Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

C H A P T E R 4 8
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Fat Grafting in Plastic Surgery
Edward I. Chang
Key Points
Harvesting techniques have not been proven to increase fat graft take; however, the yield can vary
based on handheld suction or power-assisted suction. In general, the less manipulation of the fat
graft, the better the viability.
Fat graft take following injection is never 100%, and therefore the process of fat grafting often needs
to be repeated.
The technique for injection is critical for maximizing outcomes and minimizing complications.
Fat grafting into the breast following oncologic resection has not been associated with increased risks
for tumor recurrence.
Although early animal studies demonstrated potential benefits of adipose-derived stem cells in
wound healing, the true clinical application of these has yet to be recognized.
The technique of autologous fat injection has grown in popularity over the years and has permeated
nearly all aspects of plastic surgery. The first recorded use of fat grafting was performed in 1893 by
Gustav Neuber who transferred autologous fat to correct periorbital scars. 1,2 However, since its first
description, the use of autologous fat was fraught with controversy particularly when injecting into the
breast. Concerns regarding breast cancer and possibilities of compromising detection of breast cancer
prompted the American Society of Plastic and Reconstructive Surgeons to issue a formal statement
cautioning the routine use of lipofilling. 3 Since this declaration, over a decade has passed before the
concept witnessed a rebirth with the Coleman technique that ushered an emergence of novel applications
and growing technologies by expanding its use in all aspects of plastic and reconstructive surgery. 4-8
One of the defining characteristics of the field of plastic surgery is that it is not limited to a particular
anatomic region and as such, the application of autologous fat grafting has also found utility in all areas
of the body. The use of autologous fat, now termed fat grafting or lipofilling, has been described for
cosmetic augmentation and rejuvenation of the face as well as reconstruction of facial deformities and for
both cosmetic and reconstructive procedures over the entire body including the breast, gluteal region,
and extremities. Although there are a number of synthetic tissue substitutes available, autologous fat
represents one of the most popular fillers available to plastic and reconstructive surgeons.
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Indications
Even before the American Society of Plastic Surgeons issued a new declaration regarding the safety of
autologous fat transfer, using autologous fat as a filler was growing in popularity. 9 The concept of fillers
is well accepted in the field of plastic surgery, and autologous fat is simply another filler that should be in
the armamentarium of plastic surgeons. For most patients, there are ample donor sites with sufficient
adiposity to provide injectable fat that can be obtained with low cost and also provides the added benefit
of contouring and sculpting the donor site. The use of autologous fat grafting focuses on harvesting fat
from one donor site and transferring the fat to a desired location for volume augmentation. Not
surprising, fat grafting has found broad applications both in the cosmetic arena as well as in
reconstructive operations. Plastic surgeons have employed lipofilling in facial rejuvenation and lip and
cheek augmentation. 10-12 However, its applications and successes in facial plastic surgery have since been
expanded into cosmetic augmentation of other anatomic regions, particularly the gluteal region, the calf,
and even for penile enlargement. 13-16
Not surprisingly, the concept of lipofilling as a natural filler and volume enhancer was immediately
adopted for breast augmentation. Studies have demonstrated long-term efficacy in maintaining breast
volume using autologous fat grafting. 17-19 The use of negative pressure systems such as BRAVA to
augment vascularization and engrafting of autologous fat has also been reported, although it has not been
widely adopted. 20,21 Lipofilling of the breast introduces a number of considerations and concerns that are
unique to the breast. There is little doubt that the fat grafting can add volume to the breast, which
obviates the need for a foreign body and the other potential complications associated with a breast
implant. However, fat grafting does introduce questions regarding the ability to monitor and image the
breast for malignancy and especially in the setting of breast reconstruction.
Nonetheless, the use of autologous fat grafting has found some of its greatest uses in plastic surgery not
only in breast reconstruction but also in reconstruction of head and neck defects as well as for burns and
scars. 22-24 The most widely used reconstructive application for fat grafting is for breast reconstruction. 25
Studies have demonstrated excellent volume retention, efficacy, and safety of autologous fat grafting for
breast cancer patients without increased risks of recurrence. 26-29 Further studies focusing on patient-
reported outcomes have also confirmed high patient satisfaction with lipofilling both as an adjunct in
mastectomy reconstruction as well as for reconstruction of partial mastectomy defects in the setting of
breast conservation. 29-31
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Surgical Technique
Given the increasing utilization of autologous fat grafting, there are a number of variables that are
involved in maximizing the take of the fat graft as well as acquiring the best quality fat for injection.
These variables can be classified as technical variables and patient-
 related variables; however, within
these broader categories, there are a number of components that also need to be considered including
tumescent solution, harvest technique, processing technique, and injection technique. From the
perspective of patient factors, there are also a number of considerations including the most optimal donor
site and body habitus include body mass index, comorbidities, and smoking. 32,33
Studies examining the wetting solution demonstrated a negative impact on adipocyte viability with the
use of lidocaine. Because most grafts undergo a processing step that often includes washing the harvested
fat, the effects of lidocaine are mitigated. 34 Another study found contradictory findings and
demonstrated no impact of lidocaine or epinephrine or prilocaine on fat graft viability. 35 The technique
for aspiration and injection has also been examined as a factor that could potentially impact fat graft
viability to exert mechanical stress and pressure on the adipocytes. Studies found aspiration via handheld
or with mechanical suction and centrifugation have little impact on fat graft viability; however, injection
via slow, controlled pressure to minimize the shear stress and forces on adipocytes does improve
adipocyte viability. 36,37 These additional steps are important to separate the adipocytes from the other
constituents comprising the lipoaspirate. Although some believe there are benefits in preserving the
potential growth factors contained in aspirate, there are also nonviable cells that have undergone cell lysis
during the harvesting, liquefied fat, and hematocyte component comprised of blood cells and other
contaminants. Others believe that one of the most valuable components of the lipoaspirate is the stromal
cell fraction containing the adipose derive stem cells and other pluripotent stem cells that can enhance
tissue recovery or augment fat graft take. A number of products and devices that will be described in the
subsequent section have since come to market to streamline this process to maximize both efficiency and
fat graft yield.
Aside from the technical aspects of autologous fat grafting, studies also aimed to examine patient-related
factors that may influence graft yield and viability. Patient factors such as age have been found to have an
impact on fat graft viability, and in general, younger patients tend to have superior fat viability compared
to older patients. Interestingly, obesity was also found to be a factor; although a larger amount of fat can
theoretically be harvested from a patient with a higher body mass index, the viability of the fat is actually
compromised in obese patients. Finally, the ideal location of the donor site has also been an area of
tremendous debate and investigation. Although some studies demonstrated the greatest yield and
viability of adipocytes from the medial thigh, larger and more comprehensive studies have not found any
significant benefits comparing one donor site to another. 38-40
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Fat Graft Processing
Given the increasing popularity and applications for autologous fat transfer and lipofilling in plastic
surgery, it is not surprising that commercialized products have emerged on the market to improve the
adipocyte yield, enhance adipose-derived stem cell concentration, and maximize the efficiency of the
process. In its original description, the autologous fat was harvested via syringe aspiration and then
separated from the other constituents using centrifugation. 40,41 Most studies examining this process found
this technique to be simple and atraumatic to the adipocytes; however, this is a relatively labor-intensive
method for harvesting autologous fat graft. A number of other devices have been introduced to the
market to streamline the harvesting and processing of the fat graft and have demonstrated tremendous
potential with promising results. Some devices can be attached to power-assisted suction that decreases
the energy expenditure in obtaining the fat graft and allow the fat graft to be washed while contained
within a closed system to minimize risks of contamination or exposure to air. Another device utilizes
centripetal forces to isolate the injectable fat from other contaminants and constituents of the lipoaspirate.
One device passes the aspirate through a filtration system that separates the fat from the other
components. All systems claim to provide superior adipocyte viability, fat graft yield, and stem cell
composition, but no unbiased studies are available that have demonstrated superior outcomes compared
to the traditional handheld syringe aspiration and centrifugation technique. Nonetheless, the increasing
industry involvement in device development is a clear indication of the growing popularity and potential
of lipofilling and fat grafting. 41-43
Another trademark device that has been marketed to improve the take and engraftment of the injected fat
cells is the BRAVA system. This device is solely promoted for lipofilling of the breast and is based on the
premise that negative pressure applied to a recipient bed enhances the vascularity of the recipient site by
promoting angiogenesis, which will support large volumes of fat. The product has merit because negative
pressure wound dressings have been shown to increase neovascularization of wound, promoting
granulation tissue and maximizing the wound healing process.
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Complications
As with any surgical procedure, there are potential complications, and autologous fat grafting is no
different. Although sound judgment and proper technique are paramount in avoiding complications,
complications can occur either in the recipient site or the donor site. With regards to the recipient site,
there are always risks of fat necrosis as fat retention following fat grafting is never 100%. Studies vary
tremendously based on the percentage of viable adipocytes following fat grafting, but range from 50% to
70%. 44,45 The remaining injected fat often is reabsorbed; however, in other circumstances, it can lead to oil
cysts or fat necrosis that can be palpable and cause discomfort or deformity for patients. This can be
particularly worrisome in patients undergoing breast reconstruction because a palpable mass in the
breast may require further diagnostic testing and potentially biopsies to confirm the mass is benign. 46,47
Although this can also occur in the face, the most dreaded complication following lipofilling of the face is
blindness, which results if the fat graft is injected under pressure or while advancing the cannula leading
essentially to a fat embolism in the ophthalmic or central retinal artery. 48,49 For these reasons, the fat graft
should always be injected without excessive force and always while withdrawing the cannula.
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Controversial Issues
As previously discussed, the stromal cell fraction of the lipoaspirate contains adipose-derived stem cells
that can have tremendous potential benefits predominantly shown in animal models demonstrating
improved angiogenesis and fat graft retention. Anecdotally, reconstructive surgeons noted improvements
in tissue quality particularly following radiation and perhaps dramatic improvements in facial
rejuvenation. These remarkable results can be attributed to the stem cell component of the autologous fat
graft but remain to be proven.
