Phẫu Thuật Tạo Hình (Tập 2): Phẫu Thuật Thẩm Mỹ – Neligan (Ấn bản 4)

SECTION I • Aesthetic Surgery of the Face
8 
Endoscopic brow lifting
Renato Saltz and Alyssa Lolofie
SYNOPSIS
This chapter discusses:
■ Brow aesthetics and surgical options for brow lift and forehead
rejuvenation.
■ Forehead and periocular anatomy.
■ Ideal candidates for the endoscopic brow lift technique.
■ Surgical techniques and key steps for endoscopic brow rejuvenation.
■ Long-term results and complications.
Introduction
The endoscopic approach for forehead rejuvenation and brow
lift has many advantages. It provides excellent exposure for
release of periorbital soft tissues combined with endoscopic
magnification, shorter scars, and reduced risk of alopecia and
scalp sensory changes compared to the traditional open
coronal brow lift. The technique has improved over the last
15 years with better fixation devices, a better understanding
of the longevity, and decreased complications of the proce­
dure. The endoscopic brow lift offers the patient a much easier
and safer solution for the aging forehead, the active wrinkles
from corrugator and frontalis hyperactivity, and the ptotic,
asymmetric brow.
Basic science/disease process
The anatomy of the forehead and periorbital regions should
be appreciated by the surgeon. The temporal ridge is bound
by the temporal line of fusion, which is a deep bony point of
fixation of the overlying soft tissues. In order to adequately
release and mobilize the lateral brow and temporal region, the
temporal line of fusion should be released to the level of the
supraorbital rim. There are also supraorbital ligamentous
attachments that require release in order to elevate the brow
and forehead (Fig. 8.1).
The nerves that are encountered and preserved during
endoscopic brow lift include the two main sensory nerves, the
supratrochlear and supraorbital nerves, and the main motor
branch of the facial nerve, the frontal branch. Care is taken to
appreciate and preserve these nerves during dissection. Sub­
galeal dissection lateral to the temporal line of fusion will
maintain the plane of dissection deep to the frontal branch.
Inferior lateral dissection to the level of the sentinel veins
while remaining on the superficial layer of the deep temporal
fascia also protects the frontal branch from direct division or
traction neuropraxia. Appreciation that the neurovascular
bundles for the supratrochlear and supraorbital nerves exit
the orbit 1.5 and 2.5 cm from midline respectively allows
gentle division of the periosteum at the location to avoid
division of the nerves (Fig. 8.2).
The muscles of the forehead include the frontalis, procerus,
corrugator supercilii with oblique and transverse heads, the
depressor supercilii, and the orbicularis muscles. The only
brow elevator is the frontalis muscle, while the other muscles
act as varying degrees of brow depressors. While release and
physical repositioning of the brow and forehead elevate the
brow, division and weakening of the brow depressors also
correct dynamic ptosis and glabellar frown lines (Fig. 8.3).
Key points
• Advances in endoscopic brow lift technique provide a more
precise and safer procedure to the aesthetic facial surgeon.
• Brow shape, position, and hyperactivity of the frontalis and
corrugator muscles are an integral part of periocular
rejuvenation.
• An upper blepharoplasty should not be indicated or
performed for treatment of periocular aging until the brow
position and symmetry is fully evaluated and treated.
• Modern and safe facial surgeons must incorporate
endoscopic techniques in their practices – a gold standard
treatment for periocular rejuvenation.
  Access video lecture content for this chapter online at expertconsult.com

289
Treatment/surgical technique
male pattern baldness can add the challenge of being able to
see and remove the glabellar muscles.
Other techniques for forehead rejuvenation include open
coronal, lateral temporal brow lift, direct approach through
the brow, transpalpebral brow lift with direct excision of the
corrugator muscles, and neurotoxin injections. During patient
selection, the two key problems to be addressed are eyebrow
ptosis and frontal and glabellar frown lines. Brow ptosis is a
combination of soft-tissue descent, soft-tissue deflation, and
loss of lid crease. There is no frontalis muscle lateral to the
temporal crest suggesting that 25–30% of the tail of the brow
has no “levator mechanism”.
Treatment/surgical technique
After adequate informed consent, the patient is marked for
surgery in a standing or sitting position. A temporal incision
is marked along a superior lateral vector line from the nasal
ala crossing the lateral canthus and continues to a point
approximately 2 cm behind the temporal hairline. A 2-cm
curved line is then marked medial to that point in both tem­
poral areas. Paramedian incisions are marked by a straight
line, from the mid-pupil superiorly to the anterior frontal
hairline. A 1-cm vertical line posterior to the hairline is marked
in those areas for the paramedian incisions (Fig. 8.6).
The location of the supratrochlear and supraorbital nerves
are also identified and marked. The location of the deep
branch of the supraorbital nerve when it reaches the hairline
Diagnosis/patient presentation
The ideal shape and position of the brow has changed over
the years through different cultures and fashions. Therefore,
brow aesthetics cannot be generalized and must be evaluated
in relation to gender, ethnicity, orbital shape, and overall facial
aging and facial proportions. Currently, we consider “ideal
brow aesthetics” to be when the medial brow is at or below
the level of the orbital rim, the medial brow is above the
medial cantus, and has a gentle peak on the last two-thirds
towards the lateral end with the lateral tail higher than the
medial (Fig. 8.4). With facial aging, the eyebrows gradually
fall and lose volume, encroaching on the orbit and bunching
the skin over the lateral orbital rim, creating what is known
as “temporal hooding”. Eyebrow ptosis, eyebrow asymmetry,
temporal hooding, and forehead wrinkles are all indications
for forehead rejuvenation and a brow lift (Fig. 8.5).
Patient selection
Since the introduction of the endoscopic approach in 1993 by
Core and Vasconez, I stopped performing open coronal brow
lift. Almost all of my facial rejuvenation cases today include
brow rejuvenation through an endoscopic technique. The best
candidates for endoscopic forehead lifts are patients with flat
foreheads (flat frontal bone), no receding hairlines (low hair­
line), and no redundant forehead skin. High hairlines and
Fig. 8.1  Structural landmarks in the brow. The temporal
fusion line lies at the junction of the periosteum and the
deep temporal fascia. It must be released to achieve brow
mobility. The orbital retaining ligament, situated at the
lateral supraorbital rim, must also be released.
(Reproduced from Saltz R, Codner M. Endoscopic brow
lift. In: Nahai FR, Nahai F, Codner M (eds). Techniques in
Aesthetic Plastic Surgery: Minimally Invasive Facial
Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
Superior temporal
fusion line
Inferior temporal
fusion line
Orbital ligament
Temporal ridge
Zone of fixation
Supraorbital
nerve
Supratrochlear
nerve

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SECTION I
CHAPTER 8 • Endoscopic brow lifting
Fig. 8.2  Sensory and motor nerve supply to the brow. The
supraorbital and supratrochlear nerves are protected during
dissection. The frontal branches of the facial nerve lie
anterior to the deep temporal fascia. (Reproduced from Saltz
R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F,
Codner M (eds). Techniques in Aesthetic Plastic Surgery:
Minimally Invasive Facial Rejuvenation. Philadelphia, PA:
Saunders Elsevier; 2009.)
Sentinel vein
Zygomaticotemporal nerve
Temporal branches of the facial nerve
Supraorbital nerve
Supratrochlear
nerve
Frontal branch nerves
Fig. 8.3  Brow musculature. The muscles involved with brow movement are
illustrated. The corrugators and procerus contribute to vertical and transverse brow
furrows, respectively. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In:
Nahai FR, Nahai F, Codner M (eds). Techniques in Aesthetic Plastic Surgery:
Minimally Invasive Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
Frontalis
Obicularis
Corrugator
Procerus
Fig. 8.4  Brow aesthetics. (A) The ideal brow position for females lies above the
supraorbital rim with its highest peak vertically in line with the lateral corneoscleral
limbus. (B) The lateral brow lies in an oblique line connecting the ala and lateral
canthus. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR,
Nahai F, Codner M (eds). Techniques in Aesthetic Plastic Surgery: Minimally
Invasive Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
A
B

291
Treatment/surgical technique
endoscopic forceps and ronjeurs, and a malleable Durden
suction cautery. Many different devices can be used for fixa­
tion: a drill for cortical tunnels, a drill for temporary screw
fixation, a drill for use of the Endotine devices, or a variety of
other fixation methods. The endoscopic cart should be posi­
tioned at the foot of the bed with the surgeon positioned at
the head of the bed.
The procedure starts approximately 20 min after infiltra­
tion is completed to obtain maximum vascular constriction.
The temporal incision allows visualization and dissection on
top of the deep temporal fascia. Blunt dissection is completed
in the temporal areas as well as the subperiosteal plane over
the frontal bone. Both areas are then communicated after
division of soft tissues over the temporal crest (Fig. 8.8). At
this point, a 4-mL 30° scope is introduced to continue the
dissection. The sentinel veins are identified and preserved
(Fig. 8.9). The “fusion ligament” is identified and divided
using endoscopic scissors. The dissection continues medially,
where the supraorbital nerve is identified and preserved. I do
not transect the periosteal attachments in between the corru­
gator muscles so as to minimize the medial brow elevation
and the so-called “surprised look”. At this point, the corruga­
tor muscles are identified and completely excised (Fig. 8.10).
Manual palpation and gentle pressure over the skin avoids
trauma to the dermis and possible indentations during endo­
scopic corrugator resection. In case of very thin skin and
possible indentation, I recommend immediate placement of
fat grafts with suture fixation. At this point, the surgeon
should feel how mobile the lateral brow is and be sure both
are equally mobile and symmetrical. Temporal fixation is
is also marked approximately 1 cm medial to the temporal
crest line. If the patient has brow asymmetry on preoperative
evaluation, careful examination should be performed for true
brow asymmetry or for underlying unilateral upper lid ptosis,
which causes ipsilateral elevation of the brow to compensate.
In the latter situation, repair of the eyelid ptosis often equal­
izes brow position, thus avoiding overcorrection of one brow
compared to the other.
Most commonly, the patient is placed under general anes­
thesia using an endotracheal tube secured to the upper teeth
with dental floss. Infiltration is achieved using a mixture of
20 mL of 2% lidocaine, 20 mL of 0.25% Marcaine, 1 mL of
epinephrine solution in 140 cc of normal saline. Infiltration is
done using a 20-gauge spinal needle in a tumescent fashion.
The patient is prepped and draped in a sterile fashion. The
endotracheal tube is wrapped with sterile plastic drape so it
is inside the sterile field during the entire procedure and
easily manipulated when the head is turned to either side.
While the use of the endoscopic brow lift has nearly elimi­
nated the need for open coronal brow lifts, there are additional
equipment requirements (Fig. 8.7). Equipment should be
tested prior to induction of general anesthesia and back-up
equipment should be available. The endoscopic equipment on
the cart for visualization includes a monitor, preferably high
definition; a three-chip camera; light source; ability to record
the procedure digitally as well as take still photographs;
electrocautery base unit; and suction. The additional equip­
ment on the field include an endoscope, most commonly a
4–5 mm, 30° Hopkin rod with an endoscopic sheath camera
connector, light source connector, endoscopic dissectors,
Fig. 8.5  Age-related changes in the brow. These involve
brow descent, furrowing, vertical and transverse frown
lines, and crow’s feet. (Reproduced from Saltz R, Codner
M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M
(eds). Techniques in Aesthetic Plastic Surgery: Minimally
Invasive Facial Rejuvenation. Philadelphia, PA: Saunders
Elsevier; 2009.)
Oblique frown lines:
Corrugator oblique
head (variable)
Depressor supercilii
Orbicularis oculi
Transverse frown lines:
Procerus
Vertical frown lines:
Corrugator
Crow’s feet:
Orbicularis oculi
Brow ptosis
Fig. 8.6  Preoperative markings. The course of the sensory and motor nerves to the brow are marked. In addition, the desired vector of brow elevation is also mapped. The
paramedian incisions should be in line with the desired pull of the lateral brow peak. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F,
Codner M (eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
A
B

