial attachments between skin, orbicularis,
tarsus, and the levator in the development of the
supratarsal skinfold and the importance of its recreation
in blepharoplasty.
In the early 1900s, many surgeons began to
popularize the removal of upper eyelid skin for aesthetic
enhancement. In 1907, an American surgeon named
Conrad Miller wrote one of the first books on cosmetic
surgery, entitled Cosmetic Surgery in the Correction of
Facial Imperfection. His diagrams of blepharoplasty
incisions are still similar to those used today. Kolle, in
1911, detailed the value and safety of preoperative
marking of blepharoplasty incisions to avoid excessive
skin removal. Adabert Bettman made important con-
tributions with respect to postoperative scaring. He advo-
cated precise apposition of wound edges with elimination
of tension as well as early suture removal to avoid
unsightly incisions.
In the early 1920s, Suzanne Noel, a Parisian surgeon,
wrote a book on cosmetic eyelid surgery. Noel stressed the
importance of preoperative planning using photographs.
Noel is also credited with being among the first to rec-
ognize the psychological implications of cosmetic surgery.
In 1924, Julian Bourguet was the first to describe the
transconjunctival approach for the removal of orbital fat.
Five years later, he described the removal of fat from the
two separate compartments of the upper eyelid. He is also
credited for being the first to publish “before and after”
photographs of patients undergoing cosmetic eyelid
surgery.
In the 1920s, Hunt described the coronal browlift,
and shortly after Joseph popularized the trichophytic and
midforehead browlifts. In the 1950s, Castanares precisely
detailed the anatomy of the eyelids and made an important
contribution by identifying the role of orbicularis resection
in blepharoplasty. In the 1970s, Flowers introduced the
supratarsal fixation for the low eyelid crease.
In the past two decades, the most notable advance-
ments in blepharoplasty have been made in the avoidance
of complications. The importance of preoperative
evaluation for dry eye and other ocular diseases have been
highlighted. Tenzel detailed the combination of horizontal
lid shortening and lower lid blepharoplasty for lax lower
lids. With this came the realization that such procedures
should ultimately be performed at the lateral canthus to
avoid lid margin incisions.
PERSONAL PHILOSOPHY
Blepharoplasty remains one of the most requested
aesthetic facial procedures. Both heredity and aging can
influence the appearance of the orbital area. The upper
lid begins to show evidence of aging almost before any
other facial feature. Familial fat pseudoherniation,
though not a result of aging, can be seen to begin the early
teen years. The eyes, more than any other facial feature,
are a focus of attention to both the patient and observers.
Eyelid changes, whether the result of heredity or the
effects of aging, seem to take on a magnified importance
in the orbital region. Because there is little room for error
in blepharoplasty, both careful preoperative physical
analysis and meticulous surgical execution are imperative
for a successful outcome in blepharoplasty. In general,
however, the benefits are much greater than the risks for
these procedures. Both the surgeon and the patient
universally find the results rewarding.
As in rhinoplasty or facelift surgery, each surgeon
brings to the consultation and then to the operating room
an artistic goal as to how the final result of blepharoplasty
Blepharoplasty
Norman Pastorek MD, FACS • Andres Bustillo, MD
59
C H A P T E R F I V E

should appear. Although brow position is not part of
blepharoplasty, brow position relative to the orbital rim
is significant in the final appearance of blepharoplasty
procedures. Some surgeons favor a very high brow position;
others prefer a low brow. Many patients also have a
personal bias in this regard. Patients will come to a surgeon
often based on his or her personal philosophy relative to a
“look” the surgeon is known for. This certainly is true in
both rhinoplasty and blepharoplasty. As with most artistic
vision, there is no absolute best, simply many individual
sensitivities. There are certain goals, however, that every
surgeon tries to achieve: (1) minimal scars in the upper
and lower lids, (2) least possible redundant skin, (3)
smoothest transition between bone and lid, (4) symmetry
of the lid position, (5) symmetry of fat position, (6)
maintenance of lid to limbus relationship, (7) durability
of the procedure, (8) an overall unoperated appearance,
(9) a nonfeminizing male upper lid, (10) rapid and
uneventful postoperative course, and (11) absence of
complications.
As is true for any surgical procedure, aesthetic or
nonaesthetic, proper diagnosis and evaluation of the prob-
lem are of paramount importance. This process includes
both physical and psychological assessment. Other factors
of success in blepharoplasty include a complete expla-
nation of the preoperative, intraoperative, and post-
operative facets of the procedure to the patient. The
surgeon must have a complete understanding of the
technical aspects of upper and lower lid blepharoplasty
and a complete grasp of how to manage minor and major
complications that may occur. The information that
follows is a compilation of a personal philosophy of upper
lid and skin-muscle flap lower lid blepharoplasty.
The technique chosen for lower lid blepharoplasty
merits special mention. Lower lid blepharoplasty can be
performed through a skin flap, skin-muscle flap, a trans-
conjunctival approach, or a combination of these
approaches. Each has its advantages and enthusiasts. The
author has used all of these approaches to the lower lid in
various patients with varying lid problems. This chapter
will discuss the skin-muscle flap, as it is the type of lower
lid blepharoplasty most frequently used by the author.
The advantage of the skin-muscle flap lies in versatility of
being able to alter skin excess, skin tightness, muscle
excess, muscle tension, fat volume, and fat repositioning.
The use of suspension suturing, developed many years
ago, allowed all the anatomic aberrations to be accom-
modated safely, without problems in lid margin
positioning.
ANATOMY
EYELID ANATOMY
The lower lid margin has a tangential relationship to the
lowest limit of the lower limbus. Seldom does the lower lid
cover the corneal margin by more than a millimeter. The
upper lid margin is positioned over the upper cornea at
midpoint between the upper edge and the pupillary
border (Fig. 5-1). Occasionally in a normal eye there is
visible sclera below the cornea. This variation may be
aesthetically appealing in young woman, but more often
its presence draws attention to the eyes and creates the
illusion of prominence or exophthalmos. The lateral and
medial angles of the palpebral aperture lie along a single
horizontal plane.
The superior palpebral sulcus results from insertion
of the levator aponeurosis into the lid skin (Fig. 5-2). This
60
Norman Pastorek • Andres Bustillo
Upper lid crease
Caruncle
Lateral canthus
Medial canthus
Lower lid crease
Figure 5-1 The eye is seen at rest with attention to the position of the
upper lid over the upper cornea, midway between the upper edge and
pupillary border.
Orbital septum
Orbicularis m.
Levator apononeurosis
Müllers m.
Tarsus
Tarsus
Capsulopalperbral
fascia
Septum
Figure 5-2 The upper eyelid and the relationship of the orbital septum,
obicularis oculi, and orbital fat are illustrated. Note the tarsal plate and
levator aponeurosis relationship with the levator attaching to the anterior
surface of the tarsus and interdigitating with the skin at the lid crease.

insertion varies considerably in different persons.
Measured from the lid margin, the fold or sulcus may be
as high as 12 mm in eyes that have a high prominent,
supraorbital rim and little fat in the superior
compartment. Conversely, the lid fold may be as low as
5 to 6 mm above the lid margin in an eyelid that usually
appears to be heavy and full. The inferior palpebral
sulcus marks the lower margin of the inferior lid tarsus.
The variable palpebral malar sulcus is formed by
subcutaneous adherence of skin to deeper tissues.
EYELID SKIN
The average thickness of the eyelid skin is equal to that of
a split-thickness skin graft. In no other area does the
integument approach this fragile quality. The thinness
and smooth texture of the lid skin transforms into a
thicker, coarser, more sebaceous-type skin lateral to the
bony orbital margins. The clinical significance of this
transition of skin types is in the manner each recovers
from surgical incision.
ORBICULARIS MUSCLE
Three distinct yet conjoined bands of striated muscle
encircle the orbit just beneath the skin. These muscle
bands act to close the eyes, protect the eyes, and through
their pumping action medially aid expressing fluid into
the lacrimal sacs.
The pretarsal muscle lies directly over the tarsal
plates (Fig. 5-3). The preseptal muscle covers the more
peripheral orbital septum, and the orbital muscle overlies
the orbital bone margin, blending with the frontalis muscle
over the eyebrow and the deeper corrugator supercilii
muscle medially.
The medial canthal tendons are formed by the
superficial heads of the pretarsal muscle. The tendon
attaches to the anterior lacrimal crest, and the superficial
heads of the preseptal muscle attach to the medial canthal
tendon. The deep heads of both the pretarsal and
preseptal muscles attach to the posterior lacrimal crest
posterior to the lacrimal sac.
The upper and lower pretarsal muscles join laterally
to form the lateral canthal tendon, which inserts on
the lateral orbital tubercle (Fig. 5-4). This tubercle is
positioned just behind the orbital rim. The preseptal
muscles join laterally to form the lateral palpebral raphe.
The raphe is firmly attached to the skin in this area. There
is a vascular space between the attachment of the lateral
canthus and the more superficial raphe. Unlike the
pretarsal and preseptal muscles, the orbital muscle has no
firm lateral attachment except to the skin lateral to the
lateral canthus. When the eye is firmly closed, the orbital
muscle draws the lids medially, producing the crow’s-feet
wrinkling at the lateral angle.
ORBITAL SEPTUM
The orbital septum provides the skeletal framework of
the eyelids (Fig. 5-5). Thin at its periphery, it attaches
circumferentially to the bony orbital margin and is
anatomically continuous with the orbital periosteum.
Condensation and thickening of this septal layer gives
origin to the wide, crescent-shaped superior tarsus and
the small, bar-shaped inferior tarsus. The entire structure
provides an effective diaphragm for the orbital contents
and is an efficient barrier to inflammatory and neoplastic
diseases that arise on either side of it.
Normally, the orbital septum supports the orbital
contents, especially the orbital fat. The integrity of this
membrane can be breached by trauma or weakened by
hereditary predisposition. All the important intraorbital
structures of surgical concern during blepharoplasty lie
posterior to the orbital septum.
CHAPTER 5
Blepharoplasty
61
Figure 5-3 The three aspects of the orbicularis muscle are depicted.
Figure 5-4 The upper and lower pretarsal muscles join laterally to
form the lateral canthal tendon, which inserts on the lateral orbital tubercle.
Orbital
Preseptal
Pretarsal
Preseptal
Orbital

ORBITAL FAT
Orbital fat provides a cushion and flotation to the intra-
orbital structures, both for stabilization and for
frictionless movement. Intraorbital fat fills the posterior
orbit, loosely separating the muscles, vessels, and nerves.
The anterior compartmentalization of fat outlined by
Castanares conceptualized the surgical anatomy, allowing
for an orderly, thoughtful excision of pseudoherniated fat
during blepharoplasty.
This anterior orbital fat is present just posterior to the
orbital septum as three distinct compartments in the
lower lid and two in the upper lid (Fig. 5-6). In the lower
lid the medial and central compartments are separated by
the inferior oblique muscle. This muscle lies diagonally
from the globe above, downward, and medially toward
the medial orbital wall. The lateral compartment is
separated from the central space by facial extensions of
the lateral and inferior rectus muscles. The medial fat
compartment of the upper lid is isolated from the central
part by the superior oblique muscle. The quantity of fat
in the upper compartment varies. It may stretch across
the upper lid to the lacrimal gland or be present in a small
pocket just lateral and adjacent to the medial compart-
ment. In its appearance and consistency, the lacrimal
gland in the most lateral position of the upper lid is
entirely different from fat. A constant pattern of contrasts
in texture and color is observed in the various pockets.
The fat of the medial lower compartment is always
lighter yellow, or even white, when contrasted with the
other compartments. It is also more firm and dense in
comparison with the loose fluidity of the central and
lateral divisions. The upper medial compartment may
also share some of the pale and dense characteristics of
the lower medial compartment, but the differences are not
so striking. These color and texture differences allow for
positive identification of the sometimes elusive medial
pseudohernia during blepharoplasty.
Although it is generally true that these pockets of
orbital fat are separate and distinct, surgical experience
demonstrates that there may be interconnections rather
than distinct boundaries, especially between the lower
lateral and central compartments. Tension or traction in
one area can often transmit reciprocal movement in an
adjacent pocket that seems more than simple alteration in
volume. During surgical excision, removal of one fat
pseudohernia may cause an apparent lessening of the
significance of the juxtaposed compartment. Surgical
application of this observation is discussed later in the text.
TARSAL PLATES
The dense tarsal plates contribute rigidity and stability to
the eyelids. The superior tarsal plate is 1 mm thick, with
a horizontal width of 22 to 25 mm and a vertical
dimension of 8 to 9 mm. The vertical dimension of the
smaller inferior tarsus is 4 to 5 mm (Fig. 5-7A). Both tarsi
merge with the lateral and medial lid ligaments at the
canthi. The superior and inferior periphery of the tarsi are
anatomically continuous with the orbital septum.
LEVATOR MUSCLE
The levator palpebral superioris muscle is the principal
elevator of the upper lid. It spans 5.0 to 5.5 cm from its
origin in the superior orbital apex to its insertion in the
upper lid. As it passes over the superior rectus, it begins
to thin and flatten. As the tendon emerges from beneath
the bony superior orbital rim, it fans out into the levator
aponeurosis. The aponeurosis extends across the full
length of the superior tarsus. At the upper margin of the
tarsus it fuses with the orbital septum (see Fig. 5-7B).
Together they pass downward to attach firmly to the
anterior surface of the tarsus and to the orbicularis muscle
and the subcutaneous lid tissue. This attachment is
responsible for the superior lid fold in the Caucasian eye.
Above this fusion the orbital septum is separated from the
62
Norman Pastorek • Andres Bustillo
Orbital septum
Lateral canthal
tendon
Orbital septum
Middle fat pad
Medial fat pad
Lateral fat pad
Central fat pad
Medial fat
pad
Inferior oblique m.
Figure 5-5 The orbital septum provides the skeletal framework of the
eyelids.
Figure 5-6 The fat compartments of the upper and lower lid are
shown.