Another area of great concern regarding lipofilling is the potential risk that adipose-derived stem cells
and the associated angiogenesis can impact recurrence in patients who have undergone autologous fat
transfer for breast cancer reconstruction. Complications with fat necrosis and oil cysts may mimic breast
cancer, and imaging studies and a biopsy may be warranted to rule out recurrent disease. However, no
studies have demonstrated a direct correlation with lipofilling and breast cancer recurrence. Large case-
controlled studies comparing patients who underwent fat grafting to a control cohort of breast cancer
patients demonstrated lipofilling to be a safe and effective technique in breast reconstruction without any
association with breast cancer recurrence. 50-52
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Summary
Fat grafting is a powerful tool for volume augmentation both in cosmetic as well as reconstructive
plastic surgery.
Although a number of different techniques are available for harvesting and processing of the
harvested fat, none are proven to provide superior outcomes or increased fat graft viability or fat
graft take.
There is no clinical evidence to correlate increased risks of breast cancer recurrence with lipofilling or
autologous fat grafting into the breast.
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Questions
1. A 54-year-old woman underwent fat grafting to her breasts and had the fat graft harvested from
her abdomen, hips, and flanks using tumescent fluid and suction-assisted cannulas. The patient
wakes up from anesthesia and is disoriented, with slurred speech, and complaining of vertigo and
tinnitus. What is the most appropriate next step in treatment?
a. Electrocardiogram
b. Administer intravenous intralipid
c. Ativan intravascular injection
d. Morphine intramuscular injection
e. Computed tomography (CT) scan of the head with and without contrast
2. A 62-year-old woman with a prior mastopexy and abdominoplasty undergoes an upper outer
quadrantectomy for ductal carcinoma in situ and completed postoperative radiation 8 months
earlier. She has a noticeable contour deformity from the resection in the upper pole of the breast. She
is interested in reconstruction. Which is the most appropriate means of reconstruction?
a. Lipofilling
b. Shaped silicone breast implant
c. Pedicle thoracodorsal artery perforator flap
d. Free superficial inferior epigastric artery flap
e. Free omental flap
3. A 65-year-old man presents for facial rejuvenation and undergoes a rhytidectomy with a
superficial musculoaponeurotic system plication, upper lid blepharoplasty, and autologous fat
grafting. The fat is harvested from the abdomen, love handles, and flanks using tumescent solution.
In the recovery room, the patient is complaining of severe abdominal pain. On examination, the pain
is diffuse with guarding but no appreciable mass effect or significant bruising. What is the most
appropriate next step in management?
a. Observation and trial of clear liquids
b. Narcotic pain medication
c. Abdominal binder and compression dressing
d. CT scan with and without intravenous contrast
e. Emergent reoperation
4. A 43-year-old man presents to the emergency center 1 day after autologous fat grafting to his
calves for augmentation. The fat was harvested from the abdomen, hips, and flanks and processed
through the Coleman technique and injected into both calves. A total of 120 cc was injected into the
right side and 90 cc was injected into the left calf. The patient is having severe pain in both calves,
more on the left than the right. There is postoperative swelling without evidence of a hematoma,
with paresthesias and strongly palpable pulses on in both the dorsalis pedis and posterior tibial of
both feet. What is the next most important step in the management of the patient?
a. Operating room for fasciotomies
b. Operating room for liposuction of calves
c. Interventional Radiology angiogram and angioplasty
d. Ultrasound to rule out deep vein thrombosis
e. Compression wrapping and elevation
5. A lawyer contacts you regarding a patient who underwent lipofilling to augment her breasts and
is very displeased with her result 5 months following the operation. The lawyer states that there is
asymmetry and lack of fullness in the upper portions of both breasts with insufficient cleavage to the
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patient’s liking. The lawyer examined the operative notes and states that the fat graft was harvested
from the abdomen, flanks, and upper arm and that 280 cc were injected into both breasts. The patient
was reasonably pleased with the initial result but now feels that the breasts are not much different
than prior to her fat grafting. What is the best explanation for the findings?
a. The plastic surgeon did not use tumescent solution.
b. A stem cell augmenting system should have been used.
c. The fat graft should have been harvested from the medial thigh.
d. A breast implant is always needed to supplement the procedure.
e. Some fat graft failed to survive the transfer.
6. A 54-year-old woman underwent bilateral skin-sparing mastectomies for a right-sided breast
cancer treated with adjuvant chemotherapy and hormonal therapy. She then had reconstruction with
shaped silicone implants and presents for autologous fat grafting to provide more upper pole
fullness. Two years following three rounds of lipofilling to the upper pole, the patient was found to
have a fluid collection with a nodule measuring 2.1 cm in the upper pole of the right breast. An
ultrasound-guided biopsy demonstrates atypical cells with enlarged irregular nuclei and high
mitotic figures. What is the diagnosis?
a. Fat necrosis from fat grafting
b. Oil cysts from resorbed fat graft
c. Breast implant–associated anaplastic large cell lymphoma
d. Recurrent invasive ductal carcinoma
e. Second primary invasive lobular carcinoma
1. Answer: b. The clinical presentation for this patient suggests that she had tumescent solution–
assisted liposuction, which typically contains epinephrine and lidocaine in an isotonic solution. The
symptoms presented are consistent with lidocaine toxicity. The next step in treatment is
administration of intravenous intralipids to prevent the progression of toxicity, which includes
seizures and arrhythmias.
2. Answer: c. For a partial mastectomy defect that involves a significant portion of the breast,
lipofilling is an option but would likely require multiple rounds of autologous fat grafting to achieve
a reasonable result, which is less optimal for a 62-year-old woman with prior radiation. A shaped
implant would likely not provide her with the fullness in the upper pole, and a free tissue transfer
would be an aggressive reconstruction for a partial mastectomy defect. Healthy vascularized tissue
in the form of a local pedicle flap can provide sufficient volume in a single stage operation without
the need for a free tissue transfer.
3. Answer: d. A patient with severe pain following liposuction for autologous fat grafting using the
abdominal donor site should not be managed conservatively with observation or pain medication.
Pain that is out of proportion to physical examination should raise the concern for puncturing the
abdominal wall with a possible vascular injury or bowel injury. The most appropriate next step
would be an imaging study to look for free air or active bleeding. Taking the patient back for
exploration is likely necessary, but a CT scan should be performed prior to a return to the operating
room.
4. Answer: a. The clinical picture presented is most consistent with compartment syndrome of the
lower extremities following autologous fat grafting to the calves. The symptoms of pain, paresthesias
with persistent pulses, is most consistent with compartment syndrome, which warrants immediate
decompression with fasciotomies to prevent further ischemic damage and morbidity.
5. Answer: e. There is always some resorption of the fat graft following lipofilling as the take is never
100%. The different modalities for processing, use of wetting solutions, and the fat graft donor sites
have not proved to be relevant in maximizing fat graft survival and take. The loss of volume from the
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initial postoperative period can be because of a combination of resolution from swelling and
resorption of a portion of the fat graft.
6. Answer: c. There is no evidence to suggest that lipofilling is associated with recurrent breast cancer
or an increased risk for developing breast cancer. A patient who has had shaped textured silicone
implants and develops a delayed seroma with an associated mass should be suspected of having
breast implant–associated anaplastic large cell lymphoma. The diagnosis is confirmed with staining
for CD30, and the patient should be referred appropriately for proper treatment.
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References
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Coleman, SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 suppl):108S-120S.The study was one of the
earliest studies that brought the resurgence of lipofilling and fat grafting into the modern era. While described much earlier, the concept of fat grafting
gained in popularity with increasing applications, research, and innovations following based on the findings and contribution of this paper.
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more recent studies have confirmed the findings of the ASPS task force, this study remains a landmark review of the emerging technology and safety of
fat grafting.
Pezeshk, RA, Stark, RY, Small, KH, et al. Role of autologous fat transfer to the superficial fat compartments for perioral rejuvenation. Plast
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Marten, TJ, Elyassnia, D. Fat grafting in facial rejuvenation. Clin Plast Surg. 2015;42(2):219-252.
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stem cells. Plast Reconstr Surg. 2015;135(4):999-1009.
Sinno, S, Chang, JB, Brownstone, ND, et al. Determining the safety and efficacy of gluteal augmentation: a systematic review of outcomes
and complications. Plast Reconstr Surg. 2016;137(4):1151-1156.
Rosique, RG, Rosique, MJ, De Moraes, CG. Gluteoplasty with autologous fat tissue: experience with 106 consecutive cases. Plast Reconstr
Surg. 2015;135(5):1381-1389.
Mundinger, GS, Vogel, JE. Calf augmentation and reshaping with autologous fat grafting. Aesthet Surg J. 2016;36(2):211-220.
Kang, DH, Chung, JH, Kim, YJ, et al. Efficacy and safety of penile girth enhancement by autologous fat injection for patients with thin
penises. Aesthet Plast Surg. 2012;36(4):813-818.
Coleman, SR, Saboeiro, AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg. 2007;119(3):775-785.
Kerfant, N, Henry, AS, Hu, W, et al. Subfascial primary breast augmentation with fat grafting: a review of 156 cases. Plast Reconstr Surg.
2017;139(5):1080e-1085e.
Serra-Mestre, JM, Fernandez Peñuela, R, Foti, V, et al. Breast cleavage remodeling with fat grafting: a safe way to optimize symmetry and to
reduce intermammary distance. Plast Reconstr Surg. 2017;140(5):665e-672e.