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SECTION I
CHAPTER 8 • Endoscopic brow lifting
achieved by using three interrupted Mersilene sutures from
the superficial temporal fascia (and galea) into a superior
cephalic lateral direction to the deep temporal fascia. The
central portion of the inferior scalp flap may be excised in
triangular wedges in order to prevent redundancy at the
lateral brow. Fixation of the paramedian incisions is achieved
with the Endotine device (Coapt Systems, Inc, Palo Alto, CA)
(Fig. 8.11). At this point, still under general anesthesia, the
patient is examined in a sitting position for final brow position
and brow symmetry. Measurements for comparison include
the mid-pupil to top of the middlebrow and the lateral cantus
to the tail of the brow. Measures are recorded and documented
in the operative report for future comparison. The incisions
are then approximated with 4-0 plain gut. The hair is sham­
pooed, and the patient is extubated and taken to the recovery
room. No dressings are applied.
Postoperative care
The patient should be treated with analgesics for the first
48–72 h and ice compresses to decrease pain and headaches.
The patient’s head should be kept elevated to decrease venous
congestion and improve the lymphatic drainage. Lymphatic
massage performed in the first 72 h by a certified lymphatic
massage therapist can decrease swelling and bruising,
improve patient comfort, and expedite recovery.
Fig. 8.7  Endoscopic cart. This endoscopic cart holds the monitor, light source, a
recording device, camera chassis, printer, and electrocautery unit. (Reproduced
from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M
(eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial
Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
Fig. 8.8  Release of the temporal zone of fixation. Periosteal
dissectors are used on the surface of the deep temporal fascia in
the lateral area and on the periosteum in the medial area. After
these pockets are completed, the temporal line of fusion is
released in a lateral to medial direction. (Reproduced from Saltz R,
Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M
(eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive
Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
Zone of fixation
Inferior temporal
septum
Sentinel vein
Supraorbital nerve
Supratrochlear
nerve

293
Outcomes, prognosis, and complications
cortical tunnel technique for fixation as the cause of intra­
cranial bleeding during an endoscopic brow lift.
Injury to the supratrochlear and supraorbital nerves causing
temporary paraesthesia is another potential complication.
It can be minimized by adequate scalp incision placement
avoiding trauma to the deep branch of the supraorbital nerve
as well as gentle tissue manipulation and careful soft-tissue
retraction using the endoscope. The subperiosteal dissec­
tion retains the vascular blood supply within the forehead
flap; therefore, subperiosteal dissection maximizes flap
blood supply and minimizes trauma to the deep branch of
the supraorbital nerve. Temporary paresthesia and some
irregularities of the frontalis muscle are occasionally seen
but usually improve within 2–3 weeks. Correction of eyelid
ptosis with tarsolevator advancement corrects lid posi­
tions as well as brow asymmetry from compensatory brow
elevation.
Outcomes, prognosis, and
complications
Despite the advantages, the endoscopic approach for forehead
rejuvenation and brow lift is not without complications.
Relapse has declined over the years due to increased and
better use of permanent fixation.
The “surprised look” has been eliminated by preserving a
bridge of periosteum at the midline and by avoiding fixation
in the paramedian incisions in patients that have very mobile
medial brows or a hyperactive medial frontalis muscle. Alo­
pecia was eliminated in my practice after I abandoned percu­
taneous screw fixation and changed to the completely buried
Endotine devices. The alopecia was caused by improper local
pressure in the surrounding scalp skin with the screw fixation
and staple technique. Anecdotal reports have blamed the
Fig. 8.9  Sentinel vein. The sentinel vein is encountered during endoscopic
dissection. The identification of the sentinel vein identifies a standard landmark for
the frontal branch of the facial nerve. Dissection should not proceed beyond this.
(Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F,
Codner M (eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial
Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
Fig. 8.10  Endoscopic view of corrugator. The corrugators may be resected
endoscopically with grasping forceps, taking care not to injure the supraorbital or
supratrochlear nerves. (Reproduced from Saltz R, Codner M. Endoscopic brow lift.
In: Nahai FR, Nahai F, Codner M (eds). Techniques in Aesthetic Plastic Surgery:
Minimally Invasive Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)
Procerus
muscle
Depressor
supercilii
muscle
Corrugator
muscle,
oblique head
Corrugator
muscle,
transverse head
Orbital rim
Trochlear nerve branch
Fig. 8.11  Endotine fixation. (A) The Endotine
divot hole is drilled through the first layer of
calvarial bone and situated at the caudal extent of
the incision. The Endotine is snapped into place.
(B) The scalp can then be repositioned vertically
and held in place by fixation tines. (Reproduced
from Saltz R, Codner M. Endoscopic brow lift. In:
Nahai FR, Nahai F, Codner M (eds). Techniques in
Aesthetic Plastic Surgery: Minimally Invasive
Facial Rejuvenation. Philadelphia, PA: Saunders
Elsevier; 2009.)
A
B

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SECTION I
CHAPTER 8 • Endoscopic brow lifting
Final considerations
Endoscopic, minimally invasive surgery does not mean
minimal results (Figs. 8.12–8.14), and a smaller scar is a bad
excuse for a suboptimal result. For its effectiveness, the endo­
scopic brow lift results and morbidity have to match those of
similar “open” procedures. Minimal access is better when
combined with a quicker recovery, fewer complications, and
good long-term results. The better you can see, the more
precise you can be. Endoscopy is now the “standard of care”
in many specialties – no one would do an open knee today
and say “the scar isn’t that bad”!
Fig. 8.12  This patient is shown
(A) before and (B) after
endoscopic brow lift,
demonstrating an increased
brow–lash distance and an
aesthetically pleasing arch to the
eyebrow. (Reproduced from Saltz
R, Codner M. Endoscopic brow
lift. In: Nahai FR, Nahai F, Codner
M (eds). Techniques in Aesthetic
Plastic Surgery: Minimally
Invasive Facial Rejuvenation.
Philadelphia, PA: Saunders
Elsevier; 2009.)
A
B
Fig. 8.13  (A) This male patient demonstrates brow asymmetry with the left side more inferiorly positioned than the right. He underwent endoscopic brow lift and bilateral
upper lid blepharoplasty. (B) Postoperative photos at 6 months show correction of brow asymmetry and improvement of transverse brow furrows. (Reproduced from Saltz R,
Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M (eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia, PA:
Saunders Elsevier; 2009.)
A
B
The brow lift can be summarized into four easy key surgi­
cal steps:
1. Blunt subperiostal dissection over deep temporal fascia
and frontal bone down to the supraorbital rim
2. Meticulous division and spreading of the supraorbital
rim periosteum under endoscopic visualization
3. Corrugator muscle resection under endoscopic
visualization
4. Fixation in the temporal and paramedian wounds.
Recent introduction of non-endoscopic procedures for
forehead rejuvenation like the short scar temporal, the
transblepharoplasty, and the anterior hairline approaches
A
B
Fig. 8.14  (A) This female patient illustrates brow ptosis, lateral hooding, and crow’s feet. (B) Postoperative photos at 6 months following endoscopic brow lift and upper
lid blepharoplasty demonstrate improvement of brow position with an increased brow–lash distance and a more aesthetic shape. Lateral brow aging and wrinkles are also
improved. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M (eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive
Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)

295
Final considerations
Many have questioned the effectiveness and long-term
results of the endoscopic brow lift by suggesting the operative
time is too long, it creates over-lifting, alopecia, elevates the
hairline, and widens the interbrow region. Some suggest the
endoscopic approach is unable to treat deep wrinkles and
asymmetry, and most complain of the equipment cost. Unfor­
tunately, most “naysayers” have never learned the technique
properly and continue to refuse to adopt it and teach it to their
residents and fellows.
are all “blind”. They offer operative time no better than
endoscopic surgery, blindly dissect around all potential
anomalous variations of the supraorbital nerve, and require
larger incisions with potential damage to the deep branch of
supraorbital nerve, causing sensory loss and visible scars.
The non-endoscopic, blind temporal approach is applicable
in selected patients where only lateral lift is needed, with
no forehead wrinkles, and when no corrugator release is
necessary.
Bostwick J III, Nahai F, Eaves F III. Endoscopic Brow Lift in Endoscopic
Plastic Surgery. St. Louis, MO: Quality Medical Publishing; 1996.
Core GB, Vasconez LO, Askren C, et al. Coronal face lift with
endoscopic techniques. Plastic Surg Forum. 1992;15:227–229.
Daniel RK, Tirkanits B. Endoscopic forehead lift: an operative
technique. Plast Reconstr Surg. 1996;98:1148–1157.
Del Campo AF, Lucchesi R, Cedillo Ley MP. The endo-facelift: basics
and options. Clin Plast Surg. 1997;24:309–327.
Isse NG Endoscopic forehead lift. Presented at the Annual Meeting of
the Los Angeles County Society of Plastic Surgeons, Los Angeles,
Sept 12, 1992.
Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional
lift. Case reports. Aesthetic Plast Surg. 1994;18:21–29.
Isse NG. Endoscopic forehead lift: evolution and update. Clin Plast
Surg. 1995;22:661–673.
Knize DM. Limited-incision forehead lift for eyebrow elevation to
enhance upper blepharoplasty. Plast Reconstr Surg. 1996;97:
1334–1342.
Mackay GJ, Nahai F. The endoscopic forehead lift. Operative techniques
in plastic and reconstructive surgery. Plast Reconstr Surg.
1995;2:137–144.
Matarasso A, Matarasso SL. Endoscopic surgical correction of glabellar
creases. Dermatol Surg. 1995;21:695.
Access the complete reference list online at