aponeurosis by the preaponeurotic fat. The aponeurosis
extends laterally into the lacrimal gland, separating it into
two lobes and blending with the lateral canthal tendon;
medially, it attaches to the posterior lacrimal crest.
Understanding and appreciation of the surgical
relationship of the superficial orbital septum, the deeper
orbital fat, and still deeper underlying levator aponeurosis
are of extreme importance to the blepharoplasty surgeon.
PREOPERATIVE EVALUATION
PSYCHOLOGICAL EVALUATION
In blepharoplasty, as in all aesthetic surgery, it is
important to establish that a reasonable and rational
motivation exists for the procedure before any physical
evaluation is begun. Those with sound motivations
include (1) the patient who has considered blepharoplasty
for some time, but because of other more pressing social,
family, or financial considerations has had to postpone the
consultation and surgery; (2) the patient whose livelihood
depends on youthful appearance; (3) the patient with a
significant aesthetic problem who has not focused on that
problem as the source or cause of his or her life diffi-
culties; and (4) the patient who verbalizes that the reason
for the surgery is improved self-image and self-esteem.
Those with questionable motivations include (1)
patients who present for blepharoplasty at the insistence
of another person; (2) patients who have made a sudden
decision about surgery; (3) patients who are overly
focused on a barely perceptible eyelid irregularity; and (4)
CHAPTER 5
Blepharoplasty
63
patients whose demeanor, dress, or behavior are extreme
or at odds with what is customarily expected in a person
seeking aesthetic surgery.
Generally, the patient should not have unrealistic
expectations of the aesthetic surgery. Patients who request
eyelid rejuvenation surgery and have as their goal a return
to an appearance of a younger age are usually good
candidates and, fortunately, are in the great majority.
Rarely, patients wanting blepharoplasty may seek a
completely different look, that is, palpebral fissures that
are bigger than natural or lateral canthal positions that
are markedly elevated. These patients are pursuing a
personal fantasy and may not ever be pleased with the
results of aesthetic surgery. The patient who has a lifetime
fullness of the upper lid (dermatochalasis) with minimal
upper lid show is a special case. Upper lid blepharoplasty
in these patients is not a rejuvenation procedure. The
change that occurs with blepharoplasty is a completely
different look. The newly defined look as demonstrated to
the patient preoperatively is usually most welcomed, but
a significant other may not welcome the new look. This is
one of the few instances in aesthetic surgery in which
someone other than the patient may be part of the
decision-making process (Fig. 5-8).
MEDICAL EVALUATION
Medical conditions that would preclude any facial
rejuvenation procedure should be elicited on the history
form during history taking and elaborated on at the
examination. Any systemic collagen disease, such as
rheumatoid arthritis, systemic lupus erythematosus, and
Superior transverse
ligament
Levator aponeurosis
Capsulopalpebral fascia
Tarsus
Orbital septum
Orbicularis m.
Levator apononeurosis
Müllers m.
Tarsus
Tarsus
Capsulopalperbral
fascia
Septum
Figure 5-7 The tarsal plates provide stability to the lid (A). The upper
plate is larger than the inferior plate. The levator aponeurosis extends across
the full length of the superior tarsus (B). At the upper margin of the tarsus it
fuses with the orbital septum.
A
B

periarteritis nodosa, carries with it a good possibility of
associated dry eye syndrome.
Any of the medications (allopathic or herbal) that
can interfere with the blood-clotting cascade should be
eliminated at an appropriate time before surgery so that
they are no longer a negative factor.
OPHTHALMOLOGIC HISTORY
The ophthalmologic history should include any vision
problems, the need for corrective lenses, and any sign of
actual or impending dry eye syndrome. Any history of
conjunctivitis, styes, chalazion, or ocular herpes is
significant. Recurrent chalazion is relatively common
following blepharoplasty. It is also easily treated. It is
considerably less alarming to patients if they are advised
about the possibility before surgery. Lower lid edema,
noted daily on awakening, may persist following
blepharoplasty for several weeks. A history of previous
blepharoplasty is significant, especially a history of
multiple blepharoplasty. A history of upper lid injury in
youth may be the cause of an unexpected lagophthalmos
uncovered during an examination.
OPHTHALMOLOGIC EXAMINATION
The ophthalmologic examination must include a test of
vision. Although a test of distance vision may not be
suitable, a near vision test is easily performed using the
text of the history form or a standard near vision test
card. A vision test must be documented in the record. The
upper lid protective mechanisms are evaluated by
checking the following parameters: Bell’s phenomenon
(Fig. 5-9), lagophthalmos (Fig. 5-10), facial nerve
function (Fig. 5-11), corneal sensitivity, and decreased
blinking. The extraocular muscles should be evaluated
and the results documented. The Schirmer test for dry eye
syndrome is probably not indicated for every patient
64
Norman Pastorek • Andres Bustillo
Figure 5-8 This 27-year-old patient presented for blepharoplasty with
a history of “never having eyelids.” These patients are among the very few
for whom it may be prudent to involve a significant other in the consent for
surgery. These patients will definitely look different following surgery. Both
the surgeon and patient must preclude any misunderstanding with
someone who was attracted to the original eyelid feature.
Figure 5-9 The rare patient who does not have a Bell’s phenomenon
must be identified preoperatively. The risk of exposure keratosis exists
when the eyes do not roll upward upon closure of the eyelids.
Figure 5-11 Minimal seventh cranial nerve weakness is determined by
forcefully opening the eye against the patient’s resistance.
Figure 5-10 Lagophthalmos is determined by having the patient gaze
downward while extending the neck. The upper lid is seen to be limited in
its ability to cover the cornea and seem tethered. This can occur in any
patient who has had previous upper lid blepharoplasty or an upper lid injury
in youth

undergoing blepharoplasty (Fig. 5-12). It is absolutely
indicated for any patient who has a positive history of
tearing, burning, or eye sensitivity. In these patients, an
ophthalmologic consultation will be necessary prior to
surgery to establish the level of the dry eye problem and
to determine if the surgery is indicated. Patients with
moderate to severe dry eye syndrome are probably not
candidates for blepharoplasty. Patients with mild functional
dry eye syndrome may be candidates for surgery. The
upper lid visor function is responsible for corneal coverage,
and upper lid blepharoplasty can precipitate dry eye
syndrome more readily than lower lid blepharoplasty in a
patient with functional dry eye syndrome. The blepharo-
plasty procedure in a patient with mild functional dry eye
syndrome must be done with deliberate conservatism.
Both the patient and the surgeon must recognize that a
result on the undercorrected side of perfect is desirable.
A visual field test is performed if there is a question of
visual obstruction secondary to upper lid skin redun-
dancy. A crude test can be performed with finger move-
ment. However, if the procedure is being done specifically
for visual field improvement it is probably best to have
an independent examiner determine the extent of the
problem.
EVALUATION OF EYELID AESTHETIC PROBLEM
The eyelid skin type should be noted. Is it dry, oily, thin,
or thick? The type and extent of pigmentation is
determined. Are the palpebral fissures symmetrical or
asymmetrical? Most patients with asymmetrical palpebral
fissures are unaware of the condition until it is pointed out
to them. If it has always been present it is not seen as an
abnormality. This condition is common. It is important
that the condition be pointed out to the patient prior to
surgery. It may likely become a focus of attention
following blepharoplasty as observers closely scrutinize
the result and bring the asymmetry to the patient’s
attention. The relationship of the lid margin to the limbus
should be recorded. Inequality of the upper lid
relationship to the limbus may be secondary to a mild
ptosis, may imply a unilateral exophthalmos, or can result
from a unilateral lagophthalmos. Unilateral or bilateral
mild exophthalmos is a common congenital variant.
Asymmetrical positioning of the lower lid is less common,
but can occur as a congenital condition. Any recent change
needs evaluation. A static lifelong condition probably does
not require further evaluation. However, an aggressive
upper lid blepharoplasty can make an unnoticed
palpebral fissure inequality very obvious.
The amount of upper lid skin redundancy is first
estimated with the patient’s eyes closed. The skin is gently
grasped with a forceps from the medial to the lateral lid
to give the surgeon an approximation of the amount of
skin that can be safely removed at surgery. The extent of
redundant skin lateral to the orbital rim is also evaluated.
In this chapter the assumption is made that the brow
position is adequate; that is, the brow is positioned above
the orbital rim by observation and palpation. In this
position, upper lid blepharoplasty can be done without
brow lifting. If the procedure of upper lid skin excision
ends at the orbital rim while redundant skin exists lateral
to the rim, the resulting postoperative hooding will
seriously mar the result. The skin lateral to the orbital rim
should be incorporated in the upper lid procedure. The
skin lateral to the orbital rim is thicker (it is facial skin)
than the very thin eyelid skin. The scar will take longer to
heal, will stay erythematous for a longer time, and will
require the use of cover makeup. However, the end result
is a much better looking upper lid. This needs to be
explained to the patient. Though the medial and central
upper lid is important, in modern upper lid blepharo-
plasty, the focus is on the elegant lateral upper lid.
The amount of medial and central fat pseudo-
herniation in the upper lid is noted while gentle pressure
is applied to the closed eyelids. Occasionally, a lateral
upper lid fat compartment may be present. This almost
always is associated with massive pseudoherniation of fat
in the medial and central compartments. An apparent
lateral fat compartment without large amounts of medial
and central fat should make the examiner suspicious of
ptosis of the lacrimal gland. If the lid skin is pulled tightly
upward, lacrimal gland ptosis will present as a small
nodule showing beneath the lateral orbital rim. If the
gland is ptotic, the surgeon should plan to suspend it
behind the orbital rim at the time of surgery.
Asymmetrical eyebrows must be evaluated in
preparation for upper lid blepharoplasty. Asymmetry of
the brows is common and hardly ever recognized by the
patient until it is pointed out. The eyelid skin beneath the
elevated brow usually is viewed by the patient as less
CHAPTER 5
Blepharoplasty
65
Figure 5-12 The Schirmer test will give a gross approximation of the
lacrimal function. If the paper is minimally wet it indicates a major dry eye
syndrome is present. It is probably more important to detect a minimal dry
eye syndrome by history and then obtain an ophthalmologic examination
when planning blepharoplasty.

redundant, while the skin beneath the lower lid is viewed
as more redundant. If, in such patients, asymmetrical skin
excisions are performed in the upper lid, the more
dependent lid will be pulled even further downward.
Unilateral brow elevation is highly recommended in these
patients. Again, if the brow asymmetry has been present
through out the patient’s life the patient may not
recognize this feature as abnormal. The patient must be
educated about the consequences of performing the
blepharoplasty without addressing the asymmetrical
eyebrows. The asymmetry will always be more
exaggerated following surgery. Some patients will elect
not to address the brows despite the surgeon’s best efforts
to explain the less than ideal results. Brow asymmetry
that exists only in animation is entirely different. This is a
normal expressive variant. No attempt should be made to
correct this type of animated brow asymmetry surgically.
The animated asymmetry may respond to botulinum
toxin treatment.
Occasionally, a prominent lateral bony rim may
require reduction to complete an aesthetic effect. Though
beyond the scope of this chapter, the procedure is
performed via the upper lid incision with a bone burr. Fat
excess may also be found in some patients to cause a
heavy appearance in the area beneath the lateral upper
brow. This fat may be removed by elevating the upper
outer quadrant of orbicularis muscle and sculpting the fat
over the upper outer orbital rim. The surgeon is cautioned
to be sure homeostasis is complete because this fat is very
vascular.
Testing the lower lid to determine tone will determine
the vulnerability of the lower lid to postoperative scleral
show, lateral “hound dogging,” or ectropion. Simple
observation of the lid can give the examiner an idea of the
lid strength. If the patient has scleral show before surgery,
the likelihood of this worsening with surgery must be
considered and discussed with the patient, especially if
this has been progressive. Some patients have had a small
degree of scleral show for all their life. Not only may it be
difficult to change this with surgery, but it may also not be
desirable. These patients with lifelong scleral show may
feel that their eyes are “smaller” without some white
showing beneath the limbus. These cases make up a small
percentage of the cases that present for surgery but are
worth noting. The majority of patients will be distressed if
there is an inferior repositioning of the lower lid. These
patients and other observers will see a “rounded eye”
postoperative result.
A simple snap test will reveal the lower eyelid tone
(Fig. 5-13). The lower eyelid is grasped gently with the
thumb and forefinger, pulled away from the globe and
released. A normal lid will “snap” back to contact the
globe with a spring-like action. Any degree of delay in this
repositioning is indicative of poor lid tone. The slower the
return, the more likely that some problem may occur if
the blepharoplasty is not adjusted to account for this
laxity. The worse response is the lid that stays away from
the globe until the patient blinks. The examiner must be
careful to tell the patient to not blink during this test.
Blinking as the lid is released will allow even the poorest
toned lid to reapply itself to the globe, giving the examiner
a false sense that the lid is normal. The surgeon must be
alert to the patient with a negative vector. The negative
vector is the anatomic observation, in a lateral position, of
the globe being positioned more anteriorly than the
orbital rim–malar bone complex. These patients are prone
to lower lid malpostion following blepharoplasty. The
most vulnerable case is the negative vector with an absent
lid response to the snap test. A standard blepharoplasty
procedure, in these patients, without specific attention to
lid tightening will always result in some degree of
unacceptable lid positioning. They are candidates for
surgery in only the most experienced hands.
The lower lid orbital margin is palpated to determine
if any of the baggy appearance of the lower lid is
secondary to bony protrusion. Once the problem is
ascertained to be fat pseudohernias, it is necessary to
quantify the amount of fat. By having the patient gaze
upward and then to the right and left the fat pseudo-
herniation volume is amplified. This gives the observer
an impression of the amounts and location of fat
pseudoherniation—medial, central, and lateral—that will
require treatment. The amount of skin redundancy is
estimated by gently grasping the skin with a smooth
forceps while the patient gazes forward. Orbicularis
muscle hypertrophy is estimated by observing thickness
just below the ciliary margin. Both skin and muscle may
be responsible for any swag or festooning at the orbital
rim. By having the patient squint the examiner can
observe the orbicularis tighten and the subseptal orbital
fat being pushed back into the orbit. It also gives the
examiner an opportunity to show the patient what the lower
66
Norman Pastorek • Andres Bustillo
Figure 5-13 The snap test is important in determining the integrity of
the lower lid. The normal lid will “snap” back against the globe when it is
pulled away gently and then released. Any degree of slowing of the normal
repositioning indicates the possibility of malposition of the lower lid margin
following blepharoplasty.