Khouri, RK, Eisenmann-Klein, M, Cardoso, E, et al. Brava and autologous fat transfer is a safe and effective breast augmentation alternative:
results of a 6-year, 81-patient, prospective multicenter study. Plast Reconstr Surg. 2012;129(5):1173-1187.The use of large volume fat grafting
and lipofilling for breast reconstruction was popularized and introduced using the BRAVA system. The concept has not only been adopted by numerous
other plastic surgeons all over the world, but is responsible for the increasing use in augmentation of other areas of the body. Although this is not the
most common or widely used technique for breast reconstruction, the BRAVA device and authors are pioneers in lipofilling increasing the public
awareness and interest in fat grafting.
Del Vecchio, DA, Bucky, LP. Breast augmentation using preexpansion and autologous fat transplantation: a clinical radiographic study. Plast
Reconstr Surg. 2011;127(6):2441-2450.
Haddock, NT, Saadeh, PB, Siebert, JW. Achieving aesthetic results in facial reconstructive microsurgery: planning and executing secondary
refinements. Plast Reconstr Surg. 2012;130(6):1236-1245.
Fredman, R, Edkins, RE, Hultman, CS. Fat grafting for neuropathic pain after severe burns. Ann Plast Surg. 2016;76(suppl 4):S298-S303.
Klinger, M, Caviggioli, F, Klinger, FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24(5):1610-1615.
Khouri, RK Jr, Khouri, RK. Current clinical applications of fat grafting. Plast Reconstr Surg. 2017;140(3):466e-486e
Mirzabeigi, MN, Lanni, M, Chang, CS, et al. Treating breast conservation therapy defects with brava and fat grafting: technique, outcomes,
and safety profile. Plast Reconstr Surg. 2017;140(3):372e-381e.
Niechajev, I, Sevćuk, O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg. 1994;94(3):496-506
Katzel, EB, Bucky, LP. Fat grafting to the breast: clinical applications and outcomes for reconstructive surgery. Plast Reconstr Surg.
2017;140:69S-76S.
de Blacam, C, Momoh, AO, Colakoglu, S, et al. Evaluation of clinical outcomes and aesthetic results after autologous fat grafting for contour
deformities of the reconstructed breast. Plast Reconstr Surg. 2011;128(5):411e-418e.
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Bennett, KG, Qi, J, Kim, HM, et al. Association of fat grafting with patient-reported outcomes in postmastectomy breast reconstruction.
JAMA Surg. 2017;152(10):944-950.
Komorowska-Timek, E, Turfe, Z, Davis, AT. Outcomes of prosthetic reconstruction of irradiated and nonirradiated breasts with fat grafting.
Plast Reconstr Surg. 2017;139(1):1e-9e.
Sinno, S, Wilson, S, Brownstone, N, Levine, SM. Current thoughts on fat grafting: using the evidence to determine fact or fiction. Plast
Reconstr Surg. 2016;137(3):818-824.
Nguyen, A, Pasyk, KA, Bouvier, TN, et al. Comparative study of survival of autologous adipose tissue taken and transplanted by different
techniques. Plast Reconstr Surg. 1990;85(3):378-386;
Moore, JH Jr, Kolaczynski, JW, Morales, LM, et al. Viability of fat obtained by syringe suction lipectomy: effects of local anesthesia with
lidocaine. Aesthet Plast Surg. 1995;19(4):335-339.
Livaoğlu, M, Buruk, CK, Uraloğlu, M, et al. Effects of lidocaine plus epinephrine and prilocaine on autologous fat graft survival. J Craniofac
Surg. 2012;23(4):1015-1018.
Lee, JH, Kirkham, JC, McCormack, MC, et al. The effect of pressure and shear on autologous fat grafting. Plast Reconstr Surg.
2013;131(5):1125-1136.
Rohrich, RJ, Sorokin, ES, Brown, SA. In search of improved fat transfer viability: a quantitative analysis of the role of centrifugation and
harvest site. Plast Reconstr Surg. 2004;113(1):391-395.
Geissler, PJ, Davis, K, Roostaeian, J, et al. Improving fat transfer viability: the role of aging, body mass index, and harvest site. Plast Reconstr
Surg. 2014;134(2):227-232.
Strong, AL, Cederna, PS, Rubin, JP, et al. The current state of fat grafting: a review of harvesting, processing, and injection techniques. Plast
Reconstr Surg. 2015;136(4):897-912.
Gir, P, Brown, SA, Oni, G, et al. Fat grafting: evidence-based review on autologous fat harvesting, processing, reinjection, and storage. Plast
Reconstr Surg. 2012;130(1):249-258.With the increasing use of fat grafting in all aspect of plastic and reconstructive surgery, there is an increasing
need and interest in optimizing outcomes. There are a number of important details that can impact fat graft yield and take, and few studies have
provided such a comprehensive analysis of the different factors. References 39 and 40 are landmark studies in demonstrating which factors are
important in maximizing fat graft yield and retention.
Fisher, C, Grahovac, TL, Schafer, ME, et al. Comparison of harvest and processing techniques for fat grafting and adipose stem cell isolation.
Plast Reconstr Surg. 2013;132(2):351-361.
Aronowitz, JA, Ellenhorn, JD. Adipose stromal vascular fraction isolation: a head-to-head comparison of four commercial cell separation
systems. Plast Reconstr Surg. 2013;132(6):932e-939e.
Zhu, M, Cohen, SR, Hicok, KC, et al. Comparison of three different fat graft preparation methods: gravity separation, centrifugation, and
simultaneous washing with filtration in a closed system. Plast Reconstr Surg. 2013;131(4):873-880.
Harrison, BL, Malafa, M, Davis, K, Rohrich, RJ. The discordant histology of grafted fat: a systematic review of the literature. Plast Reconstr
Surg. 2015;135(3):542e-555e.
Herly, M, Ørholt, M, Glovinski, PV, et al. Quantifying long-term retention of excised fat grafts: a longitudinal, retrospective cohort study of
108 patients followed for up to 8.4 years. Plast Reconstr Surg. 2017;139(5):1223-1232.
Kim, HY, Jung, BK, Lew, DH, Lee, DW. Autologous fat graft in the reconstructed breast: fat absorption rate and safety based on sonographic
identification. Arch Plast Surg. 2014;41(6):740-747.
Parikh, RP, Doren, EL, Mooney, B, et al. Differentiating fat necrosis from recurrent malignancy in fat-grafted breasts: an imaging
classification system to guide management. Plast Reconstr Surg. 2012;130(4):761-772.
Carruthers, JD, Fagien, S, Rohrich, RJ, et al. Blindness caused by cosmetic filler injection: a review of cause and therapy. Plast Reconstr Surg.
2014;134(6):1197-1201.
Kim, SM, Kim, YS, Hong, JW, et al. An analysis of the experiences of 62 patients with moderate complications after full-face fat injection for
augmentation. Plast Reconstr Surg. 2012;129(6):1359-1368.
Kronowitz, SJ, Mandujano, CC, Liu, J, et al. Lipofilling of the breast does not increase the risk of recurrence of breast cancer: a matched
controlled study. Plast Reconstr Surg. 2016;137(2):385-393.
Petit, JY, Maisonneuve, P, Rotmensz, N, et al. Fat grafting after invasive breast cancer: a matched case-control study. Plast Reconstr Surg.
2017;139(6):1292-1296.
Cohen, O, Lam, G, Karp, N, Choi, M. Determining the oncologic safety of autologous fat grafting as a reconstructive modality: an
institutional review of breast cancer recurrence rates and surgical outcomes. Plast Reconstr Surg. 2017;140(3):382e-392e.
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C H A P T E R 4 9
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Forehead and Brow Rejuvenation
Alan Matarasso and Darren M. Smith
Key Points
The forehead should be considered in any complete evaluation of the aging face.
Changes in skin and muscle tone, volume, and activity contribute to the appearance of aging.
Several techniques are available to treat this region.
Successful treatment of the aging brow begins with an individualized, problem-based approach.
Goals in brow rejuvenation can be summarized as restoring eyebrow height, maximizing symmetry,
and minimizing the visual impact of rhytids.
Forehead rejuvenation can be a powerful addition to other procedures such as a facelift for global
facial rejuvenation.
It is common practice to focus more on the aging of the lower two facial thirds than on the uppermost
facial third during an assessment of the aging face. This bias is further reflected by a parallel imbalance in
the literature. This disproportionate distribution of clinical and academic interest is unfortunate, given
the critical role the brow plays in interpersonal communication and overall facial appearance. Aging of
the brow (progressive descent, deepening of rhytids, and upper lid hooding) classically connotes an
angry or tired appearance. 1 Indeed, the eyes have been called the window of the soul, and as coined by
the senior author, the brow is the curtain of emotion. Restoration of the brow to a rejuvenated state
reverses this stigmatized default faces and instead frees the individual to express joy, surprise, and
confusion with their upper facial third. Additionally, the proper position and tensioning of the brow has
a significant effect on the appearance of adjacent structures. Consider, for example, the effects of a heavy
brow on exaggerating dermatochalasis of the upper eyelids. It has also been noted that sagging glabellar
skin can make the nose appear foreshortened; this phenomenon, in combination with a nasal tip
elongated with age, can give the illusion of a nose situated too low on the face. 2
Several approaches to the aging brow have evolved since the early 20th century, ranging from the least
invasive (neurotoxin) to the most invasive (open brow lift). In our experience, invasiveness is not a proxy
for effectiveness in brow lifting. Instead, the practitioner should assess the anatomical basis for the
patient’s presenting complaint and identify the appropriate intervention or set of interventions using a
problem-based treatment plan. This plan must consider not only the brow but also surrounding
structures to ensure that the upper facial third is rejuvenated as a cohesive expressive unit; unresolved
dermatochalasis, for example, will undercut the most perfectly executed brow lift. Conversely, the
forehead should be considered when assessing other elements of the upper face. An isolated upper
blepharoplasty performed in the presence of brow ptosis can over time worsen that problem, as frontalis
tone decreases with the elimination of the compensatory stimulus provided by hanging upper lid skin,
resulting in increased brow ptosis.