295.e1
Further reading
Further reading
Bostwick J III, Nahai F, Eaves F III. Endoscopic Brow Lift in Endoscopic
Plastic Surgery. St. Louis, MO: Quality Medical Publishing; 1996.
Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg.
1994;18:269–274.
Core GB, Vasconez LO, Askren C, et al. Coronal face lift with
endoscopic techniques. Plastic Surg Forum. 1992;15:227–229.
Daniel RK, Tirkanits B. Endoscopic forehead lift: an operative
technique. Plast Reconstr Surg. 1996;98:1148–1157.
Del Campo AF, Lucchesi R, Cedillo Ley MP. The endo-facelift: basics
and options. Clin Plast Surg. 1997;24:309–327.
Isse NG Endoscopic forehead lift. Presented at the Annual Meeting of
the Los Angeles County Society of Plastic Surgeons, Los Angeles,
Sept 12, 1992.
Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional
lift. Case reports. Aesthetic Plast Surg. 1994;18:21–29.
Isse NG. Endoscopic forehead lift: evolution and update. Clin Plast
Surg. 1995;22:661–673.
Knize DM. Limited-incision forehead lift for eyebrow elevation to
enhance upper blepharoplasty. Plast Reconstr Surg. 1996;97:
1334–1342.
Mackay GJ, Nahai F. The endoscopic forehead lift. Operative techniques
in plastic and reconstructive surgery. Plast Reconstr Surg. 1995;2:
137–144.
Matarasso A, Matarasso SL. Endoscopic surgical correction of glabellar
creases. Dermatol Surg. 1995;21:695.
Nahai F, Saltz R, eds. Endoscopic Plastic Surgery. St. Louis, MO: Quality
Medical Publishing; 2008.
Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast
Surg. 1996;20:129–134.
Paul M. The evolution of the brow lift in aesthetic plastic surgery. Plast
Reconstr Surg. 2001;108:1409–1424.
Ramirez OM. The anchor subperiosteal forehead lift. Plast Reconstr
Surg. 1995;95:993–1003.
Ramirez OM. Endoscopically assisted biplanar forehead lift. Plast
Reconstr Surg. 1995;96:323–333.
Rohrich RJ, Beran SJ. Evolving fixation methods in endoscopically
assisted forehead rejuvenation: controversies and rationale. Plast
Reconstr Surg. 1997;100:1575–1582.
Saltz R. Forehead rejuvenation. In: Lin SJ, Mustoe TA, eds. Aesthetic
Head and Neck Surgery: Mcgraw-Hill Plastic Surgery Atlas. New York,
NY: McGraw-Hill; 2013.
Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner
M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive
Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.
Saltz R, et al. Endoscopic mid-face lift. In: Stephen HM, ed. Year Book of
Plastic, Reconstructive, and Aesthetic Surgery. St. Louis, MO: Mosby;
2006.
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.
Vasconez LO The use of the endoscope in brow lifting. A video
presentation at the Annual Meeting of the American Society of
Plastic and Reconstructive Surgeons. Washington, DC, 1992.

SECTION I • Aesthetic Surgery of the Face
9 
Blepharoplasty
Julius Few Jr. and Marco Ellis
SYNOPSIS
■ Blepharoplasty is a vital part of facial rejuvenation. The traditional
removal of tissue may or may not be the preferred approach when
assessed in relation to modern cosmetic goals.
■ A thorough understanding of orbital and eyelid anatomy is necessary
to understand aging in the periorbital region and to devise appropriate
surgical strategies.
■ Preoperative assessment includes a review of the patient’s
perceptions, assessment of the patient’s anatomy, and an appropriate
medical and ophthalmologic examination.
■ Surgical techniques in blepharoplasty are numerous and should be
tailored to the patient’s own unique anatomy and aesthetic diagnosis.
■ Interrelated anatomic structures including the brow and the infraorbital
rim may need to be surgically addressed for an optimal outcome.
Access the Historical Perspective section online at

Introduction
Properly performed aesthetic periorbital surgery is one of
the most rejuvenating of all facial surgeries performed today.
Properly conceived and executed, it proves a tremendous
source of joy for both surgeon and patient. Done poorly,
it can lead to a lifetime of disfigurement and functional
problems for the patient, sleepless nights for the surgeon,
and dissatisfaction for both participants. The problem is
magnified because aesthetic periorbital surgical procedures
are among the most commonly performed in plastic surgery
practices.
Traditional methods of aesthetic periorbital surgery often
produce suboptimal results. A departure from the standard
techniques of the past is recommended. Most plastic surgeons
know there is a better way, and those who persist with tradi­
tional techniques may soon be deviating from a new standard
of surgical care. It is this new standard that is advocated in
this chapter. When they are understood and adopted, these
new standards eliminate the classic complications and risks
associated with traditional techniques.
Instead of the common practice of excising precious upper
and, to a somewhat lesser degree, lower eyelid tissue, it is
preferable to focus on restoration of attractive, youthful
anatomy. To expect that the simple removal of tissue will
always result in beautiful or youthful eyes is unrealistic,
because this may not fully correct the aging eye deformity.
One should first conceptualize the desired outcome, then
select and execute procedures accurately designed to achieve
those specific goals. For this task to be accomplished, several
important principles are advocated (Box 9.1). Enthusiastically
embraced, this approach is likely to result in excellent aesthetic
quality of surgical outcomes.
Basic science/disease process
Essential and dynamic anatomy
It is an absolute necessity that the surgeon understands the
essential and dynamic periorbital anatomy to effect superior
aesthetic and functional surgical results. No surgeon should
perform surgery without fully understanding the aesthetic
and functional consequences of the choices.2–5
Osteology and periorbita
The orbits are pyramids formed by the frontal, sphenoid,
maxillary, zygomatic, lacrimal, palatine, and ethmoid bones
(Fig. 9.1). The periosteal covering, or periorbita, is most firmly
attached at the suture lines and the circumferential anterior
orbital rim. The investing orbital septum, in turn, attaches to
the periorbita of the orbital rim, forming a thickened perimeter
known as the arcus marginalis. This structure reduces the
perimeter and diameter of the orbital aperture and is thickest
in the superior and lateral aspects of the orbital rim.6
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296.e1
Historical perspective
Historical perspective
As far back as the 10th and 11th centuries, Arabian surgeons
Avicenna and Ibn Rashid described the significance of excess
skin folds in impairing eyesight.1 Even at an early date, sur­
geons had excised upper eyelid skin to improve vision. Texts
published in the 18th and 19th centuries were the first to
describe and illustrate the upper eyelid aging deformities. The
term “blepharoplasty” was coined by Von Graefe in 1818 to
describe reconstructive procedures employed following onco­
logic excisions. Several European surgeons developed recon­
structive techniques for eyelid defects in the latter half of the
19th century. Graefe and Mackenzie would be credited with
applying these reconstructive principles and publishing the
first, reproducible cases of upper blepharoplasty. The concepts
of herniated orbital fat pads were described shortly thereafter
by Sichel and Bourguet, respectively. Orbital fat pads were
originally considered to be “circumscribed tumors” of fat that
made movement of the upper lid more difficult. It was a rare
condition found “most often in children”. Cosmetic blepharo­
plasty entered a period of rapid growth and research in the
1920s and 1930s. Contributions were made that described
nearly 13 different approaches and closure methods. Recent
variations in technique appear to have a basis in these early
techniques, which have cycled in popularity over the last
decade.