lid will look like in terms of the absence of redundant fat
and the amount of fine skin rhytids (Fig. 5-14). Not all
these fine skin wrinkles will be alleviated by surgery. This
should be explained to the patient.
It is important to discuss other anatomic features that
will or cannot be changed during blepharoplasty. In darkly
pigmented lids, the fine pale lid scar that is ideal may be
more obvious. In patients with thin skin or a familial
predisposition to a bluish hue from underlying vascular
patterns the “dark circles” under the eyes probably will not
change. The fine skin crepe patterns of the upper lid are
more difficult to control than those of the lower lids. Lateral
crow’s-feet will not be eradicated by upper or lower lid
blepharoplasty. Patients frequently expect periorbital
skin problems will be eased at the time of the surgery. The
limits of blepharoplasty must be explained before surgery.
Any skin lesion such as keratosis, nevus, syringoma,
trichoepithelioma, or xanthoma should be discussed as to
the possibility of excision and the anticipated result.
As for all aesthetic surgery, photographic docu-
mentation is required preoperatively. Close-up 1:5 ratio
photographs with frontal eyes open, frontal gaze upward,
frontal eyes closed, oblique eyes open, and lateral eyes
open should be obtained in addition to a 1:10 full-face
view. Use of these photographs with a digital imaging
system is the choice of the surgeon. It is not essential. The
use of preoperative and postoperative photographs, at the
conclusion of the consultation, as examples of possible
outcomes is also the surgeon’s choice.
SURGICAL TECHNIQUE
SKIN MARKING IN THE UPPER LID
The upper lid skin is cleaned with an alcohol pad to
ensure that the marking will not spread. A surgical
marker of extreme thinness in selected to prevent a thick
line. One millimeter of lid skin excision can make a
difference in the surgical result. If the surgical mark on
the lid skin is 2 mm thick on both the upper and lower
limbs of the upper lid incision, it is possible to make a
4-mm error in the lid skin excision.
Two notations should be made before marking the
skin. The relationship of the brow to the bony rim must
be determined while the patient is in an upright position.
The weight of the scalp will pull the brow upward when
the patient is supine. This movement will carry some of
the upper lid skin with it, giving an impression of less
redundant skin than is actually present. Also, the amount
of medial upper lid fat should be established while the
patient is upright. The fat will fall back into the orbit in
the supine position, giving a false sense of the amount of
fat considered for removal.
The first skin marking is made just below the natural
upper lid crease. The suture line will elevate slightly to
settle at the natural lid level that is particular to each
patient. The natural lid crease is usually apparent. If it is
not, the patient is asked to open and close the eyes several
times to make the crease appear. The average height of
the crease is 8 to 10 mm above the palpebral margin at
the center. This may vary between 6 and 12 mm. If the
height at the lid center is lower than 8 mm, then the lid-
crease marking is elevated to 8 mm to 10 mm. The
marking parallels the natural curve of the lid. The medial
mark terminates 1 to 2 mm medial to the puncta. The
incision ends here. Incisions that continue into the con-
cavity of the medial orbital rim may cause a webbed scar.
If the incision is carried onto the nasal skin it is certain to
cause an undesirable scar. Excess of creped skin in the
medial portion of the eyelid present at the conclusion of
the upper lid blepharoplasty can be removed with small
vertical triangular skin excisions. These triangular
excisions are positioned base down at the incision and
rarely even require suturing. The lateral end of the upper
lid incision continues along the natural lid crease to about
five sixths of the lid. Here the incision should become
more horizontal and then curve slightly upward. It is best
to avoid the natural line that is seen as the lid crease
extends into a lateral orbital skin rhytid. An incision in this
area is often too low to cover with makeup. More
important, however, a low incision may pull the tail of the
brow downward to cause a persistent lateral hooding, thus
countering the very purpose of the aesthetic procedure.
Curving the incision upward to end between the lateral
canthus and the lateral brow margin will reduce the lateral
hooding by elevating the skin inferior to the incision
upward. The incision ends in a position that is easily
camouflaged by makeup (Fig. 5-15). Lateral extension
beyond the orbital rim is not recommended in men.
The upper limb of the skin marking must be made to
encompass all the redundant eyelid skin. The gravity
effect of the scalp pulling the brows up must be countered
CHAPTER 5
Blepharoplasty
67
Figure 5-14 With the patient squinting the examiner can observe the
subseptal orbital fat pushed back into the orbit. The fine wrinkles are readily
apparent and not all of them will be alleviated by surgery. This should be
explained to the patient.

by gently pushing the brow downward during the marking
(Fig. 5-16). While the patient’s eyes are closed the
redundant skin is grasped with a forceps to estimate the
amount to be removed. One blade of the forceps in placed
at the lower lid mark while the other blade is used to
gather as much skin as possible without elevating the
upper lid margin away from the lower lid margin, so that
the eye does not open (Fig. 5-17). The goal is to avoid
opening the palpebral fissure and prevent lagophthalmos.
Enough medial skin must remain to drape into the
depression left by medial fat pocket excision. If the wound
is closed by tenting the skin over the depression, a
hypertrophic scar is almost certain to result. Both the
medial and the lateral ends of the marks must end in a 30-
degree angle to avoid a “dog-ear” elevation (Fig. 5-18).
ANESTHESIA OF THE UPPER LID
If upper blepharoplasty is being done alone, it is easily
performed as an ambulatory procedure under local anes-
thesia with a light premedication. A four-lid blepharo-
plasty may require a heavier premedication simply
because the procedure is longer. If the blepharoplasty is
being done as part of total facial rejuvenation, the surgeon
will choose an intravenous analgesia or general anesthesia.
The common requirement for blepharoplasty is the need
68
Norman Pastorek • Andres Bustillo
Figure 5-15 The diagram shows the classic position of the lateral upper lid incision falling into a natural lateral rhytid (A). Because of the downward thrust
of the incision and the lack of any superior skin support in the lower lateral periorbital skin, the final result may be lateral lid hooding. The diagram indicates
the upward sweep of the lateral upper lid incision that takes advantage of the natural lateral tether that is found in the temporal region (B). The tether becomes
increasingly more significant in the skin lateral to the lateral brow. It becomes increasingly less significant in the skin adjacent to the lateral canthus and absent
below this area. The authors have found an advantage in moving the lateral portion of the upper lid incision into this tethered area to elevate the skin in the
lateral canthus.
Figure 5-16 The brow-forehead complex is naturally elevated in the supine position (A). This elevation has a significant influence on the upper lid skin
redundancy. The brow must be depressed to the normal upright brow position while calculating the amount of skin to be removed (B). The brow is
depressed gently until a “stop” is felt. This is the normal position. The other alternative is to mark the upper lid skin while the patient is upright. The authors
have found this latter method more difficult when measuring small or subtle skin excess.
A
B
A
B

for local infiltrative anesthesia. The author uses lidocaine
(Xylocaine) 2% with epinephrine 1:100,000. Lesser con-
centrations seem to have a shorter effectiveness in the
eyelid skin than in other areas of the face. Longer acting
local anesthetics such as bupivacaine (Marcaine) may also
be used. A mixture of these two anesthetics has been
helpful in prolonging the pain-free period following
surgery. This benefit must be weighed against the
prolonged absence of eyelid closure function in the post-
operative period. The total volume of infiltrative lidocaine
2% with epinephrine 1:100,000 should not exceed 1 to
2 mL per eyelid. Greater amounts will distort the eyelid
and will not provide improved anesthesia. This amount of
anesthetic will provide and sustain maximum anesthesia
for 30 minutes and some anesthesia for 1 hour. Maximum
epinephrine vasoconstriction occurs 10 to 15 minutes
following injection. The eyelids maintain anesthesia after
infiltration for a shorter time than do other areas of facial
skin. The addition of a small amount (1 to 10 mL of local
anesthetic) of sodium bicarbonate to the local anesthetic
may decrease the burning sensation of the local infil-
tration. The anesthetic is infiltrated with a 1.5-inch
27-gauge or 30-gauge needle from lateral to medial. The
needle addresses the lid in a horizontal fashion, never
vertically.
Sensory innervation of the upper lid comes from four
branches of the ophthalmic nerve (cranial nerve V1). The
lacrimal nerve supplies the lateral upper lid. The supra-
orbital nerve emerges through a groove or canal at the
superior medial rim to supply the central and medial lid.
Two smaller contributions, the supratrochlear and infra-
trochlear nerves, pierce the orbital septum above and
below the trochlea of the superior oblique muscle. The
maxillary nerve (cranial nerve V2) supplies the lower lid
through a small zygomaticofacial twig and the superior
branch of the infraorbital nerve. These nerves emerge via
their respective lateral and medial foramen. There is little
need for specific nerve blocks in blepharoplasty
anesthesia. Nerve blocks for the upper lid require
penetration of the orbital septum toward the orbital roof.
It is also not advisable to attempt injection of the orbital
fat in the upper or lower lids during initial injections.
Penetration of vessels behind the orbital septum, with
secondary bleeding and possible hematoma formation, is
avoided if the anesthetic infiltration remains sub-
cutaneous. The initial sensation for the patient is that the
lids feel heavy and it is difficult to open the eyes. Once
the anesthetic becomes effective the patient may have
trouble closing the eyes because the orbicularis muscle is
affected. The levator of the lid remains unopposed,
opening the eye slightly. Any application of topical
anesthetic solution to the conjunctiva or cornea should be
avoided in standard blepharoplasty (nontransconjunctival
approach) because there is no indication for interference
with the protective corneal reflexes. Some surgeons prefer
to use corneal shields for all blepharoplasty. The incidence
of corneal injury without shields is extremely rare.
The timing of the injections depends on the speed and
experience of the surgeon. The length of time needed for
a four-lid blepharoplasty can vary from less than 1 hour
(experienced surgeon) to 3 hours. Do not expect a lid to
maintain anesthesia for much more than 1 hour. The lids
should be infiltrated accordingly. The surgeon with
modest experience may find it useful to anesthetize both
upper lids initially; then, just before beginning the skin
incision on the second upper lid, both lower lids are
infiltrated. If all lids are anesthetized at the outset, the
final or fourth lid may become sensitive just as the
incision is made. The secondary infiltration could make
precise skin and fat removal unnecessarily difficult. The
average required times for completion of lid surgery should
be recorded to allow a realistic schedule for anesthesia.
CHAPTER 5
Blepharoplasty
69
Figure 5-17 The amount of skin to be excised is the maximum that can
be removed to leave no excess postoperatively, while complete eyelid
closure remains intact. The authors find the small bayonet forceps to be
easy to use for the measurement.
Figure 5-18 This view shows the marked upper lid with the eyes open.
Note the amount of skin lateral to the lateral orbital rim. It is this lateral
excision that gives beauty to the lateral lid and prevents lateral hooding.