Moreover, the proper approach must account not only for the patient’s pathology but also for his or her
desired outcome. For example, a publicly photographed female may benefit from more aggressive muscle
interruption or resection to achieve a smoother brow; in contrast, an actor may be better off preserving
more motility (less aggressive muscle intervention) to maximize remaining facial expression at the
expense of a smoother brow. 2
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History
Aesthetic surgery of the brow has evolved considerably over time, as chronicled in detail by Paul 3 and
summarized here. The earliest description of surgical brow rejuvenation can be credited to Passot in 1919
with his direct forehead skin excision designed to correct brow ptosis. 3 The idea of frontalis and
corrugator modification to decrease muscle activity and thereby efface overlying dynamic rhytids gained
favor in the 1960s. 4,5 Pitanguy expanded on these principles in the late 1970s and described his approach
to coronal brow lifting, entailing wide exposure with muscle-weakening maneuvers and orbital rim soft-
tissue release. 6 As more sophisticated techniques evolved, the indications for brow rejuvenation
procedures expanded to include glabellar hyperactivity, transverse brow rhytids, upper eyelid aesthetics,
and lateral brow laxity. 7 Until the mid-1990s, the coronal approach remained the form of brow lifting of
choice. The mid-to-late 1990s saw the introduction of the endoscopic brow lift. 8,9 The open coronal
procedure, though successful, lost favor primarily because of patient and surgeon resistance to the long
incision and other issues, such as the potential for alopecia. Additionally, an increase in the popularity
and effectiveness of neurotomies which addressed two of the more frequent complaints of patients
seeking upper forehead rejuvenation—glabellar and forehead rhytids—further eroded the utility of open
coronal techniques. 10 Additionally, brow lift procedures in general have always engendered notable
reluctance by patients concerned with creating a look of surprise.
With interest waning in the coronal approach, practitioners began focusing on improving internal fixation
methods for use with the endoscopic technique. Brow lifting went on to inspire more disagreement over a
standard technique than most other facial rejuvenation operations. The endoscopic brow lift ultimately
created some consternation with many surgeons, as definitive strategies to obtain fixation were not
forthcoming, concerns over longevity of its results lingered, and the inability to apply this method to the
high-forehead patient persisted.
In the context of these issues, alternative approaches to brow rejuvenation, including the lateral
subcutaneous temporal brow lift (LTL) came to fruition. Our technique evolved from a biplanar
dissection in a subperiosteal and subcutaneous plane before taking its current form as a lateral
subcutaneous brow lift. Ultimately, the authors found the lateral temporal lift (with or without a
corrugator excision as indicated) to offer the benefits of previous approaches with reduced morbidity,
shorter incisions, no fixation device issues, reliable brow elevation, and consistent longevity.
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Anatomy
The normal anatomy of the forehead can be discussed in terms of skin, muscle, the innervation of that
muscle, and fat. The skin of the brow is quite thin and tightly adherent, facilitating its transmission of the
actions of the underlying muscles of facial expression. Surface landmarks are useful in assessing the
degree of pathology present. The intersection of a vertical line drawn at the alar base and the supraorbital
rim represents the medial extent of the brow. The brow extends laterally to an oblique line extending
from the alar base through the lateral canthus. According to classic standards of beauty, the brow peaks
(0.5–1 cm above the rim in women and at the height of the rim in men) at the junction of the middle and
lateral third of its width, approximately at the lateral limbus. 1 By some standards in fashion, it may be
more desirable for the brow to reach its vertical peak closer to the lateral canthus. 11
The forehead musculature demonstrates the same agonist-antagonist configuration found throughout the
body. 9 In the brow, these opposing forces take the form of the depressors (corrugators, procerus,
orbicularis oculi) acting as a unified force to draw the brow inferiorly whereas the elevator (the frontalis)
works to raise the brow. It is subtle variations in the strength of contractions that result in varying net
vectors of skin motion and thereby the multitude of facial expressions produced or enhanced by brow
appearance. The muscles of the brow are innervated by the temporal branch of the facial nerve, and this is
the only motor nerve at risk during a brow lifting procedure. The temporal branch runs in the
temporoparietal fascia and can be avoided by adhering to the deep temporal fascia during dissection and
remaining more than 1.5 cm above the lateral orbital rim. Staying in the subcutaneous plane while
dissecting the forehead avoids any possibility of motor nerve injury. The first two branches of the
trigeminal nerve, the supraorbital nerve and the supratrochlear nerve, supply sensory innervation to the
brow. The supraorbital nerve exits the supraorbital foramen in the midpupillary line. The supraorbital
foramen can often be palpated and marked on the skin to assist in efforts to avoid the nerve during
dissection. The supratrochlear nerve fibers are found in the substance of the corrugator muscle
approximately 8 to 12 mm medial to the supraorbital nerve (Figure 49.1). The supraorbital nerve plays a
far more significant role in brow innervation than the supratrochlear nerve. In the lateral temporal brow
lift, these nerves should not be at risk.
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FIGURE 49.1 This dissection demonstrates the relationship of the corrugator (being dissected with the scissor) to the
supraorbital nerve (at the fingertip). The retractor is at the nasal root.
There is minimal adiposity in the brow. Therefore, fat plays little role in the aging process of the brow,
and volume redistribution does not enter into the discussion of brow rejuvenation techniques. This
observation does not apply laterally as the brow gives way to the temple. Temporal hollowing can indeed
play a significant role in aging the face, and volumetric restoration of this region with techniques ranging
from autologous fat grafting to injection of various fillers can be an important part of a comprehensive
rejuvenation strategy for the upper facial third. Additionally, the lateral temporal fat pad can descend
and contribute to a ptotic brow appearance.
Finally, with reference to endoscopic brow lift techniques, mention must be made of the sentinel vein, a
structure that lies 1.5 cm superior and lateral to the lateral canthus. 12 The sentinel vein represents an
important landmark, as it can be used to establish the position of the temporal branch of the facial nerve
(1 cm lateral and inferior to the sentinel vein) as well as the temporal line of fusion at the temporal crest. 1
This anatomic background accounts for the changes in appearance associated with the aging brow. As
gravity and the relatively stronger depressor muscles overpower the weaker brow elevators, a frown-
muscle imbalance results in glabellar creases and central forehead furrows. 13 Compensatory frontalis
hypertrophy may result, yielding transverse forehead rhytids. Therefore, it is interesting to note that
whereas in the neck and midface it is skin laxity and loss of adipose volume that are the dominant forces
in the aging process, muscle activity and imbalance of that activity over time play a greater role in the
appearance of the brow in aging. 9 This explains why unlike antiaging procedures of the face and neck
which are aimed at excising excess skin and repositioning or revolumizing underlying fat, brow
rejuvenation procedures are focused more on rebalancing the underlying muscle equilibrium and
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repositioning ptotic tissue. This distinction does begin to fade further from the midline, as the frontalis
muscle is attenuated at its lateral extent. This anatomical fact, together with the weaker attachments of
skin to periosteum found in this region, accounts for early lateral brow laxity. 14,15 This laxity manifests as
lateral orbital hooding and contributes to the formation of crow’s feet. 1
Also of note, one must also consider the equilibrium that is present between the elevators and depressors
of the brow when performing an evaluation for dermatochalasis. If the frontalis is being relied upon to
compensate for upper eyelid ptosis, and an upper blepharoplasty is performed without regard for the
state of the brow musculature, the appearance of the brow can be adversely impacted. An isolated upper
blepharoplasty in the presence of brow ptosis may remove the stimulus for frontalis-based brow
elevation and exacerbate glabellar furrows and eyebrow malposition because of unbalanced depressor
activity. The presence of compensated brow ptosis must also be ruled out prior to performing an upper
blepharoplasty. The examiner should be alerted to the presence of this condition when there are
significant horizontal forehead rhytids at rest. These lines are indicative of a requirement for frontalis
contraction to maintain brow height at baseline. The diagnosis of compensated brow ptosis is confirmed
by having the patient close his or her eyes. If the frontalis relaxes and the brow drops, compensated brow
ptosis is present. In addition, the patient should be examined for upper eyelid ptosis, which frontalis
hyperactivity can camouflage. Isolated brow lifting procedures can unmask unrecognized upper eyelid
ptosis and contribute to an appearance of deep set eyes.
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Management of the Aging Brow
Correctable problems of the aging brow include forehead rhytids, glabellar creases (corrugator muscle
hypertrophy), lateral brow laxity, and brow ptosis (including congenital and senescent subtypes).
Congenital brow ptosis is beyond the scope of this chapter, which is addressed in discussions of
congenital facial palsies. The senior author previously introduced an algorithm designed to aid in
decision-making for brow rejuvenation from a perspective that considers the gamut of possible surgical
and nonsurgical interventions with respect to the underlying anatomical problem at hand. 7 The
following review of approaches to the aging brow takes its origins from the thought processes initially set
forth in this algorithm. The options discussed below range from noninvasive (neuromodulators) to open
approaches.
Neuromodulators are indicated in the treatment of isolated dynamic rhytids of the brow. There is also a
preventive role for neuromodulators in deterring the eventual formation of static brow rhytids. The three
neuromodulators currently in common use are botulinum toxin serotype A and include Botox
(onabotulinumtoxin A, Dublin, Ireland), Dysport (abobotulinumtoxin A, Galderma, Lausanne,
Switzerland), and Xeomin (incobotulinumtoxin A, Merz, Frankfurt, Germany). These products are all
based on botulinum toxin’s capacity to prevent nerves from releasing the neurotransmitter acetylcholine.
Acetylcholine is the neurotransmitter responsible for mediating contraction of the muscles of facial
expression. The inhibition of acetylcholine release, in turn, weakens contraction of the target muscles and
thereby softens overlying dynamic rhytids.