297
Basic science/disease process
Certain structures must be avoided during upper lid
surgery. The lacrimal gland, located in the superolateral orbit
deep to its anterior rim, often descends beneath the orbital
rim, prolapsing into the postseptal upper lid in many persons.
During surgery, the gland can be confused with the lateral
extension of the central fat pad destined for removal during
aesthetic blepharoplasty. The trochlea is located 5 mm poste­
rior to the superonasal orbital rim and is attached to the
periorbita. Disruption of this structure can cause motility
problems.7
Lateral retinaculum
Anchored to the lateral orbit is a labyrinth of connective
tissues that are crucial to maintenance of the integrity, posi­
tion, and function of the globe and periorbital. Understanding
how to effectively restore these structures is key to periocular
rejuvenation by canthopexy. These structures, known as the
lateral retinaculum, coalesce at the lateral orbit and support
the globe and eyelids like a hammock (Fig. 9.2).8–10 The lateral
retinaculum consists of the lateral canthal tendon, tarsal strap,
lateral horn of the levator aponeurosis, the Lockwood suspen­
sory ligament, Whitnall’s ligament, and check ligaments of
the lateral rectus muscle. They converge and insert securely
into the thickened periosteum overlying Whitnall’s tubercle.
Controversy exists surrounding the naming of the compo­
nents of the lateral canthal tendon. Recent cadaveric dissec­
tions suggest that the lateral canthal tendon has dual
insertions. A superficial component is continuous with the
orbicularis oculi fascia and attaches to the lateral orbital rim
and deep temporal fascia by means of the lateral orbital
thickening. A deep component that connects directly to Whit­
nall’s tubercle is classically known as the lateral canthal
tendon (Fig. 9.3).11
In addition, the tarsal strap is a distinct anatomic structure
that inserts into the tarsus medial and inferior to the lateral
canthal tendon.12 In contrast to the canthal tendon, the thick
BOX 9.1  Principles for restoration of youthful eyes
• Control of periorbital aesthetics by proper brow positioning,
corrugator muscle removal, and lid fold invagination when
beneficial.
• Restoration of tone and position of the lateral canthus and,
along with it, restoration of a youthful and attractive intercanthal
axis tilt.
• Restoration of the tone and posture of the lower lids.
• Preservation of maximal lid skin and muscle (so essential to lid
function and aesthetics) as well as orbital fat.
• Lifting of the midface through reinforced canthopexy, preferably
enhanced by composite malar advancement.
• Correction of suborbital malar grooves with tear trough (or
suborbital malar) implants, obliterating the deforming tear trough
(bony) depressions that angle down diagonally across the
cheek, which begin below the inner canthus.
• Control of orbital fat by septal restraint or quantity reduction.
• Removal of only that tissue (skin, muscle, fat) that is truly
excessive on the upper and lower lids, sometimes resorting to
unconventional excision patterns.
• Modification of skin to remove prominent wrinkling and excision
of small growths and blemishes.
Fig. 9.1  Orbital bones. Frontal view of the orbit with foramina.
Supraorbital foramen
Supraorbital fissure
Infraorbital
fissure
Zygomaticofacial foramen
Greater wing
of sphenoid
Zygomatic
Superior orbital ridge
Optic foramen
Ethmoid
Lacrimal bone
and fossa
Maxilla
Infraorbital foramen
Frontal bone
Fig. 9.2  Horizontal section of the orbit showing the lateral retinaculum formed by
the lateral horn of the levator, lateral canthal tendon, tarsal strap, the Lockwood
suspensory ligament, and lateral rectus check ligaments.
Orbicularis
Tenon’s capsule
Lateral canthal tendon
Medial canthal tendon
Fossa for lacrimal sac
Lateral check retinaculum
Medial check retinaculum
Medial rectus and sheath
Lateral rectus and sheath
Periorbita
tarsal strap is relatively resistant to laxity changes seen with
aging. The tarsal strap attaches approximately 3 mm inferiorly
and 1 mm posteriorly to the deep lateral canthal tendon,
approximately 4–5 mm from the anterior orbital rim. It short­
ens in response to lid laxity, benefiting from release during
surgery to help achieve a long-lasting restoration or elevation
canthopexy (Fig. 9.4). Adequate release of the tarsal strap
permits a tension-free canthopexy, minimizing the downward
tethering force of this fibrous condensation. This release along
with a superior reattachment of the lateral canthal tendon is
key to a successful canthopexy.
Medial orbital vault
A hammock of fibrous condensations suspends the globe
above the orbital floor. The medial components of the
apparatus include medial canthal tendon, the Lockwood

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Forehead and temporal region
The forehead and brow consist of four layers: skin, subcutane­
ous tissue, muscle, and galea. There are four distinct brow
muscles: frontalis, procerus, corrugator superciliaris, and
orbicularis oculi (Fig. 9.6). The frontalis muscle inserts pre­
dominately into the medial half or two-thirds of the eyebrow
(Fig. 9.7), allowing the lateral brow to drop hopelessly ptotic
from aging, while the medial brow responds to frontalis
activation and elevates, often excessively in its drive to clear
the lateral overhand. Constant contraction of the frontalis will
give the appearance of deep horizontal creases in the forehead
(Fig. 9.8).3
The vertically oriented procerus is a medial muscle, often
continuous with the frontalis, arising from the nasal bones
and inserting into the subcutaneous tissue of the glabellar
region. It pulls the medial brow inferiorly and contributes to
the horizontal wrinkles at the root of the nose. More com­
monly, these wrinkles result from brow ptosis and correct
spontaneously with brow elevation.
suspensory ligament, and check ligaments of the medial
rectus. The medial canthal tendon, like the lateral canthal
tendon, has separate limbs that attach the tarsal plates to
the ethmoid and lacrimal bones.13 Each limb inserts onto
the periorbital of the apex of the lacrimal fossa. The ante­
rior limb provides the bulk of the medial globe support
(Fig. 9.5).
Fig. 9.3  Lateral canthal tendon has separate superficial and deep components. The
deep component attaches inside the orbital rim at Whitnall’s tubercle. The
superficial component passes from the tarsal plates to the periosteum of the lateral
orbital rim and lateral orbital thickening. Both components are continuous with both
superior and inferior lid tarsal plates. (Adapted from Muzaffar AR, Mendelson BC,
Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and
lateral canthus. Plast Reconstr Surg. 2002;110:873–884.)
Orbicularis fascia
Zygomatic bone
Temporalis
Maxilla bone
Coronoid process of mandible
Frontal bone
Lateral canthal tendon
Lateral orbital thickening
Tarsal plates
Fig. 9.4  The deep portion of the lateral canthal tendon inserts securely into the
thickened periosteum overlying Whitnall’s tubercle. The tarsal strap is a distinct
anatomic structure that suspends the tarsus medial and inferior to the lateral canthal
tendon to lateral orbital wall, approximately 4–5 mm from the orbital rim.
Tarsus
“Tarsal strap”
Whitnall’s tubercle
Lateral canthal tendon
Orbital septum
Fig. 9.5  The medial canthal tendon envelops the lacrimal sac. It is tripartite, with
anterior, posterior, and superior limbs. Like the lateral canthal tendon, its limbs are
continuous with tarsal plates. The components of this tendon along with its lateral
counterpart are enveloped by deep and superficial aspects of the orbicularis
muscle. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular
Surgery. Philadelphia, PA: Saunders; 2004:13.)
Superior limb, medial canthal tendon
Posterior limb, medial canthal tendon
Anterior limb, medial canthal tendon
Anterior and posterior lacrimal crests
Lacrimal fossa
Fig. 9.6  Facial muscles of the orbital region. Note that the preseptal and pretarsal
orbicularis muscles fuse with the medial and lateral canthal tendons.
Superciliary corrugator
Procerus
Frontalis
Orbicularis oculi
Pretarsal
orbicularis
Preseptal
orbicularis

299
Basic science/disease process
Eyelids
The eyelids are vital, irreplaceable structures that serve to
protect the globes. Their shutter-like mechanism is essential
to clean, lubricate, and protect the cornea. Any disruption or
restriction of eyelid closure will have significant consequences
for both the patient and the surgeon.
There is much similarity between upper and lower eyelid
anatomy. Each consists of an anterior lamella of skin and
orbicularis muscle and a posterior lamella of tarsus and con­
junctiva (Fig. 9.9).15
The orbicularis muscle, which acts as a sphincter for the
eyelids, consists of orbital, preseptal, and pretarsal segments.
The pretarsal muscle segment fuses with the lateral canthal
tendon and attaches laterally to Whitnall’s tubercle. Medially
it forms two heads, which insert into the anterior and poste­
rior lacrimal crests (see Fig. 9.6).
Upper eyelid
The orbital septum originates superiorly at the arcus and
forms the anterior border of the orbit. It joins with the levator
aponeurosis, just superior to the tarsus. The sling formed by
the union of these two structures houses the orbital fat.
The levator palpebrae superioris muscle originates above
the annulus of Zinn. It extends anteriorly for 40 mm before
becoming a tendinous aponeurosis below Whitnall’s liga­
ment.7,16 The aponeurosis fans out medially and laterally to
attach to the orbital retinacula. The aponeurosis fuses with the
orbital septum above the superior border of the tarsus and at
the caudal extent of the sling, sending fibrous strands to the
dermis to form the lid crease. Extensions of the aponeurosis
finally insert into the anterior and inferior tarsus. As the
levator aponeurosis undergoes senile attenuation, the lid
crease rises into the superior orbit from its remaining dermal
attachments while the lid margin drops.
The obliquely oriented corrugator muscle arises from the
frontal bone and inserts into the brow tissue laterally, with
some extensions into orbicularis and frontalis musculature,
forming vertical glabellar furrows during contraction. Wrin­
kles from procerus and corrugators contraction can worsen
significantly after upper lid tissue excision as a result of the
frontalis muscles relaxing after being relieved of the need to
clear the obstructing lid skin.14
Fig. 9.8  Frontalis action. The frontalis muscle inserts into the medial two-thirds of
the brow. Exaggerated medial brow elevation is required to clear the lateral
overhang and to eliminate visual obstruction. Constant contraction of the frontalis
will give the appearance of deep horizontal creases in the forehead. This necessarily
means that when the lateral skin is elevated or excised, the over-elevated and
distorted medial brow drops profoundly.
Diagonal lines
Fig. 9.9  Eyelid anatomy. Each eyelid consists of an anterior lamella of skin and
orbicularis muscle and a posterior lamella of tarsus and conjunctiva. The orbital
septum forms the anterior border of the orbital fat.
Orbicularis oculi
Upper tarsal plate
Capsulopalpebral fascia
Lockwood suspensory
ligament
Müller’s muscle
Inferior rectus
Superior rectus
Levator palpebrae
Fig. 9.7  The frontalis muscle inserts predominantly into the medial half or
two-thirds of the eyebrow. The medial brow responds to frontalis activation and
elevates, often excessively, in its drive to clear lateral overhang.
Frontalis