General anesthesia is rarely necessary for blepharo-
plasty. If general anesthesia is used, the surgeon and the
anesthetist must be aware and sensitive to the problem of
postintubation coughing and postanesthesia retching.
These factors can add greatly to the postoperative edema
and ecchymosis associated with blepharoplasty.
UPPER LID BLEPHAROPLASTY
The procedure begins with placing tension on the inferior
limb upper lid marking, pulling it laterally to straighten
the mark as much as possible (Fig. 5-19). The incision is
made with a small blade (No. 15 Bard-Parker or No. 65
Beaver). The incision is made at a uniform depth through
the skin beginning medially and continuing laterally in a
single stroke. The incision is then made in the upper limb.
The lateral angle must be very crisp at 30 degrees. This
lateral angle can be made by turning the blade 180 degrees
and stroking medially from the point of convergence. The
lid skin is then removed with a curved Steven’s scissors
and a Brown-Adson forceps. Pushing the closed scissors in
a medial direction in the subcutaneous space between the
upper and lower limbs of the incision and spreading
facilitate the removal. A decision is then made to remove
or not remove orbicularis muscle (Fig. 5-20). Removal of
orbicularis muscle allows for a greater definition of the
upper lid cleft and a sculptured appearance of the upper
lid. This advantage must be weighed against the fact that
orbicularis function closes the eye and that the muscle is
present in varying degrees in different individuals. Other
considerations are that the deeply sculptured eyelid cleft
can have an aging look (cadaveric) and the sculpted look
in the male lid can appear feminine. Despite these
considerations, some muscle excision is probably desirable
in most cases except in older and thin-skinned patients in
whom the muscle can be expected to be scant or thin.
Point cautery is used to obtain absolute homeostasis.
Following removal of the redundant skin and any
indicated orbicularis muscle the medial fat pocket is
exposed by gently spreading the medial orbital septum
with a Steven’s scissors or a fine hemostat. This can be
facilitated by having the surgical assistant elevate the
brow. The color of the medial fat is whiter than the yellow
fat of the central compartment. The central fat can be
close to the medial fat. The color difference can be helpful
to avoid missing the medial fat pocket. The medial fat
pocket can be visualized by observing the slight bulging
while applying soft digital pressure to the closed eyelid.
The medial fat is gently teased through the opening in the
orbital septum (Fig. 5-21). A small amount of local
anesthesia is injected into the fat. It is then clamped and
excised. Enough fat is left at the point of excision to allow
it to be cauterized. The local anesthesia is necessary to
prevent pain with manipulation of the fat when this
70
Norman Pastorek • Andres Bustillo
Figure 5-19 The skin is stretched taught to allow an easy sweep of the
scalpel to incise the skin precisely along the surgical marking.
Figure 5-20 The thin upper lid skin redundancy has been excised with
preservation of the underlying orbicularis muscle.
Figure 5-21 The medial fat pocket is exposed by applying a small
amount of pressure to the globe and watching for slight bulging in the
medial upper lid. The orbital septum is incised and the medial fat pocket is
teased from the medial fat compartment.

procedure is done under local anesthesia. All the structures
internal to the orbital septum maintain their sensitivity.
The orbital septum is an effective barrier to the spread of
local anesthetic. The upper medial fat pocket lies between
the medial rectus muscle and the superior oblique muscle.
The superior oblique muscle is at small risk of injury if too
much tension is applied, drawing the fat up into the
wound. The hemostat is applied only when it is clear that
the muscle will not be clamped with the fat. The superior
oblique muscle, however, is rarely seen. The fat is excised
with a curved Steven’s scissors. Enough fat is left to allow
cautery with a hot tip cautery. The hot tip cautery is used
because it allows pinpoint precision hemostasis. The use
of electocautery will almost always cause pain in the
posterior orbit even when the fat is totally anesthetized. It
is not suitable for use under local anesthesia. After the
medial fat is removed the central fat is located by
applying gentle pressure to the globe. A small incision is
made at the point where the orbital septum bulges. The
fat is then gently teased into the wound. Only the fat that
lies external to the septum without retracting back into
the wound is removed. This will produce a smooth
nonretracted central lid. Overexcision of fat in the central
compartment is an error that often produces an A-shaped
retraction that defeats the intended rejuvenation. The fat
is clamped, cut, and cauterized in the same fashion as the
medial fat. The levator aponeurosis is superficial and
clearly visible beneath the central compartment fat.
Rarely, in extremely heavy lids, there is a lateral fat
compartment over the position of the lacrimal gland. If
the lacrimal gland is seen to be ptotic preoperatively, it is
easily repositioned by using a 6-0 polypropylene suture to
secure the gland capsule to the orbital roof just internal to
the orbital rim. The gland color is pink and the
consistency is lobular, which differentiates it from orbital
fat. Occasionally, a broad heavy bony orbital rim will
require reduction with a bone burr. Also, in particularly
heavy lateral lids a separate fattiness can be found deep
to the upper outer orbitalis muscle (ROOF, or retro-
obicularis orbital fat). Removal of this fat gives a refine-
ment to the heavy outer orbital rim. This retro-orbicularis
fat is extremely vascular, and complete homeostasis is
important.
Repair of the wound can be accomplished with several
varied sutures. However, the author finds polypropylene
the most nonreactive, resulting in the finest scars. Nylon
is somewhat more reactive and is more difficult to remove
because its friction quotient grips the tissue when it is
used as a continuous suture. Absorbable sutures are the
most reactive in the skin, producing redness that is not
seen with polypropylene. Braided or multifilament sutures
are the worst sutures to use for eyelid incision closure.
They are notorious for leaving suture tunnels and skin
suture marks.
The upper eyelid skin wound is closed beginning with
simple 6-0 polypropylene (Prolene) sutures from lateral
to medial to close the lateral one fourth of the wound. The
orbital septal incisions are not repaired. The lateral or
facial skin part of the wound is under the most tension
and is the most likely to separate if closed with a running
suture. The remaining wound is closed with a running
subcuticular suture beginning medially and continuing to
the simple interrupted suture closure (Fig. 5-22). The
ends of the sutures are left untied and long and are taped
to the skin above the eyebrows. The surgeon must handle
the eyelid skin very gently. If a forceps is used, only the
subcutaneous tissue is grasped. If any area of the closure
seems to need support, individual simple sutures are placed
using only a surgical twist instead of a knot. Any skin redun-
dancy noted at the medial end of the wound in handled by
removing small triangles of skin (base down at the wound
edge) both above and below the wound edge.
Skin glue alone has not been found satisfactory as a
primary closure following upper lid blepharoplasty. The
authors find the suture closure technique to produce
consistently finer scars. Skin glue is used in selected cases
as a supplemental closure following suturing. It is also
useful for closing wounds that have separated because of
trauma in the immediate postoperative period. The use of
1⁄8-inch sterile surgical tape to cover the sutured wound
gives additional support and security in the immediate
postoperative period.
Figure 5-23 presents one case of upper lid blepharo-
plasty. Figure 5-24 presents a more extensive case.
Figures 5-25 to 5-27 show pre- and postoperative views
of individuals who have undergone upper blepharoplasty.
LOWER LID SKIN MUSCLE FLAP
BLEPHAROPLASTY
The lower lid incision should be made parallel to a line 2
to 3 mm below the cilia of the lower palpebral margin. It
CHAPTER 5
Blepharoplasty
71
Figure 5-22 The upper lid wound is closed initially with several 6-0
Prolene simple sutures laterally. The wound tension is highest laterally. The
remainder of the wound is closed with a single subcuticular 6-0 Prolene
suture. The ends are left free and are not tied.

72
Norman Pastorek • Andres Bustillo
Figure 5-23 In part A, this patient’s upper lid is marked in preparation for surgery. The two lower lateral lines were placed to show how the final lateral
skin marking configuration is chosen to elevate the lateral “crow’s-foot “area rather than pull the skin lateral to the orbital rim downward. In part B, the
redundant skin has been removed. Patients, such as this one, with moderate orbicularis muscle hypertrophy can benefit from an excision of muscle from
the central aspect of the wound. The muscle excision will provide a more attractive lid cleft definition. In part C, the orbicularis muscle has been excised and
placed on the upper lid to display the amount and extent of the muscle excision. The cuff of muscle is always removed centrally with some muscle remaining
at the wound edges. Part D shows wound closure with multiple simple sutures laterally and a single subcuticular suture medially and centrally. The sutures
are removed at 4 days.
Figure 5-24 This patient has significant skin excess, muscle hypertrophy, and fat pseudoherniation (A). Skin marking of the upper lid shows the amount
of redundant skin beyond the lateral orbital rim (B).
A
B
C
D
A
B

extends medially along this line no farther than the
inferior lid puncta. Laterally, the incision curves upward
as it maintains the 2- to 3-mm distance parallel to the
ciliary margin. It then breaks at the lateral canthus into a
more horizontal position and a lateral skin crease. Older
methods required that this lateral portion of the incision
angle downward and that the skin be advanced laterally
to excise a triangle at the lateral lid. The resultant scars
were obvious, uncorrectable, and a permanent reminder
of the blepharoplasty surgery. The method described here
involves a superior elevation. It is usually necessary to
mark only the lateral limb of the incision because the
infraciliary incision is always the same position. It is
actually easier to observe the infraciliary crease without
CHAPTER 5
Blepharoplasty
73
C
D
E
F
Figure 5-24 Continued, The skin is incised along the marked lines in the
upper lid in preparation for removal (C), and skin excision is completed (D).
Because the orbicularis muscle is hypertrophic a central trough will be
excised along the entire extent of the skin excision to provide a deepening
of the upper lid cleft. A large portion of the orbicularis muscle is excised and
placed on the upper lid for the purpose of showing the amount of muscle
to the reader (E). The orbital fat can be seen bulging against the orbital
septum. Usually there are two fat compartments in the upper lid, a medial
and a central. However, a third lateral compartment may be found in some
extremely heavy lids. A lateral fat compartment is present here (F). The fat
is being removed from over the lacrimal gland, which can be seen as a
bulge just below the clamped fat pseudohernia. The remarkable amount of
fat removed from the upper lid in this patient is displayed on the upper lid
(G). The lacrimal gland is seen just above the retractor.
G

74
Norman Pastorek • Andres Bustillo
A
B
Figure 5-25 Preoperative (A) and 6-month
postoperative (B) frontal views of a 34-year-old
woman who underwent upper lid blepharoplasty.
Figure 5-26 Preoperative (A) and 6-month postop-
erative (B) frontal views of a 32-year-old woman who
underwent upper lid blepharoplasty. Preoperative (C) and
6-month postoperative (D) oblique views of upper lid
blepharoplasty.
A
B
C
D

the marking. Again, it is important to use the finest point
marker on the skin.
The marked skin is incised with a No. 15 Bard Parker
blade or a No. 67 Beaver blade down to the orbicularis
muscle while the upper lid is opened slightly to observe
and assure that the incision in no lower than 2 to 3 mm
from the lash line (Fig. 5-28). The remainder of the
incision is made with a small, sharp, straight scissors. The
CHAPTER 5
Blepharoplasty
75
lower blade of the scissors is used as a pushing dissector
subcutaneously as the upper blade cuts through the skin
in a straight line in the natural crease 2 to 3 mm below
the lash line (Fig. 5-29). No cilia are cut. The incision
ends medially at the lower lid puncta, never beyond. Any
medial extension of the incision invites postoperative
problems with tear drainage. A small skin flap is then
developed for approximately 3 mm to expose and preserve
A
D
B
C
Figure 5-27 Preoperative (A) and 1-year postoperative (B) frontal views a 34-year-old woman who underwent upper lid blepharoplasty. Preoperative
(C) and 1-year postoperative (D) oblique views.