In the upper face, neuromodulators are most frequently used at the glabella, the forehead, and the lateral
canthal lines, or crow’s feet. Vertical glabellar rhytids are caused by horizontal contractions of the
corrugators, whereas transverse forehead rhytids are caused by vertical contractions of the frontalis, and
radial lateral canthal rhytids are caused by concentric contractions of the orbicularis oculi. Decreasing
motion in the underlying muscles with a neuromodulator softens the appearance of the corresponding
rhytids running perpendicular to the axis of muscle contraction. The frozen appearance of complete
paralysis is generally to be avoided, whereas measured softening of these rhytids is preferable. Though
recommended doses by region are widely published, the key to an excellent outcome lies in
understanding an individual patient’s desires, prior experience, and understanding the patient’s anatomy
well enough to deliver a dose compatible with inducing a degree of paralysis consistent with those
desires. One technique useful for beginning injectors is to employ a planned two-stage injection
technique. At the first stage of treatment, a low dose of the desired neuromodulator is injected. The
patient is seen back for a second visit once the initial dose has had time to reach maximal efficacy (10 days
to 2 weeks is a reasonable window for this visit). The need for an additional neuromodulator is assessed
at this visit, taking the patient’s degree of residual muscle activity and his or her desired outcome into
account. An additional neuromodulator is administered at this second stage as needed on the basis of this
examination. The practitioner then knows the total dose required to reach a desired outcome for a given
patient. This dose can be repeated in one session generally at 3 months later when the first treatment
(delivered in two sessions) has worn off. Although botulinum toxin’s effectiveness generally wears off
gradually, efficacy is more rapidly lost in males.
It is critical to ensure appropriate dosing and placement of neuromodulators to achieve the desired effect
and avoid adverse outcomes. Perhaps, the most common complication to occur with administration of a
neuromodulator to the forehead is the dropped brow in which the eyebrows sag and brow (and often upper
eyelid) ptosis is exaggerated. This results from placement of either too much neuromodulators, a proper
dose of neuromodulator placed too far inferiorly, or a combination of both scenarios such that the
frontalis is no longer properly tensioned to maintain the brow at an appropriate height.
When brow ptosis is present, a surgical brow lifting procedure is required. The concept of a chemical
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brow lift produces minimal brow elevation and is based on deactivating the depressors (corrugators,
orbicularis oculi, and central frontalis muscles) while preserving sufficient muscle function to allow
emotive facial expression. An open brow lift represents a reliable method to gain wide exposure and
comprehensively address the anatomical problems responsible for aging brow appearance. It is generally
done via a coronal (gull-wing) approach or modified centrally to the widow’s peak hairline (anterior
approach) in patients with a wide forehead. The latter approach will improve the appearance of a wide
forehead. The choice of incision in an open brow lift is determined by the patient’s forehead morphology.
In patients with a wide forehead, defined as greater than 5 to 6 cm from hairline to brow, a hairline
incision is used. In patients with normal brow width, a coronal incision is utilized and excess tissue is
excised from the hair-bearing scalp.
Markings are made with the patient sitting upright. We use the landmarks noted above to mark the
location of the nerves (motor and sensory), followed by the planned incision. It is helpful to mark the
rhytids because they can become effaced by infiltration with local anesthetic solution, changes in position,
decreased tone with anesthesia, and swelling. Either sedation or general anesthesia with infiltration of
local anesthesia is utilized. We do not shave or trim any scalp hair. The incision is made as marked to the
subgaleal plane in the central scalp and to the deep temporal fascia lateral to the line of temporal fusion.
The scalp flap is elevated anteriorly using a combination of scalpel and finger dissection. Electrocautery is
used cautiously in the vicinity of hair follicles. This plane of dissection is continued until 3 cm above the
supraorbital rim, at which point the subperiosteal plane is sharply accessed with a knife and periosteal
elevator, thereby staying deep to the temporal branch of the facial nerve. The supraorbital nerves are
preserved. The corrugator muscles are resected carefully while dissecting and preserving the
supratrochlear nerves. In patients with hyperactive frontalis muscles, a wedge of frontalis is marked and
excised between the supraorbital nerves to preserve underlying fat. Connell has stated that it is important
to perform this maneuver evenly and avoid completely denuded regions interposed with areas of
untouched muscle, which would result in “islands of immobility surrounded by angry seas of muscle
hyperactivity.” The anterior flap is carefully draped over the incision to determine the appropriate degree
of resection. The wound is closed with staples in the temporal hair and in two layers centrally.
With increasing familiarity and better anatomical understanding, the endoscopic brow lift evolved into
an operation most believe capable of addressing the same issues that were previously the exclusive
domain of open procedures. The endoscopic approach is especially suited to individuals with a low brow
position, as the forehead with properly toned musculature can be expected, after wide elevation, to
redrape to a favorably cephalic position with disruption of the depressors and incision of the periosteum
for brow elevation. Further advantages of this technique are attributed to patients who are more apt to
accept this procedure with its reduced scar burden, decreased risk of scalp paresthesias, and diminished
postoperative edema. 1,16
Many variations on this procedure have evolved. That presented here is the technical sequence preferred
by the authors. 9 Again, markings are made with the patient sitting upright. The nerves, planned
incisions, and rhytids can be marked. Local anesthesia is injected with or without the use of systemic
anesthesia. The first incision is oriented vertically (this orientation minimizes the chance of nerve injury)
in the hairline at the midline of the nose and is 3 cm in length. This is carried to the subgaleal plane. An
incision is made on each side of the scalp lateral to the course of the supraorbital nerves, approximately at
the superior extent of the temporalis muscle. These are carried down to the deep temporal fascia. This
approach allows access to the forehead subgaleal plane as dissection is carried medially across the
temporal crest. After the incisions are made, the dissection is continued anteriorly from each port to 2 cm
proximal to the superior orbital rim and posteriorly as far as necessary to permit the requisite amount of
skin redraping. The pockets from each dissection are then connected with one another. The subperiosteal
plane is entered sharply, and the endoscope is then introduced into the cavity with overhead lights
turned off. Periosteal elevators are employed to develop a subperiosteal plane. The muscles comprising
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the depressor apparatus including the orbicularis oculi, the procerus, and the corrugators are sectioned
with a Takahashi forceps aided by electrocautery and external traction sutures. The eyebrow-supraorbital
rim relationship is used as a reference as the skin is mobilized and redraped cephalically.
Several modalities of skin fixation have been described, encompassing both external (e.g., bolster sutures)
and internal (e.g., fibrin glue or calvarial fixation) techniques. Calvarial fixation techniques include
cortical tunnel fixation and anchoring devices. In the cortical tunnel technique, a guarded drill is used to
create monocortical tunnels (Figure 49.2) through which sutures are passed to anchor the scalp flap.
Anchoring devices, alternatively, are attached to the calvarium and provide a point of fixation for the
scalp flap (e.g., MicroAire’s [Charlottesville, Virginia] Endotine device). Though multiple strategies of
scalp flap fixation exist, most would agree that the periosteum reattaches to the mobilized scalp flap
rapidly regardless of the method of fixation that is employed.
FIGURE 49.2 Cross-section of the outer table of the frontal bone. A guarded drill is used to create tunnels (direction of drilling
indicated by arrows) that are angled such that they connect and allow for passage of a suture.
Although the endoscopic brow lift effectively addresses central forehead and glabellar rhytids, lateral
ptosis and crow’s feet are not as readily addressed with this procedure. 1 Therefore, a conscious effort
must be made in designing these procedures to provide maximal lateral lift when indicated. Moreover, a
high hairline or an acutely sloped forehead can make this procedure technically difficult to perform
because of the curvature of the skull and the necessary vectors. 2 The degree of muscle disruption
necessary to achieve the desired result can be more difficult to judge with the endoscopic approach,
predisposing those starting with the procedure to be prone to corrugator over-resection and resultant
widening of the space between the eyebrows.
The lateral temporal subcutaneous brow lift has evolved to become the authors’ technique of choice for
managing the aging lateral brow. The lateral temporal lift can be used reliably to achieve a significant
improvement in brow ptosis with minimal morbidity. A medial subgaleal brow lift with corrugator
muscle excision and procerus disruption can be done alone or in combination with a lateral temporal
brow lift in patients with a low medial brow.
Lateral temporal brow lift markings are designed as follows. In the sitting position, the midline of the
forehead is marked (the widow’s peak is a good landmark if present). The midpupillary line,
approximately 3.5 cm lateral to the midline, is then marked. After an extensive discussion of incision
placement based on patient preference, brow pattern, hair density, and forehead width, an elliptical
incision is demarcated that is 4 to 5 cm in length and 2 to 2.5 cm in width. The closer the incision is to the
eyebrow and less ptotic the brow, the narrower is the planned excision. Conversely, the more ptotic the
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brow or farther away the incision is from the eyebrow, the wider the excision (Figure 49.3). The long axis
of the ellipse generally runs parallel to the brow and is verified prior to surgery with the patient in the
sitting position.
FIGURE 49.3 The curved arrows and corresponding hashed lines indicate possible incision positions. The red arrow and
incision correspond to positioning in a lower brow (<5–6 cm), whereas the blue arrow and incision correspond to positioning in a
higher brow (>5–6 cm). The ellipse (green) represents the skin excision, and the purple shading represents the area of
undermining.
At the beginning of the procedure, the field is injected with a lidocaine and epinephrine-containing
solution. The ellipse is preexcised (Figure 49.4). Dissection begins sharply toward the brow and ensues by
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finger-assisted (wrapped in gauze) dissection medially, laterally, and inferiorly. Scissor dissection is used
as necessary at points of adherence. The dimensions of the dissection are confirmed, and hemostasis is
obtained by electrocautery. The pocket is packed with a lidocaine with epinephrine-soaked gauze, and
the procedure is repeated on the opposite side. At this point, we return to the first side and reinspect for
hemostasis. After hemostasis is ensured, we prefer to spray Tisseel fibrin glue (Baxter International,
Deerfield, IL) into the pocket, although this is not an essential component of the procedure (Figure 49.5).