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Fig. 9.10  The anatomic variations in the upper eyelid displayed by different ethnic groups and the changes associated with senescence within each group allow for a
convergence of anatomy. (A) The occidental upper eyelid has levator extensions inserting onto the skin surface to define a lid fold that averages 6–8 mm above the lid
margin. The position of the levator–skin linkage and the anteroposterior relationship of the preaponeurotic fat determine lid fold height and degree of sulcus concavity or
convexity (as shown on the right half of each anatomic depiction). (B) In the case of levator dehiscence from the tarsal plate, the upper lid crease is displaced superiorly.
The orbital septum and preaponeurotic fat linked to the levator are displaced superiorly and posteriorly. These anatomic changes create a high lid crease, a deep superior
sulcus, and eyelid ptosis.
A
6–8 mm
Occidental
B
8–13 mm
Deep set
(levator dehiscence)
Müller’s muscle, or the supratarsal muscle, originates on
the deep surface of the levator near the point where the muscle
becomes aponeurotic and inserts into the superior tarsus.
Dehiscence of the attachment of the levator aponeurosis to the
tarsus results in an acquired ptosis only after the Müller’s
muscle attenuates and loses its integrity.14
In the Asian eyelid, fusion of the levator and septum com­
monly occurs at a lower level, allowing the sling and fat to
descend farther into the lid.15,16 This lower descent of fat
creates the characteristic fullness of their upper eyelid. In
addition, the aponeurotic fibers form a weaker attachment to
the dermis, resulting in a less distinct lid fold (Fig. 9.10).
Septal extension
The orbital septum has an adhesion to the levator aponeurosis
above the tarsus. The septum continues beyond this adhesion
and extends to the ciliary margin. It is superficial to the
preaponeurotic fat found at the supratarsal crease. The septal
extension is a dynamic component to the motor apparatus, as
traction on this fibrous sheet reproducibly alters ciliary margin
position (Fig. 9.11). The septal extension serves as an adjunct
to, and does not operate independent of, levator function, as
mistaking the septal extension for levator apparatus and pli­
cating this layer solely results in failed ptosis correction.17
Lower eyelid
The anatomy of the lower eyelid is somewhat analogous to
that of the upper eyelid. The retractors of the lower lid, the
capsulopalpebral fascia, correspond to the levator above. The
capsulopalpebral head splits to surround and fuse with
the sheath of the inferior oblique muscle. The two heads fuse
to form the Lockwood suspensory ligament, which is analo­
gous to Whitnall’s ligament. The capsulopalpebral fascia
fuses with the orbital septum 5 mm below the tarsal border
and then inserts into the anterior and inferior surface of the
tarsus.18 The inferior tarsal muscle is analogous to Müller’s
muscle of the upper eyelid and also arises from the sheath of
the inferior rectus muscle. It runs anteriorly above the inferior
oblique muscle and also attaches to the inferior tarsal border.
The combination of the orbital septum, orbicularis, and
skin of the lower lid acts as the anterior barrier of the orbital
fat. As these connective tissue properties relax, the orbital fat
is allowed to herniate forward, forming an unpleasing, full
lower eyelid. This relative loss of orbital volume leads to a
commensurate, progressive hollowing of the upper lid as
upper eyelid fat recesses.19
The capsulopalpebral fascia and its overlying conjunctiva
form the posterior border of the lower orbital fat. Transection
of the capsulopalpebral fascia during lower lid procedures,

301
Basic science/disease process
C
0 to minimum
Baggy eyelid
D
0 to minimum
Asian
(C) In the aging eyelid, the septum becomes attenuated and stretches. The septal extension loosens which allows orbital fat to prolapse forward and slide
over the levator into an anterior and inferior position. Clinically, this results in an inferior displacement of the levator–skin attachments and a low and anterior position of the
preaponeurotic fat pad. (D) The youthful Asian eyelid anatomically resembles the senescent upper lid with a low levator–skin zone of adhesion and inferior and anteriorly
located preaponeurotic fat. The characteristic, but variable, low eyelid crease and convex upper eyelid and sulcus are classic. (Adapted from Spinelli HM. Atlas of Aesthetic
Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:59.)
Fig. 9.10, cont’d
particularly transconjunctival blepharoplasty, releases the
retractors of the lower eyelid, which can reduce downward
traction and allow the position of the lower lid margin to rise.
Retaining ligaments
A network of ligaments serves as a scaffold for the skin and
subcutaneous tissue surrounding the orbit. The orbital retain­
ing ligament directly attaches the orbicularis at the junction
of its orbital and preseptal components to the periosteum of
the orbital rim and, consequently, separates the prezygomatic
space from the preseptal space. This ligament is continuous
with the lateral orbital thickening, which inserts onto the
lateral orbital rim and deep temporal fascia. It also has attach­
ments to the superficial lateral canthal tendon (Figs. 9.3, 9.12,
& 9.13).20 Attenuation of these ligaments permit descent of
orbital fat onto the cheek. A midfacelift must release these
ligaments to achieve a supported, lasting lift.21
Blood supply
The internal and external carotid arteries supply blood to the
orbit and eyelids (Fig. 9.14). The ophthalmic artery is the first
intracranial branch of the internal carotid; its branches supply
the globe, extraocular muscles, lacrimal gland, ethmoid,
upper eyelids, and forehead. The external carotid artery
branches into the superficial temporal and maxillary arteries.
The infraorbital artery is a continuation of the maxillary artery
and exits 8 mm below the inferomedial orbital rim to supply
the lower eyelid.22
The arcade of the superior and inferior palpebral arteries
gives a rich blood supply to the eyelids. The superior palpe­
bral artery consists of a peripheral arcade located at the
superior tarsal border – the area where surgical dissection
occurs to correct lid ptosis and to define lid folds. Damage to
a vessel within this network commonly results in a hematoma
of Müller’s muscle, causing lid ptosis for 2–8 weeks postop­
eratively. Likewise, on the lower lid, the inferior palpebral
artery lies at the inferior border of the inferior tarsus.
The supratrochlear, dorsal nasal, and medial palpebral
arteries all traverse the orbit medially. Severing these arteries
during fat removal, without adequately providing hemostasis,
may lead to a retrobulbar hematoma, a vision-threatening
complication of blepharoplasty.
Innervation: trigeminal nerve and facial nerve
The trigeminal nerve along with its branches provides sensory
innervations to the periorbital region (Fig. 9.15). The ophthal­
mic division enters the orbit and divides into the frontal,
nasociliary, and lacrimal nerves. The terminal branch of the
nasociliary nerve, the infratrochlear nerve, supplies the medial

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CHAPTER 9 • Blepharoplasty
Fig. 9.11  The orbital septum has an adhesion to the levator aponeurosis above the
tarsus. The septal extension begins at the adhesion of the orbital septum to the
levator and extends to the ciliary margin. It is superficial to the preaponeurotic fat
found at the supratarsal crease. (Adapted from Reid RR, Said HK, Yu M, et al.
Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr
Surg. 2006;117:65–70.)
Müller’s muscle
Levator
aponeurosis
Tarsus
Septal
extension
Orbital
septum
Orbicularis
Fig. 9.12  The orbicularis muscle fascia attaches to the skeleton along the orbital
rim by the lateral orbital thickening in continuity with the orbicularis retaining
ligament. (Adapted from Ghavami A, Pessa JE, Janis J, et al. The orbicularis
retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg.
2008;121:994–1001.)
Orbicularis oculi
Orbicularis retaining
ligament
Nasal bone
Maxilla bone
Frontal bone
Zygomatic bone
Orbicularis retaining ligament
Lateral orbital thickening
Corrugator supercilii
Fig. 9.13  The orbital retaining ligament directly attaches the orbicularis oris at the
junction of its pars palpebrarum and pars orbitalis to the periosteum of the orbital
rim and, consequently, separates the prezygomatic space from the preseptal space.
(Adapted from Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the
ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg.
2002;110:873–884.)
Orbicularis oculi
Prezygomatic space
Orbitomalar ligament
Septum orbitale
Globe
Fig. 9.14  Arterial supply to the periorbital region.
Dorsal nasal artery
Lateral nasal artery
Inferior palpebral artery
Angular artery
Supraorbital artery
Infraorbital artery
Superficial temporal
artery
Lacrimal artery
Zygomaticofacial artery
Transverse facial artery
Facial artery
Supratrochlear artery
Medial palpebral artery (superior)
1. Peripheral arcade
2. Marginal arcade
Medial palpebral artery
(inferior)
Fig. 9.15  Sensory nerves of the eyelids.
Infraorbital nerve
Infratrochlear nerve
Supratrochlear nerve
Supraorbital nerve
Lacrimal nerve
Zygomaticofacial
nerve
Zygomaticotemporal
nerve

303
Basic science/disease process
Youthful, beautiful eyes
The characteristics of youthful, beautiful eyes differ from one
population to another but generalizations are possible and
provide a needed reference to judge the success of various
surgical maneuvers. Attractive, youthful eyes are bright eyes.
Bright eyes have globes framed in generously sized horizontal
apertures (from medial and lateral), often accentuated by a
slight upward tilt of the intercanthal axis (Fig. 9.17). The
aperture length should span most of the distance between the
orbital rims. In a relaxed forward gaze, the vertical height of
the aperture should expose at least three-quarters of the
cornea with the upper lid extending down at least 1.5 mm
below the upper limbus (the upper margin of the cornea) but
no more than 3 mm. The lower lid ideally covers 0.5 mm of
the lower limbus but no more than 1.5 mm.4,15
In the upper lid, there should be a well-defined lid crease
lying above the lid margin with lid skin under slight stretch,
slightly wider laterally. Ideally, the actual pretarsal skin visu­
alized on relaxed forward gaze ranges from 3 to 6 mm in
European ethnicities. The Asian lid crease is generally 2–3 mm
lower, with the distance from lid margin diminishing as the
crease moves toward the inner canthus. Patients of Indo-
European and African decent show 1–2 mm lower than
European ethnicities. The ratio of distance from the lower
edge of the eyebrow (at the center of the globe) to the open
lid margin to the visualized pretarsal skin should never be
less than 3 : 1 (see Fig. 9.1), preferably more.
Scleral show is the appearance of white sclera below the
lower border of the cornea and above the lower eyelid margin.
In general, scleral show is contradictory to optimal aesthetics
and may be perceived as a sign of aging, previous blepharo­
plasty, or orbital disease (e.g., thyroid disease). More than
0.5 mm of scleral show beneath the cornea on direct forward
gaze begins to confer a sad or melancholy aura to one’s
appearance. However, in some youthful persons, the large­
ness of these apertures gives dramatic emphasis to the eyes
and may be considered a strong and positive feature.
conjunctiva, and lacrimal sac. The lacrimal nerve supplies the
lateral conjunctiva and skin of the lateral upper eyelid. The
frontal nerve, the largest branch, divides into the supraorbital
and supratrochlear branches. The supraorbital nerve exits
through either a notch or a foramen and provides sensory
innervations to the skin and conjunctiva of the upper eyelid
and the scalp. The supratrochlear nerve innervates the skin of
the glabella, forehead, medial upper eyelid, and medial con­
junctiva. A well-placed supraorbital block will anesthetize
most of the upper lid and the central precoronal scalp.6,14,23
The maxillary division exits the orbit through one to three
infraorbital foramina. It provides sensation to the skin of the
nose, the lower eyelids, and the upper lid. Dissection is neces­
sary lateral to the infraorbital nerve for successful midfacelift­
ing and around the nerve for placement of tear trough
implants.
The facial nerve exits the stylomastoid foramen and divides
in the substance of the parotid gland into the superior tempo­
rofacial and inferior cervicofacial branches (Fig. 9.16). The
temporofacial nerve divides into the frontal, zygomatic, and
buccal nerves; the cervicofacial nerve divides into the buccal,
mandibular, and cervical nerves. There are significant varia­
tions in the branching of the facial nerve, which is responsible
for facial expression. Innervation of facial muscles occurs on
their deep surfaces. Interruption of the branches to the orbi­
cularis muscle from periorbital surgery or facial surgery may
result in atonicity due to partial denervation of the orbicularis
with loss of lid tone or anomalous reinnervation and possibly
undesirable eyelid twitching.15
The frontal branch of the facial nerve courses immediately
above and attached to the periosteum of the zygomatic bone.
It then courses medially approximately 2 cm above the supe­
rior orbital rim to innervate the frontalis, corrugators, and
procerus muscles from their deep surface. A separate branch
travels along the inferior border of the zygoma to innervate
the inferior component of orbicularis oculi.24 The surgeon
should take great care when operating in this area to avoid
damaging this nerve during endoscopic and open browlifts.
Fig. 9.17  On relaxed forward gaze, the ideal upper lid should rest approximately
2 mm below the upper limbus. The lower lid ideally covers 0.5 mm of the lower
limbus. The ratio of distance from the lower edge of the eyebrow to the open lid
margin to the pretarsal skin ratio should be greater than 3.
3–5X
X
Fig. 9.16  Anatomy of the brow and temporal region. The light green opaque area
denotes the deep temporal fascia and the periosteum where sutures may be used to
suspend soft tissue. Wide undermining, soft-tissue suspension and canthopexy are
safely performed here.
Temporal branches (facial nerve VIII)
Zygomatic branches (facial nerve VIII)
∗∗∗
∗∗∗
∗∗∗∗