76
Norman Pastorek • Andres Bustillo
the pretarsal fibers of the orbicularis oculi muscle (Fig.
5-30). By preserving this pretarsal muscle sling, the lower
lid can be expected to have a more immediate tension
response after surgery, reducing the possibility of scleral
show or ectropion. A curved Steven’s scissors is the used
to separate the pretarsal and preseptal muscle to the
puncta (Figs. 5-31 and 5-32). Blunt dissection with a
cotton-tipped applicator sweeps and separates the
orbicularis muscle from the orbital septum down to the
bony inferior orbital rim exposing the lateral, central,
medial orbital rims.
A decision is made at this point to excise, preserve, or
reposition the orbital fat. When abundant fat is present in
all compartments, some fat must be removed. The author
has found that fat preservation with repositioning can be
valuable when a deep tear-trough deformity exists. In the
central lid precise fat excision will create a smoothness
at the bony rim–central orbital septum junction. In the
lateral and central compartments the fat is removed to a
level 1 mm below the bony rim. The fat is removed by
Figure 5-28 The lateral lower lid wound site is marked 2 to 3 mm below the lash line only in the lateral 6 to 7 mm of the lid (A). The lateral lower lid
wound is incised with a scalpel (B).
Figure 5-29 Following a blade incision of the lateral lid at 2 to 3 mm
below the lash line, the remaining incision is made at the same distance
below the lash line with a small sharp scissors.
Figure 5-31 The diagram shows the path of the scissors separating the
pretarsal and the preseptal muscles. The pretarsal muscle is left intact to act
as an active muscle sling in the immediate postoperative course. The lower
lid function is realized more quickly to help prevent any of the sequelae of
a lax lower lid.
Figure 5-30 The skin flap is developed for approximately 3 mm to
expose and preserve the pretarsal fibers of the orbicularis oculi muscle.
A
B

first incising the orbital septum and then teasing the fat
into the wound. If this is done under local anesthesia it
must be done with gentleness. Aggressive traction will
cause pain. The fat redundancy is then infiltrated with
local anesthesia, clamped, excised, and cauterized. (The
same procedure is followed as in the upper lid described
previously.) The central compartment fat is always the
most obvious. The lateral compartment orbital septum is
the thickest. The medial fat compartment is usually the
most elusive. Identification and notation of this compart-
ment preoperatively is important. At times, it may by
necessary to apply gentle pressure to the closed eye and
watch for the location of orbital septum bulging to locate
the medial fat compartment. Once identified, the orbital
septum is incised with the scissors and the fat is teased
into the wound. Before infiltrating and clamping the fat,
the inferior oblique muscle should be observed. In
contrast to the upper lid, this muscular structure is almost
always visible and should be found before clamping to
avoid injury to the muscle. The fat in this medial location
is also more dense and vascular than the other com-
partments of the lower lid (Figs. 5-33 to 5-35).
Homeostasis must be absolute to avoid a bleeding medial
fat stump that could retract back into the orbit.
When a preoperative tear trough problem is in need
of correction, the medial fat is handled differently. There
have been many papers and presentations on this subject.
Most authors have recommended that the fat or the
orbital septum be sutured into the tear-trough depression.
At times, especially when this technique is first used by
the surgeon, the lid margin can be pulled downward or
worse, everted when the orbital septum is sutured to the
periosteum. The tarsal plate and the orbital septum are a
single continuous structure. The author has found the
following technique useful. In those individuals who
require filling of the tear trough, the medial orbitalis
muscle (the portion of the orbicularis muscle extending
over the orbital rim) is elevated with a small short
dissector for a distance of approximately 1 cm. This area
must be thoroughly infiltrated with local anesthetic if the
procedure is done under local anesthesia. Once the muscle
is elevated, the surgeon should observe if the elevation is
completely under the tear trough. Incising the orbital
septum along the orbital rim opens the fat compartment.
The fat is then allowed to spill into the wound. It is
pushed gently into the space beneath the elevated muscle.
It has not seemed necessary to secure the fat in the new
position. Whether the fat is secured with sutures or not
the results have effaced the depth of the tear trough.
CHAPTER 5
Blepharoplasty
77
Figure 5-32 The surgical photograph shows the same orientation as in
the previous figure. The small Steven’s scissors is used to tunnel between
the orbicularis muscle above and the orbital septum below. The scissors is
then turned 90 degrees and the muscle is transected.
Figure 5-33 The medial fat compartment is handled differently
depending on whether a tear-trough deformity is present. If a tear-trough
depression could benefit from elevation, a pocket is developed by elevating
the medial orbicularis muscle from its attachment to the maxilla. This
attachment is tenacious. The orbital septum is incised at the orbital rim
(arcus marginalis) and the fat is spilled into the wound. The medial orbital fat
is then tucked beneath the muscle. It does not need to be sutured in this
position to be effective, although it can be sutured to the periosteum.
Figure 5-34 If no tear-trough deformity exists and the medial fat
compartment is seen as a medial fat pocket, then the fat is excised. The fat
is teased into the wound. The amount of fat that lies on the opened orbital
septum is usually the correct amount to be removed. The goal is to have
the level of the fat at 1 mm below the orbital rim.

Once the medial fat has been dealt with, the surgeon
should go back to the lateral compartment to be sure that
the proper amount of fat has been removed. One of the
most common complaints following lower lid blepharo-
plasty is the presence of persistent bulging in the area of
the lateral fat compartment. If more fat can be teased into
the wound, it should be removed.
Once homeostasis is obtained, the skin-muscle flap
is redraped superiorly. Under local anesthesia, the
redundant skin is removed while the patient is looking
upward, with a straight Steven’s scissors (Fig. 5-36). The
amount removed should leave a small gap between
the upper and lower limbs of the lower lid incision. The
suspension suture will close this gap. If the patient is
under general anesthesia, the lower lid is positioned so
that the lid margin is crossing the limbus at an
appropriate position. At this point, the decision about
how much lower lid skin is to be removed during
blepharoplasty should be made. If the lower lid falls
inferiorly and redundant skin and muscle are removed to
accommodate this inferiorly positioned lid, a rounded
palpebral fissure, scleral show, or ectropion becomes a
definite possibility. After the redundant lid is excised, the
surgeon should observe the field to see if any thickness of
muscle is present along the inferior limb of the wound. As
the skin-muscle flap is draped superiorly it is not
uncommon to see the preseptal muscle overlie the
pretarsal muscle, causing an elevation or ridge below the
subciliary incision. Women always want this subciliary area
smooth. Any redundant muscle is removed. Homeostasis
is again established. At this point, the suspension suture is
then placed (Figs. 5-37 to 5-50). The suspension is
always a vertical vector elevation. The suture found to be
most effective is the 5-0 clear Prolene. The suture
placement is between the deep preseptal orbicularis
muscle and the lateral orbital rim periosteum at the
region of the lateral orbital tubercle. The knot should be
buried. If any tethering is noted in the skin of the lower
lid, the suture should be placed at a deeper level. It is also
important not to place the suture so tightly that the lower
lid skin gathers at the lateral rim. The skin at the lateral
extreme of the wound should be smooth. The suture must
be cut on the knot.
Once the suspension suture has been placed, the
wound is closed with a running 6-0 Prolene suture from
78
Norman Pastorek • Andres Bustillo
Figure 5-35 When the patient is under local anesthesia, the fat is
infiltrated with a small amount of local anesthetic; it is clamped and excised.
Enough fat is left remaining to allow cautery of the fat stump without
touching the forceps. The authors use a hot tip cautery for hemostasis.
Under local anesthesia, electocautery applied to the clamp itself will cause
pain in the posterior orbit no matter how effectively the fat has been
infiltrated with local anesthetic.
Figure 5-36 Skin removal is of critical importance in lower lid
blepharoplasty. Even 1 mm too much can result in a scleral show, yet 1 mm
less can result in a perceived persistent redundancy. With the patient in
upward gaze an amount of skin is removed so that it appears that 1 to 2 mm
too much has been removed. Experience has shown that the lateral
suspension suture will close this gap. The result will be an attractively tight
appearing lower lid without scleral show. Both skin and the attached
preseptal orbicularis muscle are removed. If only skin is removed, a slight
elevated roll will result just beneath the lash line.
Orbital m.
Pretarsal m.
Orbital tubercle
Lateral canthal tendon
Reflected preseptal m.
Figure 5-37 The diagram indicates the two position points of the
suspension suture for lower lateral support. The superior position is
through the periosteum at the orbital tubercle. The lower position is
through the preseptal orbicularis muscle in direct vertical line from the
superior position. The muscle in the diagram shows the muscle reflected for
the purpose of anatomic demonstration.

CHAPTER 5
Blepharoplasty
79
Orbital m.
Pretarsal m.
Lat. palpebral raphé
Preseptal m.
Preseptal m.
Figure 5-38 The vertical arrow shows the position of the suture
placement in relationship to the lateral palpebral raphe and the preseptal
muscle.
Figure 5-39 The illustration shows the position of the lateral
suspension suture with the small wound gap in the lower lid.
Figure 5-40 The illustration shows the upper movement of the lower
lid with tightening of the suspension suture. All tension is removed as the
two wound edges become apposed. The wound is then closed under no
tension.
Figure 5-41 The illustration shows transparent view of the lateral
suspension suture placement. The suture is tight and the knot is buried.
Figure 5-42 The suspension suture being used here is a blue
polypropylene 5-0 suture for demonstration purpose. The actual suture
used is a clear polypropylene suture. Note that the suture is at the
lateralmost extent of the lower lid incision.
Figure 5-43 The patient with the lateral suture in place is asked to look
upward to demonstrate the maximum tension on the lower lid incision.
Note that without the placement of lower lid sutures there is no separation
of the wound. The suspension suture is relieving all tension.

lateral to medial. The medial ends of the suture are left
long and taped to the cheek skin. Short suture ends can
turn back toward the globe to irritate the cornea. Three
1⁄4-inch sterile surgical tape strips are place laterally to
provide an upward pull on the cheek skin to decrease any
downward pressure on the wound. Figures 5-51 to 5-54
show pre- and postoperative views of patients after lower
blepharoplasty.
POSTOPERATIVE CARE
No bandages are used on the lids, but the eyes are covered
by cold compresses as continuously as possible until
bedtime the day of the surgery. The wounds are lubricated
with a steroid-antibiotic ophthalmic ointment. If the upper
lid wounds have been covered with 1⁄8-inch sterile surgical
80
Norman Pastorek • Andres Bustillo
Figure 5-44 A few simple sutures have been used to close the lower
lid wound. The alternative closure would be a running cutaneous 6-0
polyropylene suture. The authors find it difficult to use a subcuticular suture
in the lower lid.
Figure 5-45 In this patient the orbital fat has been dealt with by
excision and repositioning. The decision is now made about the amount of
redundant skin and the lateral suspension suture. Note that the incision in
the lower lid extends slightly beyond the lateral canthus margin.
Figure 5-48 With gazing upward and opening the mouth a
remarkable separation of the wound occurs. Without the assistance of the
suspension suture the downward traction would most likely result in scleral
show, lateral “hound dogging,’ or the round eye presentation.
Figure 5-46 The lower lid skin-muscle flap has been elevated and
draped over the superior margin of the incision. With the patient’s eyes
closed there is no tension on the skin-muscle flap.
Figure 5-47 The amount of skin removed here with the patient’s eyes
closed seems appropriate. But, without the suspension suture the patient
will develop a scleral show as healing occurs. The lid must be supported
when this amount of skin is removed using the skin-muscle flap approach.

CHAPTER 5
Blepharoplasty
81
Figure 5-49 The lateral suspension suture has been placed between
the lateral orbital tubercle periosteum and the exact vertical pretarsal
orbicularis muscle on the skin-muscle flap. Note that the suture has been
placed deeply in the muscle. No puckering or tethering is seen in the lower
lid skin. Also observe that the orbicularis muscle has been draped over the
malar bone to create a smooth transition between the orbital margin and
the lower lid. It is this smoothing effect of the suspension suture that has
eliminated the need for fat repositioning in the lateral half of the lower lid.
Figure 5-50 The strength of the suspension suture can be seen as the
patient gazes upward with her mouth wide open. With this maximum
tension on the wound there is no separation at the wound. The final skin
sutures can be placed gently with enough force to simply bring the edges
together.
Figure 5-51 Preoperative (A) and 1-year postoperative (B) frontal views of a 34-year-old blepharoplasty patient.
A
B
A
B
Figure 5-52 Preoperative (A) and 1-year postoperative (B) frontal views of 42-year-old blepharoplasty patient.

tapes, then the ointment is not used. Some bloody
spotting will be noted and should not cause alarm. Pain is
not a major problem. A burning sensation for 1 to 1.5
hours after surgery is not unusual. This discomfort can
almost always be relieved with minor analgesics such as
acetaminophen with or without codeine. Anything that
would produce vasodilatation should be avoided. The
patient is instructed not to consume coffee, alcohol, or
highly spiced foods and to keep exertion limited to
activities of daily living. On the second postoperative day,
compresses are used 20 minutes per hour. Maximum
postoperative edema is usually seen on the morning of the
second postoperative day. Sutures are removed on the
fourth postoperative day. Makeup can be applied on the
fourth postoperative day to the lid skin and to the wound
itself on the sixth postoperative day. Contact lens use may
begin on the fourth postoperative day. Most patients feel
comfortable returning to work or normal activities on the
seventh postoperative day. Partial exercise can begin at
2 weeks and full exercise at 4 weeks. One or 2 weeks
before the operation, the patient is given preoperative and
postoperative instructions and an accounting of the
expected events following surgery. This material is best
prepared from the surgeon’s own experience.
Serious complications of blepharoplasty are, for-
tunately, uncommon. There are many frequent minor or
lesser complications and sequelae that occur following
blepharoplasty. These lesser sequelae are complex and
related to subjective aesthetic judgments as well as to
specific objective observations. Many of these sequelae are
temporary and are related to variations in the healing
process.
Most texts on blepharoplasty list the complications of
blepharoplasty and the management of these problems.
Although a complete understanding of these more specific
complications is imperative, each surgeon must develop a
much broader perception of the postoperative blepharo-
plasty course to include all gradations of normal
82
Norman Pastorek • Andres Bustillo
Figure 5-53 Preoperative (A) and 9-month postoperative (B) frontal views of a 43-year-old blepharoplasty patient.
Figure 5-54 Preoperative (A) and 1-year postoperative (B) frontal views of a 33-year-old blepharoplasty patient.
A
B
A
B