The wound edges are approximated, and gentle pressure is held on the flap for 3 minutes to allow the
Tisseel to set. The wound is then closed with 3-0 monoderm Quill (Surgical Specialties Corporation,
Tijuana, Mexico) and interrupted Prolene (Ethicon, New Brunswick, NJ) sutures. No dressing is used
(Figure 49.6).
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FIGURE 49.4 The skin ellipse has been preexcised.
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FIGURE 49.5 Fibrin glue is sprayed into the pocket, exposed here with a lighted retractor.
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FIGURE 49.6 The appearance of the lateral temporal lift incision (arrows) immediately after closure.
We have found this procedure to be reliable and safe over a decade-long experience encompassing more
than 400 consecutive patients undergoing lateral temporal lifts as described here (Figures 49.7 and 49.8). 17
We have followed these patients for between 1 and 10 years. Those treated with this procedure were
uniformly pleased with the results. The lateral temporal lift produces long-lasting results, with only one
patient in this series requiring correction of relapse. Scar revisions were necessary in two patients. Late
fluid collections containing serous fluid and old blood were identified in 3% of patients. These collections
generally did not require a return to the operating room and could be aspirated in the office. Skin
ischemia and necrosis occurred in two patients after the procedure. The incision from the lateral temporal
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lift heals quite well, and the resulting scars are often nearly imperceptible.
FIGURE 49.7 A 42-year-old woman is shown before and after a lateral temporal lift and upper and lower blepharoplasty.
FIGURE 49.8 A 70-year-old woman is shown before and after a lateral temporal lift, facelift, and upper blepharoplasty.
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Summary
The aging forehead represents something of a paradox in aesthetic surgery. The upper facial third is
critically important in facial expression, and the rhytids and ptosis associated with aging dramatically
impact the ability of the brow to accurately express an individual’s intended emotions. However, despite
the forehead’s important role in emotional communication and its great susceptibility to the passage of
time, rejuvenation of the brow can be overlooked or minimized in consultations for facial rejuvenation.
Similarly, the frequency with which the aging brow and strategies for its management are addressed in
the literature pales in comparison to explorations of senescence and rejuvenation of the face’s lower two-
thirds. There are numerous options available to the surgeon looking to treat the aging brow. This includes
surgical procedures and injectables that can be efficacious in addressing brow rhytids. These strategies
may be used to address the aging brow alone or as part of a broader approach to facial rejuvenation.
Ultimately, as in all procedures designed to reverse the changes of facial aging, it is an understanding of
regional anatomy, the forces at play responsible for age-related changes, and the individual patient’s
desired outcome that are the ingredients essential to choosing and implementing an appropriate
treatment plan for brow rejuvenation and achieving patient satisfaction.
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Questions
1. Performing an isolated upper blepharoplasty in the context of brow ptosis is inadvisable primarily
because:
a. The brow ptosis will remain uncorrected.
b. The brow ptosis may worsen.
c. Compensated lower lid ptosis may be unmasked.
d. A Spock-like configuration of the brows may result.
e. It is difficult to accurately plan the upper lid skin excision in the setting of brow ptosis.
2. Deep horizontal forehead rhytids at rest should alert the examiner to the possible presence of:
a. Chronic frontalis over-treatment with botulinum toxin
b. Dermal pathology requiring evaluation by a dermatologist
c. Congenital brow furrows
d. Compensated brow ptosis
e. A hyperhydrotic brow
3. The temporal branch of the facial nerve can be most practically avoided during brow rejuvenation
procedures by:
a. Adhering to the deep temporal fascia during dissection
b. Dissecting in the temporoparietal fascia
c. Dissecting in the superficial temporal fascia
d. Using a nerve stimulator during dissection
e. Meticulous intramuscular dissection
4. In a lateral temporal brow lift, a patient with a narrower brow:
a. Should always have a hairline incision
b. Should always have an incision in the hair-bearing scalp
c. Should have their incision placed based on a conversation with the patient to assess his or her
preference and an evaluation of brow pattern, hair density, and forehead width
d. Is more likely to have hypertrophic corrugator muscles
e. Is less likely to have hypertrophic corrugator muscles
5. The supratrochlear nerves:
a. Run in the substance of the frontalis muscles and are the dominant source of brow sensation
b. Run in the substance of the frontalis muscles and the supraorbital nerve is the dominant
source of brow sensation
c. Run in the substance of the corrugator muscles and are the dominant source of brow sensation
d. Run in the substance of the corrugator muscles and the supraorbital nerve is the dominant
source of brow sensation
e. Have a sensory and motor component
1. Answer: b. Hanging upper lid skin can provide a compensatory stimulus of frontalis contraction.
In the ptotic brow, eliminating this compensatory stimulus may cause frontalis relaxation and
worsening of the brow ptosis. There is no relevant phenomenon called compensated lower lid ptosis.
A Spock-like appearance results from unbalanced disruption of medial brow elevators, not isolated
upper lid blepharoplasty.
2. Answer: d. Significant horizontal brow rhytids at rest could indicate that the frontalis is
chronically contracting to compensate for a ptotic brow. This condition should be tested for in
individuals with this presentation prior to upper blepharoplasty. The test is performed by having the
patient close his or her eyes. If the brow drops, compensated brow ptosis is present. Chronic
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botulinum treatment would likely smooth brow rhytids. Dermatologic evaluation is not necessitated
by this condition. Congenital brow furrows are not a commonly recognized occurrence. A
hyperhydrotic brow is not related to the presence of brow rhytids.
3. Answer: a. The temporal branch of the facial nerve runs in the temporoparietal fascia
(synonymous with the superficial temporal fascia). Dissecting in either of these planes risks damage
to the nerve. Adhering to the deep temporal fascia during dissection is safe as the nerve runs
superficial to this plane. Utilizing a nerve stimulator during dissection is unnecessary for this
procedure given the clear anatomical relationships. The temporal branch of the facial nerve does not
have an intramuscular course in the field of a brow lift.
4. Answer: c. Although a patient with a narrower brow would likely benefit from an incision in the
hair-bearing scalp, the factors mentioned in answer c must be taken into account. The degree of
hypertrophy of the corrugator muscles is not related to the width of the brow.
5. Answer: d. The supratrochlear nerves run through the corrugators and should be avoided during
corrugator resection. The supraorbital nerve is the dominant source of brow sensation. The
supratrochlear nerve does not have a motor component.
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References
Codner, MA, Kikkawa, DO, Korn, BS, Pacella, SJ. Blepharoplasty and brow lift. Plast Reconstr Surg. 2010;126:1e-17e.This excellent article
provides an anatomy-based approach to identifying problems and their solution in managing signs of aging in the upper facial third.
Connell, BF, Lambros, VS, Neurohr, GH. The forehead lift: techniques to avoid complications and produce optimal results. Aesthetic Plast
Surg. 1989;13:217-237.
Paul, MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg. 2001;108:1409-1424.
Marino, H, Gandolfo, E. Treatment of forehead wrinkles. Prensa Medica Argentina. 1964;51:1368.
Uchida, JI. A method of frontal rhytidectomy. Plast Reconstr Surg. 1965;35:218-222.
Pitanguy, I. Section of the frontalis-procerus-corrugator aponeurosis in the correction of frontal and glabellar wrinkles. Ann Plast Surg.
1979;2:422-427.This seminal article clearly addresses the importance of muscle release in treating brow rhytids. The author’s technique and experience
are discussed.
Matarasso, A, Hutchinson, OH. Evaluating rejuvenation of the forehead and brow: an algorithm for selecting the appropriate technique. Plast
Reconstr Surg. 2000;106:687-694.The aging brow is addressed from a functional anatomical perspective, and the management algorithm presented
offers an excellent framework for considering strategies to address the changes of aging in this region.
Matarasso, A, Matarasso, SL. Endoscopic surgical correction of glabellar creases. Dermatol Surg. 1995;21:695-700.
Matarasso, A. Endoscopically assisted forehead-brow rhytidoplasty: theory and practice. Aesthetic Plast Surg. 1995;19:141-147.
Matarasso, A, Terino, EO. Forehead-brow rhytidoplasty: reassessing the goals. Plast Reconstr Surg. 1994;93:1378-1389.
Daniel, RK, Tirkanits, B. Endoscopic forehead lift: an operative technique. Plast Reconstr Surg. 1996;98:1148-1157.
Trinei, FA, Januszkiewicz, J, Nahai, F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg.
1998;101:27-32.
Duchenne de Boulogne, GB. The Mechanism of Human Facial Expression. 
 New York, NY: Cambridge University Press; 1990.
Gasperoni, C, Salgarello, M, Gargani, G. Subperiosteal lateral browlift and its relationship to upper blepharoplasty. Aesthetic Plast Surg.
1993;17:243-246.
Lemke, BN, Stasior, OG. The anatomy of eyebrow ptosis. Arch Ophthalmol. 1982;100:981-986.
Mackay, GJ, Nahai, F. The endoscopic forehead lift. Operative techniques. Plast Reconstr Surg. 1995;2:137-144.
Matarasso, A, Smith, DM. The lateral temporal subcutaneous brow lift: a method for consistent, stable brow rejuvenation. ISAPS News.
2016;10:35.This article presents the technique of brow rejuvenation preferred by the authors of this chapter.
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C H A P T E R 5 0
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Blepharoplasty
Sheri Slezak and Katherine E. Duncan
Key Points
Functional assessment of the aging eye must check for visual acuity, eyelid ptosis, dry eyes, history
of refractive surgery, asymmetry, thyroid disease, and eyelid tone.
Cosmetic assessment of the aging eye should include the skin, brow, cheek, and tear trough as well
as upper and lower lid skin redundancy, fat prominence, and muscle function.
Upper lid blepharoplasty includes skin resection and limited or no muscle and fat excision. Fat is
preserved or added rather that resected to avoid superior sulcus hollowing. Ancillary brow
procedures may be needed.