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The intercanthal axis is normally tilted slightly upward
(from medial to lateral) in most populations. Exaggerated tilts
are encountered in some Asian, Indo-European and African-
American populations. Such upward tilt of the lateral canthal
axis may give the eye a youthful appearance, which is aes­
thetically pleasing in any ethnic group. The lower lid that
droops in its lateral aspect and the eye with a downward tilt
generally convey to the viewer an aging, ill-health distortion,
or unattractiveness.25
Etiology of aging
In the upper lid, excessive skin due to loss of elasticity and
sun damage is one of the major causes of an aged appearance
in the periorbital area. If there is an excess of skin that hangs
over the lid or the upper eyelid appears to have multiple
folds, it is difficult to have a rejuvenated appearance with
cosmetics alone. In addition to relaxed skin changes, excessive
fat herniation can cause bulging, resulting in a heavy appear­
ance to the upper lid area. Although this fat is normal orbital
fat, it appears to be protruding outward because of the laxity
of the orbital septum, which holds the fat in place. Theoreti­
cally, replacement of the fat into a position that maintains a
normal level of fat in the orbital area seems an optimal solu­
tion. However, this is not easily accomplished and may result
in complications that are difficult to correct. Therefore, the
skin and fat that seem to be in apparent excess should be
treated accordingly.
The etiology of aging changes in the lower lids is similar
in some ways but quite different in others. Aging changes
include relaxation of the tarsal margin with scleral show,
rhytides of the lower lid, herniated fat pads resulting in
bulging in one or all of the three fat pocket areas, and hollow­
ing of the nasojugal groove and lateral orbital rim areas.
Hollowing of the nasojugal groove area appears as dark
circles under the eyes, mostly because of lighting and the
shadowing that result from this defect (Fig. 9.18).26 It is clear
that evaluation of all aspects of aging changes in the lids is
important so the surgeon can plan the most effective operative
procedure.
Diagnosis/patient presentation
Evaluation basics
The first essential step is to look at the patient carefully,
thoroughly, and critically. The surgeon should be seated
directly in front of the prospective patient with the patient’s
eyes at his or her eye level. Note the general impression and
feeling generated from looking at this person (Fig. 9.19).
One should also look for areas of symmetry or asymmetry.
Notice the shape of the eye; the prominence or asymmetry of
the globes; and evidence of exposure, dryness, or injection of
vessels. Look for evidence of decreased tone and dropped
posture of the lower lids. What is the posture of the upper lid?
Are the upper lids symmetric? Is there lid ptosis? At what
level does the upper lid traverse the globe? What levels do
the upper and lower lids sit in relation to the limbus?
Next, have the patient relax the brow and close the eyes.
Do the lids close? Then ask the patient to open the eyes. Is it
necessary to raise the brows to effect comfortable forward
Fig. 9.18  Morphed digital photography (split right half = current preoperative
photograph; split left half = photograph 20 years ago), demonstrating descent of
periorbital fat and skin during the aging process. (From Odunze MO, Reid RR, Yu
M, et al. Periorbital rejuvenation and the African-American patient: a survey
approach. Plast Reconstr Surg. 2006;118:1011–1018.)
vision? Does the corrugator frown increase in prominence
with the eyes closed and the forehead relaxed? Is there trans­
verse brow wrinkling? Is one brow lower? Which one and
how much? Is there a prominent frown?
Assess the lower lid tone by pulling the lid away from the
globe and releasing, making sure the patient does not blink
(modified snap test). Does each lid spring back immediately,
reluctantly, or not at all? Is it held against the globe by only the
tear seal? Most people presenting for blepharoplasty have a
significant decrease in their lower lid tone, often asymmetric.
What, if anything, would improve the aesthetic appearance
of the eyes and periorbital region? Are there festoons or deep
grooves (i.e., nasojugal grooves or tear trough deformities)?
Is there excess skin, muscle, or fat? Quantitate any excess soft
tissue on a simple eye diagram. Does restoration of lateral
canthal posture correct the illusion of excess skin on the lower
eyelid? Does it diminish it? Does the orbital septum appear
to be excessively relaxed? Note the tilt of the intercanthal axis
or lack thereof.
The “four-finger lift” is performed by encircling the outer
orbit with the tips of the index, middle, ring, and little fingers
on one hand. With the index and middle fingers above the
lateral brow, place the ring finger lateral to the canthus and
little finger beneath the lateral canthus just lateral to the malar
prominence. Gently move the four fingers posteriorly and
superiorly to lift the lateral brow, canthus, and cheek. If this
test restores youthfulness and attractiveness, a canthopexy,
browlift, and midfacelift may be beneficial.
Medical and ophthalmic history
A thorough history and physical examination should be per­
formed before surgery (Box 9.2). In addition, an adequate
eye history encourages positive outcomes and reduces eye
complications.
Contact lens wear poses particular risks when eyelid
surgery is performed. The natural progression of aging dries
the eyes out, and long-term contact lens wearing hastens this

305
Diagnosis/patient presentation
process considerably. Traditional blepharoplasty techniques
consistently produce vertical dystopia with increased scleral
exposure, making the lens wear difficult if not dangerous.
Ptosis and canthopexy surgery may alter the corneal curvature
and require that contacts be refitted. The patient should dis­
continue contact lens wear in the perioperative period to
allow healing without the need to manipulate the eyelids.
Levator dehiscence or attenuation commonly accompanies
long-term hard contact lens wear, caused by the mechanical
stresses posteriorly from the rigid lens rubbing against the
posterior lamella of the lid.27
The same population that seeks aesthetic surgery also
gravitates toward refractive surgery, such as LASIK (laser-
assisted in situ keratomileusis). A history of such surgery is
necessary information because periorbital surgery, particu­
larly canthopexies and levator surgery, can affect the refractive
characteristics, cause mechanical irritation of the conjunctiva
and cornea, or affect the corneal flap.28 Ptosis repair or debulk­
ing of heavy upper lids can change the corneal curvature,
resulting in the need for a new prescription for eyeglasses.
Canthopexy normally raises the contact point of the lid with
BOX 9.2  Important information to obtain during history and physical
examination
• Medication use: particularly anticoagulants, anti-inflammatory
and cardiovascular drugs, and vitamins (especially vitamin E).
• Herbal supplement use: herbs represent risks to anesthesia and
surgery, particularly those affecting blood pressure, blood
coagulation, the cardiovascular system, and healing.
• Allergies: medication and type.
• Past medical history: especially hypertension, diabetes,
cardiovascular and cerebrovascular disease, hepatitis, liver
disease, heart disease or arrhythmias, cancer, thyroid disease,
and endocrine disease.
• Bleeding disorders or blood clots.
• Psychiatric disease.
• Alcohol and smoking history.
• Recreational drug use, which may interact with anesthesia.
• Exposure to human immunodeficiency virus and hepatitis virus.
• Any history of facial herpes zoster or simplex.
Fig. 9.19  Mid-cheek deflation due to loss of superficial and deep fat. SMAS, superficial musculoaponeurotic system. (Adapted from Rohrich RJ, Pessa JE. The fat
compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227.)
Laxity of the orbital septum
Laxity and descent of the orbicularis oculi
Laxity of the SMAS covering zygomaticus muscles
and other elevators of the upper lip
Deepening of the nasolabial fold
Jowl formation
Descent of the lid-cheek junction
Descent of the check fat pad with laxity of the orbitomalar ligament