postoperative healing, postoperative problems, and true
complications that deviate from the ideal result. When this
more graduated approach is related to the postoperative
course chronologically in days and weeks, it becomes a
valuable informational source to the patient.
SLOWLY RESOLVING PROBLEMS
These postoperative problems generally resolve after the
second postoperative week.
Eyelid Ecchymosis
The usual progression of ecchymosis is from blue-black
through magenta to yellow and on to normal skin color
within 1 to 2 weeks. An occasional patient may retain a
uniform or patchy subcutaneous hemosiderin deposit for
a considerable time. This most commonly occurs along
the palpebral malar sulcus following a particularly dense
ecchymosis in the darkly pigmented patient. It is totally
unpredictable in patients with no previous history of
bruising. Permanent pigmentation is very rare. Particularly
stubborn problems may take up to 18 months of con-
tinuous reassurance. No particular treatment seems to
hurry the resolution process. However, some patients
seem to benefit from the application of Arnica montana.
Camouflage makeup is an appropriate recommendation.
Tearing
Tearing and burning may persist as a mild annoyance
beyond the immediate postoperative period without any
visual disturbance. This is secondary to the minimal
palpebral margin separation, which allows some drying of
the conjunctiva. These symptoms are almost always self-
limiting, but the use of artificial tears before retiring may
be advisable. Continued follow-up is necessary until the
symptoms abate.
Contact Lens Difficulties
Some difficulty with the insertion of contact lens may be
anticipated. The alteration of the lid tension may change
the clarity of vision. A change in lens prescription should
wait several months of healing. Some patients who
maintain the use of hard contact lenses may discover
difficulty in removing the lens. The lens issuer can provide
a small suction cup device specifically designed to assist
removal. The problem should be anticipated prior to the
surgery.
Recurrence of Dormant Inflammatory Lesions of the
Upper Lid
Long-dormant chalazions can be reactivated in the first
few weeks following surgery. A preoperative questionnaire
is helpful in alerting the surgeon to anticipate this
problem. This relatively painless swelling of the upper lid
results from the obstruction of the opening of a
meibomian gland. The swelling is localized between the
upper lid margin and the incision. The problem is not an
infection, but an inflammation related to the inspissated
accumulation of glandular secretion. Surgery is not
indicated. The problem responds to warm compresses and
possibly prophylactic antibiotics.
Hyposensitivity of the Lids
The hyposensitivity of the upper lids may persist beyond
the immediate postoperative period. It is most likely
secondary to persistent mild lid edema. It always resolves.
Wound Problems at the Time of Suture Removal
The lateral extension of the upper lid incision may be
subject to overlapping during the postoperative edema
phase of healing. If this is found, the wound should be
teased open and the wound resutured. If healing is
allowed without addressing the overlap, an unattractive
scar will result.
Changes in Texture and Appearance of Lower Lid
Skin
Noticeable laxity, fine creping, and slight shine can be
expected to persist in the lower lid skin for 10 days or
more when postoperative edema is pronounced. This
appearance can be most upsetting to the unprepared
patient. Calm reassurance is helpful.
Persistent Sensation of Tightness
A sensation of tightness or resistance to opening or closing
the eyes without any evidence of a functional problem
may persist for several weeks. Explaining that this is a
self-limiting condition will relieve anxiety.
Contact Dermatitis
Antibiotic ointments, especially those containing neomycin,
are a common source of contact dermatitis. In patients not
previously sensitized, a recurrence of lid edema associated
CHAPTER 5
Blepharoplasty
83
Box 5-1
Problems Seen Shortly After Surgery
These problems can be expected to resolve quickly, in
1 or 2 weeks:
■
Chemosis, especially of the lower lateral lid (1 week)
■
Subconjunctival hemorrhage (3 weeks)
■
Separation of the lateral lower lid from the bulbar
conjunctiva (may be helped by surgical tape support in
the immediate postoperative period)
■
Tearing
■
Burning sensation
■
Visual blurring secondary to ointment
■
Edema of the lids
■
Pain (unusual beyond the first few postoperative hours,
may be felt with coughing or sneezing if a suspension
suture has been used)
■
Asymmetry secondary to swelling
■
Insensitivity of the upper lids noted when applying
makeup

with itching may develop after several days of ointment
usage. It is common for patients to continue to use the
ointment on the lids beyond the immediate postoperative
period for which it was intended. Discontinuing the
ointment and the use of cold compresses usually will
reverse the problem. Oral corticosteroids are used for the
most severe cases.
OTHER POSTOPERATIVE PROBLEMS
It is important that patients fully understand all of the
problems that will or will not be resolved with
blepharoplasty. Nonresolvable problems in the periorbital
area are the most frequent source of alienation between
the patient and surgeon. Although these problems are not
seen as complications from the surgeon’s viewpoint, they
may be considered a complication by the patient.
Malar Bags
The persistence of malar bags probably evokes the most
persistent postoperative complaints. Uninformed patients
always expect their removal as part of blepharoplasty or
find their relatively increased prominence following
removal of lid fat intolerable. The malar bag is always
seen as a stigma of aging and the patient is not easily
swayed from this conclusion. Preoperative discussion of
the problem is obviously imperative.
Animated Lateral Wrinkling
Lateral temporal and upper malar wrinkling that occurs
when the patient smiles is not changed by blepharoplasty.
It may become relatively more conspicuous. The patient
may have not had a preoperative awareness of the
problem or may be disappointed that the blepharoplasty
did not eradicate them. The patient will hold a mock
smiling appearance to demonstrate to the surgeon how
unhappy he or she is with the results of the procedure.
This condition must be evaluated and carefully discussed
with the patient before surgery. Botox treatment following
the surgery will definitely help the appearance.
Other preoperative sources of postoperative dissatis-
faction are persistent fine wrinkling, asymmetrical
palpebral fissures, asymmetrical brow position, persistent
scleral show, and persistent lid pigmentation.
AESTHETIC PROBLEMS FOLLOWING
BLEPHAROPLASTY
Persistence of Fat Pseudohernias
Persistent fat pseudohernias most commonly occur in the
lateral compartment. The compartment should be evaluated
preoperatively with the patient in extreme superolateral
gaze to determine the extent of the fat problem. This fat
compartment can be elusive. The author always deals
with this compartment first and goes back at the
conclusion of the procedure to check that more fat is not
present. Additional fat can be removed after a minimum
of 3 months of postoperative healing. It can be removed
via a transconjunctival approach or via a subciliary
approach. The thickness of scar tissue in the area and the
thickness of orbicularis muscle make the dissection
deceptively deep to remove the redundant fat.
Persistent fat in the medial and the central
compartments of the lower lid can usually be removed via
a transconjunctival approach.
Persistence of fat in the medial upper lid is also
common when there is an extraordinary amount of fat
preoperatively. The fat is removed via an incision in the
upper medial lid incorporating the original scar. Again,
subcutaneous scar tissue may make the excision more
difficult than the surgeon anticipates from the appearance
of the problem. Additional skin is excised only if there is
overlap of the skin edges following removal of the fat.
Persistence of Redundant Skin in the Lower Lid
The surgeon with limited experience should view this
problem not as a complication but as an acceptable
conservative consequence and an easily corrected alter-
native to a complication. It is difficult for even the most
experienced surgeon to attain consistent perfection in the
amount of skin removal. The surgeon should acknowledge
the problem when the patient inquires. Denying or
minimizing the significance of the redundancy could be
particularly upsetting to the patient in the short-term
postoperative period. Once the patient hears that the
redundancy is a minimal problem to “fine tune” once
healing has occurred, anxiety abates. The skin excess can be
dealt with by skin flap or minimal skin-muscle flap excision.
Persistent Redundant Skin of the Upper Lid
Most cases of minimal upper lid skin persistency are
secondary to a miscalculation of the brow position while
the patient was supine. The upward displacement of the
brow gives an erroneous measure of the amount of upper
lid that will require removal. This is especially true of the
lateral brow and skin. Persistent medial skin is more
common in the aged eye. The apparent skin excess seen in
the patient following secondary upper lid blepharoplasty
is noted only with eyes open. The patient and surgeon
may estimate the excess at 2 to 3 mm. However, with eyes
closed there is no excess and no skin can be grasped with
a forceps. These patients should not have additional skin
removed. It will lead to a lagophthalmos and may cause
the brows to descend.
Prominent Orbicularis Ridge Beneath the Lower Lid
Incision
This problem results when the preseptal orbicularis
muscle in the skin-muscle flap is elevated and overlaps
the pretarsal muscle. At the time of wound closure this
muscle overlap and consequent ridging should be obvious
84
Norman Pastorek • Andres Bustillo

and its presence anticipated. This problem can be
addressed following complete healing of the wound. A
small skin flap is elevated, the muscle is excised,
homeostasis is established, and the wound closed.
Scar Problems
Asymmetrical scars of the upper lid can be avoided if the
lid skin is marked under magnification with a very fine
pen. A wide pen mark can lead to a difference of 2 mm
between eyes in the final scar. It is important to remember
that the lower limb of the upper lid incision will always
elevate as the wound is closed. Also, if the natural lid
crease is at different positions when comparing the two
lids an adjustment must be made to bring the two upper
lid scars into symmetry.
Webbed Scars
A webbed scar can result from carrying the medial upper
lid incision beyond the medial canthal sulcus and onto the
nasal skin. Healing of this scar will elevate into a web. By
using the web as the central limb of a Z-plasty, the
problem can be eliminated.
Vertical Scars in the Lateral Lower Lid
Early texts on blepharoplasty advocated a subciliary
incision ending with an incision angled downward at the
canthus that allowed for the lid skin to be pulled laterally.
The skin laterally was excised as a Burrow’s triangle. This
always resulted in an obvious scar, which is almost
impossible to camouflage. This technique is not advised.
The lower lid incision should always be horizontal. The
direction of lid pull should always be vertical.
Scars in Mid Upper and Lower Lid
Scars in this area usually result from overlapping the skin
edges or wound separation during the initial healing
stage. The wound edges should be adjusted at the time of
suture removal and resutured.
Suture Marks
Suture marks occur when undue tension is placed on the
wound edges or when the sutures are allowed to remain
long enough to produce inflammation at the suture
placement sites. Monofilament sutures always cause less
inflammation than braided or absorbable sutures.
Removal of sutures by the third or fourth day is essential
in preventing suture marks.
Suture Tunnels and Incisional Milia
The use of any braided suture material encourages
epithelial growth along the path of the suture. The
resultant tunnel will trap epithelial debris. The solution is
to connect the two openings with a tiny blade incision.
Milia or small sebaceous cysts may result from blockage
of many eyelid sebaceous gland ducts along the suture
line or trapping of epithelial debris in the wound. Milia
appear as extremely superficial white skin inclusions;
sebaceous cysts are deeper. Either is easily resolved by a
minute pointed blade incision and expression of the
sebaceous material.
PROBLEMS OF LOWER LID POSITION
Scleral Show
Ideally, the lower lid margin contacts the corneal limbus.
Postoperatively the lid margin may be displaced 1 mm
inferiorly following conservative skin-muscle excision. It
can be seen following a skin-muscle blepharoplasty in
which no skin was removed, even when the preoperative
muscle tone was normal. This minimal scleral show or
almost scleral show is an equivocal complication,
especially since it is frequently seen as a normal variant.
Usually, this minute scleral show is considered as com-
plementary to the “wide-eyed” or “bright-eyed” youthful
appearance following blepharoplasty. The surgeon may
notice the minimal displacement of the lid, but is wise to
allow the patient to initiate and reference to it.
Moderate Scleral Show, Inferior Rotation of the Lid
Margin, and Ectropion
These complications may result from unrecognized lid
laxity preoperatively, excessive removal of lid skin, or
both. Indication for surgical intervention to reverse a
minimal scleral show is determined by the patient’s
perception of the problem. An optimistic approach to
some resolution of the problem over time is warranted.
Upward massage and closed-eye squints (to strengthen
the orbicularis) will produce some reversal of minor lower
lid displacement. If the visible sclera remains a focus of
dissatisfaction over a period of months, an additional
procedure, such as lateral orbicularis muscle suspension
following minimal elevation of skin and muscle, usually
produces a satisfactory elevation of the lid margin.
Moderate to severe scleral show, lateral lower lid
rotation (hound dogging), or ectropion following ble-
pharoplasty will require either horizontal lid shortening
alone when the complication is related solely to poor lid
tension or a horizontal lid shortening in combination with
skin grafting (and possible mucosal grafting) when the
skin deficit has caused a vertical shortening and tethering
of the lid. Certainly, prevention by careful preoperative
assessment and conservative surgery is preferable to
producing these complications.
PROBLEMS OF UPPER LID POSITION
Blepharoptosis
Postoperative lid ptosis either existed preoperatively and
was not recognized or is secondary to some interference
with the levator mechanism. The levator can be injured if
CHAPTER 5
Blepharoplasty
85