Lower lid blepharoplasty is performed through transcutaneous or transconjunctival incisions and
resects minimal skin. It resects, repositions, releases, or adds fat, with lid support techniques as
needed. The eyelid-cheek junction is modified as indicated.
Ancillary procedures to orbital rejuvenation may include browlift, onabotulinum toxin, peels, laser,
or fillers.
Complications following upper lid surgery are rare but include lagophthalmos and dry eye. Lower
lid surgery carries more risk, including ectropion, corneal abrasion, exposure keratopathy or dry
eyes, diplopia, and chemosis. A retrobulbar hemorrhage can result in pain, proptosis, and vision loss
and is a surgical emergency.
The eyes are a focal point of beauty and expression: art and literature is replete with images that allude to
the importance of the eye. Saint Jerome said that “The face is the mirror of the mind, and eyes without
speaking confess the secrets of the heart,” Henry Thoreau wrote that “The eye is the jewel of the body,”
and Ralph Waldo Emerson said that “One of the most wonderful things in nature is a glance of the eye; it
transcends speech; it is the bodily symbol of identity.” We endow the eye with far more than its
physiology: it is the pathway to the mind and the soul. Although 20/20 vision is desirable, the eye is also
admired for its color, shape, expressiveness, lashes, and size. Therefore, it is not surprising that males and
females of diverse backgrounds desire to change the appearance of their eyes to enhance their beauty and
to avoid the signs of aging that are so evident around the eyes.
Periorbital aging causes predictable changes in the skin, fat, muscle, and bone. The brows descend,
producing a sad or fatigued appearance. There is excessive skin in the upper lid that may cover the lid
crease or the eyelashes and may obstruct the upper visual field. Lateral hooding due to excess skin and
brow ptosis can cause a frowning look. The lacrimal gland may descend from attenuated ligaments. Fat
may atrophy, producing superior sulcus hollowing, or the fat pads may herniate and protrude. The lower
lids may become lax with increasing scleral show. The pretarsal roll in the lower lid descends and
flattens. The septum attenuates and bulging of the lower eyelid fat is seen. Malar bulging with attenuated
skin and muscle can be seen as the midface descends. The tear trough becomes more pronounced and the
lateral canthus may become lax, causing lid malposition and rounding of the lateral commissure (Figure
50.1).
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FIGURE 50.1 Characteristic signs of aging in the eyes. The blue arrow marks the orbitomalar ligament, the black arrow the
zygomaticofacial ligament, and the yellow arrow the nasojugal groove.
Blepharoplasty can reverse many of these undesired effects and restore the periorbital area to a more
youthful state. Blepharoplasty is among the most common aesthetic procedures performed. According to
American Society of Plastic Surgeons statistics, 209,571 blepharoplasties were performed in 2017, the 4th
leading cosmetic procedure for plastic surgeons. Blepharoplasties are performed also by
ophthalmologists and otolaryngologists, making it one of the most common aesthetic procedures. The
goal of blepharoplasty is to restore a more youthful appearance without any compromise of physiologic
function. Many successful techniques have been described and refined over time, and techniques vary
with the patient’s particular anatomy. Outcomes are usually excellent, and patients are happy with their
improved aesthetics.
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Anatomy
Correction of the orbital aging process requires a firm knowledge of normal and abnormal anatomy.
Different patients may demonstrate varying anatomical problems and concerns.
The upper and lower eyelids surround the palpebral fissure and meet at the medial and lateral canthi.
The lateral canthus is 2 mm higher than the medial canthus. With the eye in primary position, the margin
of the upper eyelid should cover the superior 1 to 2 mm of the cornea whereas the margin of the lower
eyelid is usually within 2 mm of the inferior border of the cornea.
The brow should sit at the level of the supraorbital rim in men and above the rim in women. The peak of
the brow is at the junction of middle and lateral thirds of the brow (Figure 50.2).
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FIGURE 50.2 Surface anatomy of the upper eyelid, eyelid folds, and canthal tilt.
The most superficial layer of the upper and lower eyelids is skin. Eyelid skin is one of the thinnest in the
body with little subcutaneous tissue. The orbicularis muscle is immediately under this layer of skin and is
responsible for closure of the eyelids. It is innervated by the facial nerve (mnemonic OO7). The muscle
consists of three concentric circles: pretarsal, preseptal, and orbital. The pretarsal portion is important for
involuntary blinking. The preseptal and orbital portions of the orbicularis are involved with voluntary
blinking and forced eyelid closure. The orbital portion of the orbicularis can cause brow depression in the
upper lid, and attenuation of this muscle can contribute to festoons in the lower lid (Figure 50.3).
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FIGURE 50.3 Muscle contributions to the medial canthus. The complex origin of the deep and superficial heads of the canthal
portion of the orbicularis muscle.
The orbital septum is contiguous with the periosteum of the orbit, and delineates the preseptal and
postseptal space. Posterior to the bands of orbital septum are the fat pads of the orbit. Fat pads serve to
cushion the eye, promoting smooth movement of the eyelids and eye muscles within the orbit. The upper
lid has two fat compartments, the central and medial (or nasal) fat pad, separated by the superior oblique
extraocular muscle. The medial fat pad is lighter in color than the central fat pad and sits near the
supratrochlear nerve and vessels. Laterally, in a shallow fossa of the frontal bone lies the two lobes of the
lacrimal gland (orbital and palpebral). When the ligaments that connect the glands to the bone
(Sommering ligaments) attenuate, the palpebral lobe can cause a prominent fullness in the lateral upper
lid fold (Figure 50.4).
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FIGURE 50.4 Anatomy of the orbital fat pads and the interpad septae that are addressed during blepharoplasty.
The main retractors of the upper eyelids, the levator muscle and Müller muscle are posterior to the fat
pads. The levator is innervated by cranial nerve III and Müller muscle is innervated by the sympathetic
nervous system. The levator muscle has anterior fiber projections into the skin and orbicularis just above
the tarsal plate, and this defines the lid crease. Typically, the lid crease is found 6 to 10 mm above the lid
margin, near the most superior aspect of the tarsal plate. The lid crease is generally lower in men (6–
8 mm) than women (8–10 mm; Figure 50.5).
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FIGURE 50.5 Layers of the upper eyelid: orbicularis muscle (A), fat compartments (B), and levator muscle and tendon (C).
The tarsus, or tarsal plate, is the cytoskeleton structure of the eyelid. It is made up of connective tissue
and Meibomian glands, which secrete an oil that prevents evaporation of the eye’s tear film. The tarsus is
usually 8 to 10 mm in height in the upper lid. The levator aponeurosis inserts onto the anterior surface of
the tarsus. The palpebral conjunctiva is the most posterior layer of the eyelids continuous with the bulbar
conjunctiva, forming the mucosal layer of the ocular surface. The superior tarsal conjunctiva contains an
abundant number of goblet cells responsible for forming the mucous layer of the tear film.
The lower eyelid anatomy is similar to the upper eyelids, although some differences exist. The tarsal plate
of the lower eyelid is shorter, only 3 to 4 mm in height. There are three orbital fat compartments in the
lower lid: the lateral, central, and medial fat pads. The medial and central fat pads are divided by the
inferior oblique extraocular muscle. The lower eyelid retractors include the capsulopalpebral fascia and
inferior tarsal muscle, and are analogous to the levator and Müller muscle of the upper eyelid (Figure
50.6).
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FIGURE 50.6 Cross section of the lower lid demonstrating the anterior and posterior lamella.
The orbital fat pads behind the septum are separated from the inferior fat pad by the orbitomalar
ligament, which stretches from the bone through the muscle and attaches to the orbicularis and skin. The
medial portion of this arc is called the tear trough or nasojugal groove and extends inferolaterally from
the medial canthus to approximately the midpupillary line, where it connects with the orbitomalar
ligament. The tear trough ligament is an osteocutaneous ligament between the palpebral and orbital
portions of the orbicularis oculi muscle. A tear trough may become more prominent with age, as the
tissue above this area is protruding (from fat pad herniation) and the area below it is descending (from
malar fat pad descent or subcutaneous thinning; Figure 50.7).
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FIGURE 50.7 Lower lid ligaments. A. Surface anatomy of the tear trough deformity and midfacial aging. B. Three-dimensional
anatomy of malar bags created by edematous soft tissue that is surrounded by the orbicularis oculi, the malar periosteum, and
the zygomaticocutaneous and orbitomalar ligaments.
Beneath the orbitomalar ligament is the prezygomatic space where the suborbicularis oculi fat resides.
The inferior border of the prezygomatic space is defined by the zygomatical-facial (or cutaneous)
ligament, which forms attachments from the bone to the dermis. This usually represents the lower edge
of the orbicularis. Inferior to this ligament, the malar fat is present anterior to the facial muscles. This is
the area where fat, excess skin, muscle, edema, and lymphatic swelling can cause malar mounds and
festoons. Malar mounds are defined as chronic soft tissue edema between the infraorbital rim and the
midcheek. If chronically and severely swollen, then the skin and muscle in this area may elongate and
form permanent cascades called festoons (Figure 50.8).
FIGURE 50.8 Lower lid fat compartments. A. Anatomy of the deep supporting structures of the posterior lamella, including the
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tarsoligamentous sling and the medial and lateral horns of the levator muscle. B. Three fat compartments in the periorbital
region include the orbital, SOOF (suborbicularis oculi fat), and malar fat pads.
The lateral canthus is dense connective tissue running from the tarsus to the lateral orbit. It has a deep
limb that attaches to a tubercle 1.5 mm posterior to the lateral orbital rim (Whitnall tubercle) as well as a
superficial limb, which inserts on the rim. The tendon is approximately 10 mm in length. The medial
canthus has a large anterior limb and a small posterior limb, inserting on the anterior or posterior lacrimal
crest, respectively. They surround the lacrimal sac (Figure 50.9).