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CHAPTER 9 • Blepharoplasty
anesthetic improvement results from removal of benign
lesions about the eyes, especially those that rise above the lid
margin. Any cancerous (or precancerous) lesions must be
removed before any aesthetic procedure is performed to
preserve eyelid skin for reconstruction, if needed.
Eyelid measurements are documented for use during ptosis
surgery and, if necessary, for insurance purposes. In the eyelid
of the white individual, the aperture (distance between the
upper and lower eyelids) averages 10–12 mm. The margin–
reflex distance (MRD), measured from the light reflex on the
center of the cornea to the upper eyelid margin, ranges from
3 to 5 mm. True blepharoptosis is defined by the degree
of upper lid infringement upon the iris and pupil. As the
MRD decreases towards zero, the severity of blepharoptosis
increases. Before method selection, the levator function must
be determined by measuring the upper eyelid excursion from
extreme downward gaze to extreme upward gaze; it generally
ranges from 10 to 12 mm. If ptosis exists, the type of repair
depends upon the severity of the ptosis and the reliability of
the levator to recreate smooth, upper lid elevation. Moderate
or severe levator dysfunction corresponds to eyelid excursion
of 7–9 mm and 4–6 mm, respectively. A deep upper lid sulcus
with a high lid fold in the presence of a droopy eyelid usually
indicates a levator dehiscence, which is often unilateral or
asymmetric.31,32
Pseudoptosis occurs when excess upper lid skin covers the
eyelid, depressing the eyelashes, forming hooding and simu­
lating ptosis. It is easily differentiated from true ptosis by
simply elevating the brow or the hooded skin itself to deter­
mine the true resting lid level.33 Photographic evidence of this
is often necessary for insurance purposes when a levator
aponeurosis repair or a excisional blepharoplasty is planned.
When the hooded skin hangs over the lashes, the lashes turn
downward and sometimes interfere with vision or rub against
the cornea. True trichiasis (misdirected lashes) may also exist,
but inward-turning lashes can be trained to return to their
natural posture after eyelid repair with lash rotation.
Brow ptosis is a common aspect of facial aging. It adds
weight and volume to the upper eyelid, to develop, or exac­
erbate, eyelid ptosis. The more ptotic brow is often selectively
elevated or over-elevated by frontalis muscle contraction,
which may confuse the surgeon as to whether eyelid ptosis or
retraction exists. The ability to differentiate the causes of
droopy eyelids – brow ptosis (brow weight resting on the
eyelids), dermatochalasis (excess skin), and blepharoptosis
(levator attenuation or dehiscence) – will enable the surgeon
to select the proper correction.
Unilateral as well as bilateral upper eyelid retraction is
commonly associated with prominent globes, which are often
asymmetrically proptotic. Most commonly, it is the result of
Graves’ ophthalmopathy, which can lift the lid above the
superior limbus. A thyroid evaluation is appropriate before
any surgery to correct retraction. If it is stable for more than
6 months, levator recession surgery can be combined with fat
reduction blepharoplasty, but lid skin should rarely, if ever, be
removed.
Long-term soft contact lens wear is also a common cause
of lid retraction that raises the lid to the superior limbus or
above. Congenitally shallow or traumatically small orbits are
also a cause of lid retraction, as is idiopathic retraction.27 If the
retraction persists in spite of taping the brow or lid tissue out
of the way of vision, the surgery to correct the retraction must
the globe and can increase the tension of the lid with the globe
and can increase the tension of the lid against the cornea,
affecting corneal curvature. It can cause conjunctival chemosis
or produce corneal erosion early postoperatively. Dry eye
exposure problems are most prevalent in patients who have
undergone LASIK surgery because the flap disrupts corneal
innervations, forming an anesthetic effect that suppresses
tear production. When in doubt, such patients should be
reviewed by their refractive surgeon before undergoing
blepharoplasty.
One should check for a history of other eye procedures,
including glaucoma surgery (forms a bleb of conjunctival
tissue on the superior limbus), retinal, strabismus, and cata­
ract surgery. Evaluate carefully for a history as well as physical
evidence of facial muscle weakness, extraocular muscle
imbalance, Bell palsy, or trauma, in addition to orbicularis
hyperactivity such as blepharospasm or hemifacial spasm.
Any ocular condition may affect the type or result of eyelid
surgery.29
Superior or lateral visual field loss suggests functional
ptosis or pseudoptosis. A 12–20° or a 30% improvement of the
superior visual field, between a taped and untaped upper lid,
may qualify for medical necessity.
Chronic eye irritation, such as tearing, dryness, excessive
blinking, discharge, eyelid margin inflammation, crusting,
burning, or itching, must be brought under control before any
surgery. Dry eyes should be aggressively sought out and
treated before surgery.
Dry irritated eyes before surgery will lead to irritated
eyes after surgery, and the surgeon may be blamed. On
questioning, most patients will rarely admit to dry eyes,
although it is known that the eyes dry out considerably
throughout our lifetime. Treatment options include artificial
tears, ointment, anti-inflammatory drops, and punctal plugs
or punctal closure.29,30
Exophthalmos, unilaterally or bilaterally, associated with a
thyroid disorder should be completely stabilized for approxi­
mately 6 months before elective aesthetic surgery. However,
there may be an urgent requirement in active Graves’ disease
to perform procedures to protect the globe or the vision.13
Ocular examination
An ocular examination before elective periorbital aesthetic
surgery should include all of the elements covered in the
following sections (Fig. 9.20).
Visual acuity
The most essential preoperative test is assessment of visual
acuity, by the surgeon or ophthalmic colleague. Document the
vision with the patient wearing glasses or contact lenses if
they are needed. Note any vision deficits and have them
evaluated before surgery. The most common cause of unrec­
ognized loss of vision is amblyopia (lazy eye), which is present
in 2% of the general population. A patient may often be
unaware of the unilateral amblyopia (or any loss of vision)
until the eyes are tested individually.
External examination
The periorbital skin and tissues are examined for benign or
malignant lesions, including xanthelasma, syringoma, basal
cell carcinoma, benign moles, skin tags, and chalazia. Marked

307
Diagnosis/patient presentation
A
Visual acuity via Snellen chart
B
Schirmer’s test
C
Snap back lost
D
Malar support
Positive vector
Negative vector
Fig. 9.20  (A–E) Evaluation of the patient should include an appreciation of visual acuity (with and without correction), baseline tear production, intrinsic lid tone, lower
eyelid support, and tear film quality. The tests performed and their interpretation should be tailored by the clinician within the context of each patient and applied on an
individual basis. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:31.)
E
Tear film breakup time

308
SECTION I
CHAPTER 9 • Blepharoplasty
globe (i.e., the optic nerve or brain). Refractive errors, amblyo­
pia, and corneal or retinal problems will not present with an
abnormal papillary response.
Extraocular muscles
The extraocular muscles are tested for deviations, motility
problems, or restrictions. Eye deviations often present with
amblyopia unilaterally and corresponding reduced vision.
One should examine the patient for the presence of an intact
Bell phenomenon, an upward and outward rotation of the
cornea with lid closure. This can be accomplished by gently
forcing the upper eyelids open during closure. The presence
of an intact Bell reflex affords protection for the eye and cornea
in the event of incomplete eyelid closure. If the eyelid fails to
close during sleep, the cornea may remain uncovered and dry
out. Thus, the absence of Bell phenomenon raises the risk for
postoperative problems, especially in those with pre-existing
problems or dry eyes.29
Globe
The globe is examined for clarity of the cornea, iris, and lens.
The corneal light reflex should be sharp and no lesions noted
anywhere on the globe. If there is any question of a corneal
defect, a slit-lamp examination is needed, either by a surgeon
or by an ophthalmologist on referral. Any whitening of the
cornea is possibly an infectious infiltrate and should be treated
aggressively with antibiotics.
Tear film
Assessment of tear production is a necessary but unreliable
task. Schirmer testing consists of placing filter paper strips in
Fig. 9.21  The anatomy of the tear trough deformity demonstrates the muscular
triangle formed by the orbicularis oculi, levator labii superioris, and levator labii
superioris alaeque nasi. (Adapted from Hirmand H. Anatomy and nonsurgical
correction of tear trough deformity. Plast Reconstr Surg. 2010;125:699–708.)
Tear trough
Orbicularis oculi
Levator labii superioris
alaeque nasi
Levator labii superioris
Fig. 9.22  Tear trough test. The ability to place the side of a finger into the bony
furrow under the nasojugal groove suggests a potential benefit from tear trough
augmentation.
Tear trough
either precede or accompany the eyelid or brow surgery.
Retraction can also be accompanied by contralateral blepha­
roptosis according to Hering’s law.
Orbits and malar eminence
The relative position of the globe to orbital anatomy greatly
influences appropriate surgical technique. There is a normal
10–12 mm projection of the globe seen in a profile photograph,
as measured from the lateral orbital rim at the level of the
canthal tendon to the pupil. Proptosis and enophthalmos are
relative anterior and posterior displacement of the globe,
respectively. Hertel exophthalmometry can be used to quan­
titate the degree of relative projection for documentation
purposes.15,24
The tear trough is at the inferior orbital rim most medially,
triangulated by the orbicularis, levator labii superioris alaeque
nasi, and levator labii superioris muscles (Fig. 9.21). The
indentation is at the junction of the thin eyelid skin above and
the thicker and different nasal and cheek skin below, with
attenuated subcutaneous tissue overlying the maxillary bone.
It is the deepening of this groove that leads to true indentation
and significantly impacts facial appearance. The relative lack
of subcutaneous tissue in this area is subject to worsening
concavity with aging. The cause of the deformity is due to a
combination of orbital fat herniation, skin laxity and malar
volume loss, and ptosis of skin and subcutaneous tissue.26 The
ability to place the side of the finger into the bony furrow
under the nasojugal groove suggests a potential benefit from
a tear trough implant or the addition of soft-tissue augmenta­
tion (Fig. 9.22).34
Pupils
The pupils are evaluated for direct and consensual response
to light. An abnormal result indicates a problem behind the