the fat dissection is carried deep in the central com-
partment or laterally where it becomes more superficial
and divides the lacrimal gland. Mild ptosis can persist for
several months following a blepharoplasty procedure that
includes fixing the lid skin to the levator just above the
tarsal border (supratarsal fixation). This procedure has
been fostered as a way to obtain a deep upper lid sulcus
but is not recommended by the authors.
Correction of a persistent ptosis should await
resolution of the healing process following blepharoplasty.
Lagophthalmos
The inability to completely close the palpebral fissure
following blepharoplasty is usually temporary. With normal
lacrimal function and a normal Bell’s phenomenon, it is
usually noticed when the patient sleeps and causes no
discomfort. It also may be seen as a slight tethering when
the patient’s head is back and looking downward. This
minimal lagophthalmos is most commonly seen following
secondary or tertiary blepharoplasty or when a primary
blepharoplasty is done in conjunction with a browlift or
foreheadlift. The constant tendency for the upper lid skin
to stretch as an accommodation to tension usually prevents
functional problems following generous excisions of upper
lid skin. However, there are limits to the ability of the upper
lid
to
accommodate.
The
cases
most
prone
to functional lagophthalmos problems are aggressive
secondary or tertiary blepharoplasty, aggressive forehead-
brow elevation in conjunction with upper lid blepharoplasty,
and cases in which an earlier eyelid trauma had produced a
lagophthalmos but went undetected before surgery.
At the completion of the upper lid wound closure in
primary blepharoplasty it is common to see a palpebral
fissure separation of up to 4 mm. Much of this observation
is due to activity of the levator while the orbicularis is
anesthetized. If the palpebral fissure separation is 5 to
6 mm, the possibility of lagophthalmos is real. Over-
estimation of skin excision can occur when the thin lid
marking is spread widely during four-point skin fixation
at the time of the skin incision. It is not difficult to replace
a strip of upper lid skin if over-resection is suspected at
the conclusion of the procedure. A strip of replaced skin
will be totally viable without the need for a pressure
bandage. The replaced skin will be totally unnoticeable in
several weeks.
HEMATOMA OF THE LIDS
Careful homeostasis at every point of the blepharoplasty
procedure has been persistently emphasized in this
chapter. Development of a hematoma in the immediate
postoperative period requires reopening the wound and
establishing homeostasis. In the first few hours following
surgery, hematoma must be differentiated from edema
and ecchymosis. These problems usually involve the lower
lid. Progressive enlargement, elevation of the lower lid
margin, a deep purple discoloration, and firmness to
touch are indications of the need for prompt exploration.
When the bleeding involves a vessel associated with fat
resection the vessel can be hard to find because of
extravasation and the fat stump retracting back into the
orbit. The time to control these vessels is at the moment
any bleeding is detected following release of the fat
stump. Slow development of ecchymosis and a pitting
edema just above the orbital rim is more likely edema
than a hematoma. Pitting edema is unlike the tense
fullness found with hematomas. This ecchymosis and
edema can be treated expectantly.
Lid hematoma discovered after the immediate
postoperative period should be allowed to liquefy (7 to 9
days) and be removed by needle aspiration and gentle
pressure expression. This may require several daily visits
for repeated treatments. Failure to remove the clot will
result in a firm nodular scar that may persist for many
months.
OVERCORRECTION OF FAT POCKETS
Excessive removal of fat from the lower lid can give a
cadaveric appearance as the concave effect of the lower
lid brings the bony rim into relief. In this chapter, the
authors have addressed repositioning of the medial fat in
those patients in whom a tear-trough deformity exists
medially. Certainly, in these cases, fat removal will worsen
the appearance. In the central and lateral lid the fat
removal is carefully executed so that the level is no more
than 1 mm below the bony margin. In the upright position
this will translate to a smooth transition between the bony
rim and the remaining central and lateral orbital fat.
If over-resection of fat is recognized intraoperatively,
orbital fat can be replaced in small amounts as needed.
These grafts of orbital fat have a high success rate. If the
over-resection is noted in the postoperative period,
injected fat from donor submental or abdominal regions
may be used in small amounts to elevate the depressed
area. Some experience is needed to produce a perfect
result. Fat injected in this area can move to an adjacent
area of the lid.
FUNCTIONAL PROBLEMS ASSOCIATED WITH
BLEPHAROPLASTY
Dry Eye Syndrome
Dry eye syndrome is the most common functional
problem following blepharoplasty. In most cases this is
related to exposure of the cornea in patients with a
subclinical dry eye syndrome. In patients with minimal
dry eye problems that have only a functional and no
anatomic component preoperatively, a perfectly per-
formed blepharoplasty should have little negative effect
on increasing the problem. But the surgeon can never know
86
Norman Pastorek • Andres Bustillo

if the dry eye syndrome might progress coincidentally
with the blepharoplasty. In patients with an anatomic
cause for the dry eye syndrome, if the anatomic com-
ponent can be corrected with the blepharoplasty, they may
experience an improved quality of life. If the anatomic
cause of the dry eye syndrome were worsened, then the
dry eye syndrome would become more severe. In these
patients, the easiest solution is not to operate. If the
patient is accepted as a surgical candidate, the most
conservative approach and procedure is indicated.
Patients with certain systemic diseases are known to be
prone to postoperative blepharoplasty dry eye syndrome;
these diseases include systemic lupus erythematosus,
scleroderma, Wegener’s granulomatosis, ocular pemphigoid,
Stevens-Johnson syndrome, ocular rosacea associated
with acne rosacea, and paresis or paralysis of the seventh
cranial nerve.
A history of any ocular symptom of itching, foreign
body sensation, burning, or mucoid secretion should
alert the examiner to a potential problem. Surgery in
these patients is performed only after ophthalmologic
consultation.
Once a patient presents with dry eye syndrome
following blepharoplasty the use of artificial tears,
nocturnal lubricants, and lid taping to ensure corneal
protection and the participation of an interested ophthal-
mologic colleague are all necessary over an extended
period.
Epiphora
Tearing following blepharoplasty is common in the
immediate postoperative course. Persistence of tearing
may indicate interference with the lacrimal canaliculi by
mechanical obstruction, distortion secondary to lateral
tension, or external rotation of the puncta out of the normal
tear collection pathway.
Examination of the outflow tract by an ophthal-
mologist experienced in this testing may be necessary to
evaluate obstruction and to assure an anxious patient that
there has been no injury to the duct system.
Surgery on the lacrimal system for epiphora should
follow only after 6 months of hopeful spontaneous
resolution.
ORBITAL HEMATOMA
In addition to the cessation of medication known to cause
operative bleeding, preoperative laboratory evaluation is
indicated with any history of easy bruising, previous
surgical bleeding, or a suspicious family history.
Intraoperative orbital bleeding is rare during
blepharoplasty. The method of lid anesthesia advised in
this chapter specifically avoids penetration of the orbital
septum with a needle to prevent intraorbital vessel injury.
Cautious intraoperative attention to homeostasis,
especially when fat is being excised, has been stressed.
Any recurrence of bleeding following cautery homeostasis
requires immediate attention before visualization of the
bleeding vessel is obscured by extravasation.
Orbital hematoma in the immediate postoperative
period is also a rare complication. The sudden intense
pain associated with lid swelling and proptosis is a
surgical emergency. Bleeding is usually arterial and
associated with lower lid blepharoplasty. Increasing
pressure within the orbit can damage the optic nerve and
lead to blindness. Any sudden increase in pain in the
immediate postoperative period must call attention to the
possibility of orbital hematoma. The wound should be
opened, clots expressed, and the vessel controlled. If the
orbital pressure causes any decrease in vision or if the
intraocular pressure approaches 80 mm Hg, a lateral
canthotomy and inferior cantholysis should be performed.
These procedures release the diaphragmatic confining
effect of the orbital septum and inferior lateral canthal
tendon and thus decompress the orbit, relieving pressure
on the central retinal artery and optic nerve. The wound
should be left open and small drains should remain in
place for 24 to 48 hours.
DIPLOPIA
The extraocular muscles are always at risk in
blepharoplasty. The superior oblique, inferior oblique,
and the medial rectus muscles can be damaged if medial
compartment fat is clamped without first specifically
observing that the fat is free of any muscle. Extraocular
muscles may be traumatized by cautery, by blind clamping
for homeostasis, or during direct cautery dissection of fat.
Fortunately, most visual disturbances from muscle
imbalances secondary to surgical trauma show progressive
improvement with eventual return to normal. Secondary
surgery to restore continuity of transected muscle or
balance by muscle resection may be required when the
injury is severe, but usually such surgery is recommended
only after several months of observation.
BLINDNESS
Blindness following blepharoplasty is an extremely rare
occurrence. In most cases other than orbital hematoma,
there has been no specific causal relationship between the
blepharoplasty and the loss of vision. The suspected cause
of the blindness—toxic amblyopia, idiopathic optic nerve
atrophy, retrobulbar optic neuritis, or optic nerve changes
secondary to systemic disease—seems beyond prevent-
ability. Still, the possibility of blindness following
blepharoplasty does exist. To the author’s knowledge, all
reported cases thus far have followed surgery on the lower
lids, and all have been unilateral. The moral issue of
performing blepharoplasty on a patient with one seeing
eye must be resolved by the individual surgeon and the
patient’s informed consent.
CHAPTER 5
Blepharoplasty
87

Future Considerations
Though the current surgical treatment of eyelid to
reverse the effects of aging and correct the effects of
heredity will continue to be important in the future,
newer procedures may be expected to either augment
or replace what we now see as state of the art. Many
modalities may augment or even replace surgical
treatment of the aging eyelid. Many light therapies of
various wavelengths have been available in the recent
past, and the progress in this area of medical skin
rejuvenation has been most remarkable. A steady
progression of lasers has proved effective in the
treatment of the eyelids. Intensive pulsed light, intensive
fluorescent pulsed light, LED (light-emitting diode)
therapy, and photodynamic therapies all have had some
recent profound effect on eyelid skin. Newer variations
and advances are inevitable. Treatment for collagen
induction by surgical needling, radiofrequency treatment,
and fine point laser penetration for collagen stimulation
all have had some positive effect on the eyelid skin. The
future for this type of treatment looks very positive. The
rapid development of dermatologic treatment by topical
application will undoubtedly continue to be of great
value in the treatment of the aging eye. There is no limit
to the possibilities. There exists the possible
breakthrough in gene therapy or hormonal therapy that
may applicable in this area of interest. The progressive
surgeon must be acutely aware of all that is new in this
area of expertise, but also must be aware of which new
modalities and products are of proven use and which are
being popularized by medical suppliers and
manufacturers creating public interest in the media before
the modalities are clinically validated.
SUGGESTED READING
1. Baker SR: Orbital fat preservation in lower lid blepharoplasty.
Arch Facial Plast Surg 1999;1:33-37.
2. Castanares S: Blepharoplasty for herniated infraorbital fat:
Anatomical basis for a new approach. Plast Reconstr Surg
1951;8:46.
3. Castanares S: Anatomy for a blepharoplasty. Plast Reconstr
Surg 1974;53:587.
4. Fagien S: Reducing the incidence of dry eye symptoms after
blepharoplasty. Aesthet Surg J 2004;24:464-468.
5. Honrado CP, Pastorek N: Longterm results of lower-lid
suspension blepharoplasty: A 30-year experience. Arch Facial
Plast Surg 2004;6:150-154.
6. Katzen LB: The history of cosmetic blepharoplasty. Adv
Ophthal Reconstr Surg 1986;5:89-96.
7. Jelks GW, Jelks EB: Preoperative evaluation of the
blepharoplasty patient: Bypassing the pitfalls. Clin Plastic
Surg 1993;20:213-223.
8. McCord CD, Boswell CB, Hest TR: Lateral canthal tightening.
Plast Reconstr Surg 2003;112:222-237.
9. Pastorek N: Upper lid blepharoplasty. Facial Plast Surg
1996;12:157-169.
10. Patipa M: The evaluation and management of lower eyelid
retraction following cosmetic surgery. Plast Reconstr Surg
2000;106:438-453 (discussion, 454-459).
11. Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New York:
Raven Press, 1985.
88
Norman Pastorek • Andres Bustillo