FIGURE 50.9 Anatomy of the deep supporting structures of the posterior lamella, including the tarsoligamentous sling, the
medial and lateral horns of the levator muscle, medial and lateral canthi, and Whitnall and Lockwood ligaments.
The vascular supply of the eyelids is formed by the anastomoses of the branches of the internal and
external carotid arteries. The marginal arcade is usually found 2 to 3 mm from the lid margin on the
anterior surface of the tarsus. The upper lid has an additional peripheral arcade, found on the anterior
surface of the Müller muscle. The marginal arcade ought to be avoided during injection of local
anesthetics to avoid a hematoma. The venous drainage follows the same pattern.
The Asian eyelid differs significantly from Caucasian anatomy. The upper lid crease may be absent, low,
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or present only laterally because of lack of connections between the skin and levator. A medial epicanthal
fold may be present, and the upper tarsus may be shorter. The Asian upper lid has more fullness because
of preaponeurotic fat that extends more caudally, and there is an upward lateral canthus tilt.
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Preoperative Evaluation
Patients seek blepharoplasty for many reasons. They complain of excess skin, fatty bags, wrinkles, and
dark circles. They may have reduced visual fields and a tired or angry appearance. General aesthetic
goals include a crisp upper crease with pretarsal show of 3 to 6 mm, a full orbital sulcus, and a brow in
good position. Aesthetic features of the lower lid include pretarsal muscle fullness with a smooth lid-
cheek junction, and a well-defined almond-shaped lateral commissure.
Determining the patient’s motivations for surgery, goals and expectations is crucial to the success of any
surgical intervention. For example, patients who are interested in restoring function will generally be
satisfied with removal of vision-obstructing excess skin only; whereas, patients who want to improve
their appearance may require a greater amount of skin removal, removal of prolapsed fat, and greater
attention to symmetry to meet expectations. It is important to impart to the patient a clear understanding
of what goals and expectations can and cannot be achieved with surgery. Patients with unrealistic self-
image or who are not capable of understanding the limitations of the procedure are poor surgical
candidates.
Preoperative evaluation of the patient begins with taking a careful history. It is important to specifically
ask about visual problems, ophthalmology visits, and prior refractive surgery. Blepharoplasty should not
be considered within 6 months of refractive surgery as this predisposes the patient to dry eyes. The use of
neurotoxin and/or fillers should be elicited as this can alter the physical examination. Specific questioning
about coagulopathies, blood thinning medicines, herbal medicines, thyroid disease, allergies, high blood
pressure, and glaucoma is required. Dry eye history is elicited by asking about blurry vision that clears
with blinking, a burning or irritating feeling, conjunctival injection, the sensation of a foreign body in the
eye, or frequent use of artificial tears.
Physical examination of the patient should focus on the structure, function, and appearance of the
eyelids, eyebrows, cheeks, and forehead. Symmetry of the two eyes is also evaluated. This is very
important as there is always some degree of asymmetry, but patients do not always recognize this
preoperatively. Postoperatively, however, the patient may detect the smallest of differences. A
preoperative picture is helpful in every patient, so that the presurgical state can be reviewed.
Careful attention should be given to the position of the eyebrows. The normal brow position in men is
along the superior orbital rim. In females, the eyebrow sits slightly higher than the orbital rim, especially
in the mid lateral area. Descent of the eyebrow position is an age related change than can make
dermatochalasis more severe, and this can be treated surgically with a brow lifting procedure. When
assessing eyelid and eyebrow position, it is important that the frontalis muscle is relaxed. Patients may
compensate for eyebrow and eyelid ptosis by contracting the frontalis muscle, which can lead to
subjective complaints of fatigue and heaviness of the eyelids.
The position of the eyelid margin should then be assessed. If the margin of the eyelid is more than 2 mm
and lower than the superior limbus, the patient may have eyelid ptosis, typically caused by dehiscence or
stretching of the levator aponeurosis. The margin to reflex distance (MRD1) can also be noted. This is the
measurement in millimeters from the light reflex on the patient’s cornea to the level of the center of the
upper eyelid margin, with the patient gazing in the primary position. If the margin to reflex distance is
2 mm or less, the patient is considered to have visually significant ptosis. If present, ptosis can be
corrected at the time of blepharoplasty. The amount of excess skin of the upper eyelid (dermatochalasis)
should be assessed. If it overhangs the lid margin or sits on the eyelashes of the upper lid, it may be
visually significant. Attention should also be given to any medial or lateral bulging: this may represent fat
or lacrimal gland prolapse. Fat herniation can be accentuated by pushing gently on the globe.
In contrast to upper eyelid blepharoplasty, lower eyelid blepharoplasty is generally cosmetic. In assessing
a patient for lower lid blepharoplasty, it is important to evaluate the amount of excess skin present, the
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presence of orbital fat prolapse, and the tear trough appearance. The position of the lower lid is recorded
relative to the limbus. The degree of lower eyelid laxity is assessed by a snap back test. This is done by
distracting the lower lid inferiorly from the globe and seeing how quickly it returns to its original
position. A normal lid will snap back into its normal position instantaneously. A delay of 2 to 5 seconds
for the lid to return to its native state or the need to blink to return to normal state is indicative of
abnormal laxity. A lid distraction test pulls the lower lid from the globe anteriorly, and a distance of
greater than 6 mm is considered abnormal. A squint test delineates the function of the lower orbicularis.
The patient squeezes the eyelids tightly together and the orbicularis contracts. This gives the surgeon a
sense of the muscle tone and location of fat (Figure 50.10).
FIGURE 50.10 A. Snap back test. B. Distraction test.
The position of the globe relative to the orbital rim in noted. If the globe is more anterior than the orbital
rim, this is called a positive vector and may suggest thyroid disease or a patient prone to dry eye
problems. If the globe is posterior to the rim, this is called a negative vector.
Lastly, examination of the ocular surface for dryness is important as this can be exacerbated by surgical
interventions. If patient complaints or exam findings suggest dryness, an objective test such as the
Schirmer test can assess for quantity of tears present. This is done by placing a 5 by 35 mm strip of filter
paper in the lateral conjunctival cul-de-sac, and waiting 5 minutes. Normal eyes show 10 or more mm of
wetting of the filter paper. In clinical practice, Schirmer testing is infrequently used. Staining of the ocular
surface with fluorescein dye and examination under blue light reveals punctate staining corneal erosions
in patients with dry eyes. This examination is more efficient in identifying patients with dry eye and is
preformed routinely in ophthalmology offices.
A visual acuity examination of each eye individually should be performed. The presence or absence of
the Bell phenomenon is also noted. This is done by forcibly holding the eyelids open as the patient tries to
close them, and seeing if the globe rolls up to protect the cornea. Absence of this reflex puts the eye at risk
for dryness and ulceration if postoperative lagophthalmos is present (Table 50.1).
TABLE 50.1
Common Eyelid Terminology
Anterior lamella—Skin and orbicularis
Posterior lamella—Tarsus and conjunctiva
Lower lid retractors—Made up of the capsulopalpebral fascia (a fibrous extension from the inferior rectus that inserts onto the inferior
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tarsus) and inferior tarsal muscle. Support normal lower lid position and provide 3–4 mm of inferior displacement of the lower lid margin
with downgaze
Orbitomalar ligament—Cutaneous crease at the level of the orbital rim. Also called the orbicularis retaining ligament
Arcus marginalis—Thickening of the orbital septum where it fuses with the periosteum of the orbital rim
Lockwood ligament—Suspensory ligament that runs horizontally along the inferior orbit and supports the globe
Whitnall ligament—Dense white band of fibrous tissue running horizontally along the superior orbit. Supports the structures in this area
and acts as a fulcrum for the levator muscle
Whitnall tubercle—Small elevation of the zygomatic bone just inside the lateral orbital rim that serves as the attachment point for the
lateral canthal tendon, the lateral horn of the levator aponeurosis, the check ligament of the lateral rectus and Lockwood ligament
Suborbicularis oculi fat (SOOF)—Fat pad deep to the orbicularis oculi overlying the maxillary and zygomatic periosteum. Descends with
aging
Retro-orbicularis oculi fat (ROOF)—Fat pad deep to the brow, which may also descend with aging
Dermatochalasis—Excess skin of the upper or lower eyelid, and may obstruct the upper visual field
Blepharochalasis—Excess skin caused by repeated episodes of edema
Steatoblepharon—Excess or protruding fat
Canthopexy—Tightening of canthus by suturing
Canthoplasty—Tightening of eyelid by division of the canthus and reinsertion
Ectropion—Outward turning of the eyelid margin, caused by aging, cicatrices, paralysis, or mechanical
Entropion—Inward turning of the eyelid margin, which can result in trichiasis (rubbing of the lashes against the eye) and corneal
abrasions, due to age, cicatrices, or spasticity
Epiphora—Excessive tearing, often a result of a blockage in the nasolacrimal system
Festoon—Excessive skin and muscle with swelling below the orbitomalar ligament from long-term edema
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Operative Technique
In the past, operative techniques included aggressive fat and skin removal but this led to an unnatural,
hollowed appearance. Modern techniques rely on a careful diagnosis of the patient, restoration of more
youthful anatomy, and preservation of fat.
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Upper Lid Techniques
Repair of dermatochalasis and ptosis can offer functional as well as aesthetic improvement. Functional
benefits are noted for an MRD1 of 2 mm or less measured in primary gaze, superior visual field loss of
12 degrees or 24%, and downgaze ptosis impairing reading documented by MRD1 of 2 mm or less
measured in downgaze. Improved qualitative findings have also been noted in patient-reported
functional impairment from upper eyelid droop, head tilt induced by visual field impairment, and
interference with occupational duties resulting from visual impairment caused by the upper lids.
The steps of the basic upper eyelid blepharoplasty are outlined next. Additional procedures involving the
correction of brow ptosis or eyelid blepharoptosis are described elsewhere in this book.
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