HISTORY
Even though the history of upper eyelid cosmetic ble-
pharoplasty dates back 2000 years, cosmetic blepharo-
plasty of the lower eyelids was not described until the
early 20th century.1 Julian Bourguet first described the
transconjunctival approach to excising herniated orbital
fat from the lower eyelid in 1924.2 Castanares made
significant contributions to the field by describing the fat
compartments of the upper and lower eyelids.3 In 1960,
Reidy described the skin-muscle flap approach, which
became the accepted lower blepharoplasty technique for
over 20 years.4 Although it still is one of the most
commonly performed techniques, the skin-muscle flap
procedure has a high rate of postoperative complications
such as lid retraction and ectropion.5 During the 1970s,
Parkes described the pinch technique for the treatment of
excess skin of the eyelid.6 He advocated excising excess
fat, when indicated, from an anterior approach, after the
pinch of skin was removed. In 1978, Furnas described
the use of the skin-muscle flap for lower eyelid festoons.7
In the 1980s, Tenzel and McCord described performing
lateral eyelid tightening procedures at the time of lower
lid blepharoplasty in patients with preoperative eyelid
laxity.8,9
The transconjunctival blepharoplasty (TCB) became
popular and accepted when Baylis reintroduced the tech-
nique in 1989 as a safe lower blepharoplasty approach
with minimal risk and complications.10 He advocated the
use of the pinch skin excision technique in conjunction
with TCB, when indicated. In 1992, Hamra repopularized
the skin-muscle flap approach.11 The TCB, however, con-
tinues to be the preferred lower blepharoplasty technique
for most ophthalmic plastic surgeons and many plastic
surgeons owing to its reduced incidence of complications.
PERSONAL PHILOSOPHY
There are many advantages of TCB over traditional
subciliary skin-muscle flap blepharoplasty. It is the
primary procedure we perform in our practice for fat
prolapse in the lower eyelid. The transconjunctival
approach avoids the need to incise the orbicularis oculi
muscle or the orbital septum, thus dramatically reducing
the risk of postoperative lid retraction and ectropion. By
not cutting the muscle, there is also much less bleeding
associated with the surgery. TCB also allows for a much
shorter surgical time. This lower blepharoplasty tech-
nique, when performed properly, is quick, easy, and gives
a natural, nonsurgical postoperative appearance.12
We believe that most lower blepharoplasty procedures
could be performed with some variation of the TCB. The
primary indication for TCB is blepharochalasis with
prolapse of the orbital fat pads anteriorly, causing an
unacceptable cosmetic appearance. This is generally
secondary to atrophy or loss of elasticity of the orbital
septum due to aging changes or chronic inflammation.
Also, certain patients genetically have fat prolapse and
will seek correction at a younger age.
A skin pinch blepharoplasty is performed in 50% of
the patients when excess skin is noted following fat removal
or at the preoperative examination. Failure to perform
a skin pinch when indicated will lead to further
pronouncement of the excess skin in the lower eyelid. Fat
repositioning can be performed in conjunction with TCB
in patients with significant tear-trough deformity. Lateral
canthopexy is indicated in the presence of a moderate
amount of laxity of the lower eyelid. Lateral canthoplasty
is required when patients present with severe lower eyelid
laxity or ectropion. Failure to address these conditions at
the time of TCB can result in iatrogenic postoperative
eyelid malposition.
Chemical peel or laser skin resurfacing can be
performed at the same time as TCB, but it is not our
preferred method. CO2 laser blepharoplasty is more time
consuming and has the potential risks of operating room
fires and damage to the globe and surrounding structures.
Furthermore, because some form of cautery is required on
the field to control bleeding anyway, we find it easier to
use cutting cautery for the entire procedure.
TCB is contraindicated in patients with “festoons” of
the lower eyelid or individuals with midfacial ptosis from
facial nerve paralysis. These patients are better treated
Transconjunctival Lower
Blepharoplasty
Harry Marshak, MD • Steven C. Dresner, MD
89
C H A P T E R S I X

with a traditional subciliary skin-muscle flap approach to
the orbital fat, with excision of excess skin and muscle,
along with canthoplasty to prevent eyelid retraction. They
may also require midface elevation.
ANATOMY
The lower eyelid can be divided into an anterior, middle,
and posterior lamella (Fig. 6-1). The anterior lamella
consists of skin and orbicularis oculi muscle. The orbital
septum comprises the middle lamella, while the posterior
lamella consists of the tarsal plate, lower lid retractors,
and conjunctiva. It is the tarsal plate that gives the eyelid
its strength and structure. Its height is approximately 4 to
5 mm and its thickness is about 1 mm. The lower lid
retractors, also known as the capsulopalpebral fascia,
originate from the tendon of the inferior rectus muscle
and insert on the inferior border of the tarsal plate. The
orbital septum originates at the inferior orbital rim as the
arcus marginalis and fuses with the capsulopalpebral
fascia just before its insertion on the tarsus. The orbital
septum serves as the anterior boundary for the orbital fat.
It is the weakening of the septum with age or recurrent
inflammation that allows for the anterior herniation of the
orbital fat.11,13
There are three fat pads in the lower eyelid: medial,
central, and lateral (Fig. 6-2). These fat pads are sur-
rounded and divided by fine septae. The medial and
central pads are divided by the inferior oblique muscle.
The central and lateral pads are divided by the inferior
arcuate ligament. The inferior oblique muscle originates
from the inferior medial orbital wall and traverses
through the lower eyelid to insert on the posterior lateral
aspect of the globe. Its anterior course divides the medial
and central fat pads of the lower eyelid. Extreme care
must be taken to avoid damage to this muscle during
blepharoplasty.
The caruncle is located next to the medial canthus
and represents the transition zone between the nonker-
atinized epithelium of the conjunctiva and the keratinized
epithelium of the skin. Incision of the caruncle should be
avoided during surgery because scarring in this area can
occur and can be unsightly and uncomfortable for the
patient. The canaliculus extends medially from the punc-
tum and carries tears into the lacrimal sac. The vertical
portion extends 2 mm inferior to the punctum. The
horizontal portion then extends 8 mm medially to the
lacrimal sac, running 1.5 to 2 mm inferior to the lid margin.
It is critical not to cut the canaliculus during surgery as
severe tearing problems will result. TCB incisions should
never extend medial to the punctum.
PREOPERATIVE ANALYSIS
A complete history and physical examination are
performed in the blepharoplasty consultation (see
90
Harry Marshak • Steven C. Dresner
Orbital septum
Orbicularis m.
Levator apononeurosis
Müllers m.
Tarsus
Tarsus
Capsulopalperbral
fascia
Septum
Figure 6-1 Eyelid cross-sectional anatomy. The lower eyelid can be
divided into an anterior, middle, and posterior lamella. The anterior lamella
consists of skin and orbicularis oculi muscle. The orbital septum forms the
middle lamella and the posterior lamella consists of the tarsal plate, lower lid
retractors, and conjunctiva. The lower lid retractors, also known as the
capsulopalpebral fascia, originate from the tendon of the inferior rectus
muscle and insert on the inferior border of the tarsal plate. The orbital
septum originates at the inferior orbital rim as the arcus marginalis and fuses
with the capsulopalpebral fascia just before its insertion on the tarsus
Figure 6-2 Preaponeurotic orbital fat pads. There are three fat pads in
the lower eyelid: medial, central, and lateral. The medial and central pads
are divided by the inferior oblique muscle. The central and lateral pads are
divided by the inferior arcuate ligament. The inferior oblique muscle is
almost always encountered as it divides the medial and central fat pads.
Middle fat pad
Medial fat pad
Lateral fat pad
Central fat pad
Medial fat
pad
Inferior oblique m.

Chapter 1). It is important to evaluate the degree of fat
prolapse in each of the three fat compartments of the
lower eyelid to determine a plan for appropriate surgical
excision. The patient can be laid back in the examination
chair, allowing gravity to retract the prolapsed fat pads
posteriorly. The patient can be given a mirror to show how
he or she might look if the fat pads are recontoured. An
assessment should then be made as to the presence and
degree of excess skin of the lower eyelid. This assessment
is best performed with the patient looking up, to give the
surgeon an idea of how much skin can be safely removed.
A snap test is also performed to evaluate lid laxity
(Fig. 6-3). The surgeon must determine all the pertinent
preoperative factors that can lead to postoperative lower
eyelid malposition at the time of the consultation.
With this information in hand, a surgical plan can
then be created. This would entail one of the following:
skin-muscle flap; TCB; TCB and skin pinch technique;
TCB and canthopexy; or TCB and canthoplasty.
SURGICAL TECHNIQUE
TCB can be performed under local anesthesia, monitored
anesthesia, or general anesthesia. The advent of laryngeal
mask airway (LMA) has made general anesthesia much
easier. The LMA avoids the need for endotracheal intu-
bation and muscle relaxants. It can be used in conjunction
with a propofol drip allowing for quick awakening and
recovery after the procedure. We believe LMA in con-
junction with a propofol drip provides the safest method
of anesthesia in most patients because it allows the
anesthesiologist to have control of the airway without the
need for muscle paralysis as required with an endotracheal
tube. Furthermore, because oxygen is being delivered to
the patient through the LMA and not via mask or nasal
cannula, the risk of operating room fire from electrocautery
or laser is greatly reduced.
The preferred local anesthetic is 1% lidocaine with
epinephrine mixed equally with 0.50% bupivacaine
with epinephrine and a 1/10 mixture of hyaluronidase.
The lidocaine and bupivacaine provide early and late
local anesthesia. The epinephrine provides hemostasis.
Hyaluronidase causes lysis of intercellular bonds, allowing
for better dispersion of the injection. This reduces the
amount of postinjection edema, allowing for better
manipulation of the tissue during TCB and skin pinch
procedures. Approximately 5 mL of the local anesthetic
mixture is injected into each lower eyelid transcon-
junctivally via the eyelid fornix. Only one injection site is
required. Gentle pressure is applied to facilitate spreading
of the solution and to prevent hematoma formation.
The surgery starts with the retraction of the lower lid
using a rubber-coated Desmarres retractor by the assistant
(Figs. 6-4 and 6-5). The globe is protected and retracted
posteriorly with the Jaeger lid plate. The coating of
Desmarres and Jaeger lid plate prevent possible
conduction of the electrocautery to the eyelid and globe.
The conjunctiva and lower eyelid retractors are then
incised 3 mm below the inferior border of the tarsal plate
with a Colorado tip electrocautery, which provides precise
cutting and coagulation. The incision should begin lateral
to the level of the punctum and extend the full length of
the lid.
The dissection is begun centrally, to avoid the inferior
oblique muscle, and performed in layered fashion through
the conjunctiva and lower eyelid retractors (Fig. 6-6).
Care is taken to avoid cutting too deep until the inferior
oblique muscle can be identified. A cotton-tip applicator
is used to ballot the conjunctiva and lid retractors
inferiorly and allow the fat pads to reposition anteriorly.
During incision and dissection of the lower eyelid, care
must be taken to avoid perforation of the skin anteriorly.
Perforation usually occurs when the surgeon is unclear as
to the level of dissection.
Once the fat pads are identified, gentle posterior
pressure on the globe is applied to allow the fat pads to
prolapse forward. Each fat pad is gently teased anteriorly
with forceps. The base of the fat pad is cauterized to
contract the fat posteriorly and to provide hemostasis.
The amount of fat to be debulked is then excised with
cutting cautery. Only a moderate amount of fat should be
excised from each fat pad to prevent a skeletonized
appearance of the orbit postoperatively. The excised
segment of each fat pad is set aside so that an equal
amount of fat can be taken from the corresponding area
on the contralateral eyelid. If an asymmetry was noticed
CHAPTER 6
Transconjunctival Lower Blepharoplasty
91
Figure 6-3 Snap test. The lower eyelid is pulled downward and
outward. The rate of return of the eyelid is measured before the patient
blinks. The lid laxity is directly related to the length of time it takes for the
lower eyelid to return to its normal position. The patient has severe laxity if
the lower eyelid does not return to normal position prior to the patient
blinking.

92
Harry Marshak • Steven C. Dresner
A
B
C
D
E
F
Figure 6-4 Intraoperative photos of transconjunctival lower blepharoplasty. The conjunctival fornix is exposed and the initial transconjunctival incision
is made (A). The lid is retracted with a coated Desmarres retractor and the eye is protected with a lid plate. The incision is made with the Colorado tip bovie.
The fat pad is exposed as the conjunctiva and lower lid retractors are incised (B). A cotton-tip applicator is used to ballot the tissue and expose the fat (C).
The lateral, central and medial fat pads are exposed (D). The fat is excised with cutting electrocautery (E). Skin is grasped between two forceps during the
pinch blepharoplasty (F).

during the preoperative evaluation, a disproportionate
amount of fat should be excised. At the end of the case,
the conjunctiva and lower lid retractor flap is draped
superiorly into its anatomic position, covering the wound.
Suturing of the wound is not necessary.
Fat transposition can be performed in conjunction
with TCB in patients with tear-trough deformity (Fig.
CHAPTER 6
Transconjunctival Lower Blepharoplasty
93
6-7). TCB is performed normally, with debulking of the
central and lateral fat pads. A pocket is dissected at the
medial orbital rim, either in the subperiosteal or
suborbicularis plane. The medial fat pad is then placed
into the pocket as a pedicle flap. It is positioned over the
rim to correct the tear-trough deformity. Transcutaneous
sutures are used to hold the pedicle in position.14
G
H
Figure 6-4 Continued. The skin stands up by itself after pinching (G). The skin is then excised with scissors (H).
Figure 6-5 View of the transconjunctival incision. Desmarres and Jaeger lid retractors are used to expose the conjunctiva of the lower eyelid (A and B).
The conjunctiva and lower eyelid retractors are then incised 3 mm inferior to the inferior border of the tarsal plate with Colorado tip electrocautery. The
incision should begin lateral to the level of the punctum and extend the full length of the lid.
A
B

94
Harry Marshak • Steven C. Dresner
A
B
C
Figure 6-6 Lower eyelid dissection. The dissection is begun centrally, to avoid the inferior oblique muscle, and performed in layered fashion through
the conjunctiva and lower eyelid retractors (A). A cotton-tip applicator is used to ballot the conjunctiva and lid retractors inferiorly and allow the fat pads to
reposition anteriorly (B). Once the fat pads are identified, gentle posterior pressure on the globe with the Jaeger retractor is applied to allow the fat pads to
prolapse forward. Each fat pad is gently teased anteriorly with forceps. Only a moderate amount of fat should be excised from each fat pad.
Figure 6-7 Fat repositioning for tear-trough deformity. Tear-trough
deformity is an indentation in the nasojugal fold. This area can be partially
improved with fat repositioning during the transconjunctival lower
blepharoplasty. A pocket is dissected at the medial orbital rim, usually in the
subperiosteal plane (A). The medial fat pad is then placed into the pocket
over the orbital rim as a pedicled vascularized flap (B and C).
A
B