309
Patient selection
maneuvers required be organized in a meaningful way (Box
9.4).35 Preoperative planning should take place with the
patient upright under good lighting and with complete facial
relaxation. It is also important to document the brow, canthus,
and upper and lower eyelid posture and position, and all
other desired alterations preoperatively. The preoperative
photographs and surgical plan should be easily visible to the
surgeon during the entire surgery.
Skin and muscle are quantified for excision in millimeters
or any standardized system comfortable to the surgeon. Fat
excision is measured in terms of cubic centimeters (cc) or
milliliters (mL). A pea-sized amount is roughly equivalent to
0.5 cc or 0.5 mL. Determination of fat excision should be
approximated in multiples of this standard measure. Mea­
surements should be consistent with the patient in a vertical
position to avoid lid hollowness or concave depressions. In
proptotic patients, more aggressive fat excision offers the
possibility of reduction of globe projection, but skin removal,
of any quantity, is most likely contraindicated.
Anatomic-directed therapy
Upper eyelid position
In the typical person with the brow in an aesthetically pleas­
ing position, 20 mm of upper lid skin must remain between
the bottom of the central eyebrow and the upper lid margin
to allow adequate lid closure during sleep, a well-defined lid
crease, and an effective and complete blink.
Lower eyelid tonicity
The presence of atonic lower lids and lateral canthal laxity
may give the impression that there is excess skin requiring
removal. However, lower lid posture and optimal lateral
canthal position should be restored manually before deter­
mining the amount of skin and other tissues to be removed.
Lid and canthal restoration frequently eliminates skin excess.
When skin removal is indicated, the surgeon will often need
to remove skin more centrally than laterally.9,36
Eyelid ptosis or retraction
A patient’s response to phenylephrine testing can also guide
therapy. Müller’s muscle receives its innervation from sym­
pathetic fibers within the oculomotor nerve and can be directly
activated with α-adrenergic eye drops. In general, the patient
receives three drops of 2.5% phenylephrine over the course of
the lateral third of the lower eyelid. The irritation of any
foreign object against the globe stimulates reflex tearing, pos­
sibly yielding a deceptively good test result. A topical anes­
thetic (tetracaine or proparacaine) eases discomfort and reflex
tearing, giving a better assessment of basal tear secretion.
After 5 min, normal tear production should be greater than
15 mm; 5–10 mm indicates borderline tear secretion, and less
than 5 mm is hyposecretion.
Basal tear production diminishes with age in all persons to
a degree that usually becomes symptomatic by 50 years of
age. In contact lens wearers, allergy sufferers, people with
arthritis, and those with autoimmune diseases, this process
accelerates and they often become symptomatic in their 30s.
It is important for patients to be aware of this age-related
decrease in tear production preoperatively.
Photographic documentation
No other area of cosmetic surgery is more dependent on
accurate photography than the periorbital region (Box 9.3). It
is essential in documenting existing anatomy and pathologic
changes. Accurate photography assists in surgical planning,
intraoperative decision-making, and documentation of results,
and it may be necessary for legal protection.35
Unintentional deception in eye appearance
There is a natural phenomenon that prevents surgeons from
fully appreciating the potential adverse effects of the surgery.
Women, and some men to whom appearance is important,
subconsciously and automatically modify their appearance
when they are confronted with a mirror, a camera, or someone
carefully examining their appearance. They lift the chin, tilt
the head backwards, elevate the eyebrows, and smile slightly.
This gives the illusion of elevated lower eyelids (although it
alters the intercanthal axis, turning it downward), and it
cleans the upper lids. These unintentional changes simulate a
browlift, although the medial brow is typically disproportion­
ately elevated. This disguises from the surgeon, both on direct
inspection and in photographs, the accurate preoperative
appearance and true outcome of the surgery. When the mirror
and camera disappear, the brow drops, the corrugators con­
tract, and the lower lids drop to their natural posture. This
then, is the face the real world is seeing.
Patient selection
Operative planning
Before surgical planning, one must have a meaningful con­
ceptualization of the desired result. Only then can the surgical
BOX 9.3  Recommended photographic views
• Full face, upright (at rest) frontal, oblique, and lateral views.
• Full face, upright and smiling.
• Direct periorbital views in upward gaze and downward gaze and
with eyes gently closed.
• A view with a finger slightly elevating the brows with the eyes
open and another with the eyes closed.
BOX 9.4  Preoperative periorbital plan
The preoperative periorbital plan should include the following:
• The patient’s specific concerns and desires for improvement.
• Brow position.
• Lower eyelid tonicity.
• Eyelid ptosis, retraction, or levator dehiscence.
• Exophthalmos or enophthalmos.
• Supraorbital rim prominence or hypoplasia.
• Suborbital malar and tear trough deformities.
• Excision of necessary skin, muscle, and fat – only if necessary.

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CHAPTER 9 • Blepharoplasty
canthopexy attachment commonly needs to be placed higher
than is aesthetically most desirable. In addition, the canthal
fixation must be placed more anteriorly to accommodate the
proptotic globe, and occasionally the canthus needs an exten­
sion to reach the bone or augmentation of the orbital rim.
Tear trough deformities
The tear trough deformity is a type of relative infraorbital
malar hypoplasia where there is an asymmetric bony depres­
sion along the medial infraorbital rim. Tear trough implants
(see Fig. 9.19) are reserved for severe deformities where the
volume of surgical fat repositioning is inadequate and cost of
filler exceptional.34,40
If the surgeon can place the side of his or her finger into
this diagonally recessed bone, augmentation of the concavity
should be considered. Factors such as age, skin quality, and
severity of the hollowing dictate the appropriate procedure.
Young patients with good skin quality will benefit from
hyaluronic acid fillers placed between the deep dermis and
orbicularis oculi fascia. This outpatient procedure can be
performed concomitantly or weeks after blepharoplasty once
perioperative swelling subsides (Fig. 9.23). Older patients
require orbital fat repositioning from the medial and central
compartments during a transconjunctival blepharoplasty.
Alternative soft-tissue injectables include autogenous fat,
hydroxyapatite, and micronized acellular dermis.
Optimal brow positioning
Aesthetic surgery of the forehead is thoroughly reviewed in
Chapter 7. Brow positioning is a cornerstone of blepharoplasty
surgery. Most of the aesthetic improvement of the upper
orbital region comes from proper brow positioning and
canthopexy. When advocating periorbital rejuvenation, it is
therefore appropriate to consider repositioning the resting
brow position when considering blepharoplasty.41
A low resting brow is extremely common and occurs in
people of all ages. The lateral overhang of the eyebrow, upper
eyelid, and juxtabrow skin can cause visual field obstruc­
tion. These tissues progress downward from degenerative
changes resulting in stretching of the forehead and brow
tissues. The recurring pull of the orbicularis, corrugator, and
procerus muscles contributes to descent of the brow. Many
adults presenting for aesthetic surgery have significant – but
often undetected – “resting” brow ptosis. This phenomenon
has been termed “compensated brow ptosis”, where brow
ptosis remains undetected because of the compensatory
activation of the frontalis muscles to clear the obstructing lid
overhang.42
If the brow is simply elevated to its proper position, the
seemingly elevated upper lid tissue either disappears or
diminishes dramatically, leaving most if not all of the irre­
placeable eyelid skin. Furthermore, any scars resulting from
skin excision, when it is required, remain short and need not
extend beyond the orbital rim.
If a blepharoplasty alone is performed in these patients, the
visual incentive to elevate the brow disappears. The frontalis
relaxes and the brow drops – exaggerating the aged, tired look
that the blepharoplasty was supposed to correct (Fig. 9.24). In
addition, the weakened frontalis now fails to oppose the cor­
rugators and relaxes its pull on the glabellar and interbrow
1 min and a final drop applied 1 min later. After several
minutes, the patient’s eyelid position is re-measured. Posterior
approaches to ptosis correction are typically reserved for
patients with mild ptosis (1–3 mm) and a positive response.
In patients with unilateral eyelid ptosis, one may be
tempted to operate on the normal eye, which may appear to
be retracted, instead of the “disguised” ptotic eye. As a con­
sequence of Hering’s Law, both levators are energized equally
in an attempt to clear the visual axis of the ptotic lid, thereby
making the normal lid appear retracted. Covering each eye
separately and observing the lid position often leads to the
discovery of the ptotic eye as the pathologic source. The
retracted eye will drop to its normal position once the ptotic
eye is covered, only to have the ptotic eye rise when it is
uncovered. Symmetric elevation of the brow is similarly
helpful in patients in whom asymmetric brow pseudoptosis
obstructs peripheral vision.
It is easy to correct existing true ptosis, or true retraction,
at the time of blepharoplasty surgery. Even when ptosis is
mild, correction avoids the probable worsening of the ptosis
by the additional insults of a weakened levator due to surgical
trauma, an edematous or bruised lid, a hematoma in the
levator muscle, a cicatrix associated with even the smallest
amount of orbital bleeding, or a simple asymmetric surgical
rendering.37,38
Globe position and malar prominence
The position of the globe greatly affects the procedural choices
and quality of outcome in periorbital surgery. The high fre­
quency of asymmetry in globe prominence is often not
appreciated in aesthetic periorbital surgery. Unless it is recog­
nized and treated appropriately, unfortunate outcomes are
almost inevitable.
In patients with infraorbital malar hypoplasia or tear
trough deformity, it is not possible to achieve optimal aesthetic
results without some contour correction. If the globe extends
anteriorly past the inferior orbital rim, lower lid surgery will
increase scleral show and lid deformity unless the lid and
canthal posture are raised, the orbital rim–malar complex is
enhanced, or the prominent globe is retropositioned. This
bone deficit of the lower orbit, which occurs most commonly
in men, creates an exophthalmos of the lower half of the globe.
These patients can be described as vector-negative or having
hemiexophthalmos. A youthful, vector-positive profile con­
sists of an inferior orbital rim and malar soft tissue that are in
the same plane of the globe (see Fig. 9.20).39
When a vector-negative profile exists, there is a relative
scarcity of lower eyelid skin. Lids must not be shortened
either by blepharoplasty. To do so causes the lid margins to
ride down the globe surface, resulting in more scleral show
and pathologic exposure. Similar to proptotic patients, sus­
pension canthopexy must be placed more superiorly and
anteriorly to prevent scleral show. This relative lack of lower
lid skin can also be increased with lower lid spacers, canthal
tendon elongation, or orbital fat reduction.
In exophthalmos, tightening the lower lid, even when it is
repositioned with a canthopexy or a lid shortening, may cause
some severe potential problems. When it is horizontally
tightened, the lid takes the course of least resistance and
migrates under the proptotic globe, especially when the
canthal attachment is not lifted. To overcome this, the

311
Treatment/technique
Surgery is not always the first and immediate response.
Patients in their 30s and 40s will frequently benefit from
office-based, non-surgical care. Chemodenervation can mini­
mize the early appearance of brow ptosis and fine-line rhytides
along the lateral orbital rim. Fillers, which range in cost and
resorption rates, can augment the infraorbital rim in negative
vector patients. Photodynamic and laser therapy are alterna­
tives to treat minor skin excess. It is prudent to develop lasting
relationships with patients and provide the least invasive,
targeted procedure needed for rejuvenation.
Upper eyelid surgery
The most common approach to upper blepharoplasty has
been the en bloc excision of skin, muscle, and fat in an attempt
to debulk the eyelid. However, traditional blepharoplasty
may not always fulfill the promise of producing youthful,
aesthetically pleasing eyelids. In particular, aggressive upper
skin, thereby accentuating the glabellar crease and frown – a
heavy price to pay for an aesthetic procedure designed to
rejuvenate the face. These features can be prevented by a
concomitant or preceding temporal browlift that restores the
eyebrows to their proper position and checks against a
profound drop in the resting posture of the brow after
blepharoplasty.
Treatment/technique (Video 9.1 )
Continuum of aesthetic enhancement
The goal of the eyelid surgeon when evaluating patients is to
develop an individualized treatment plan for the classic
symptoms of periorbital aging. While surgical techniques
deliver the most dramatic and lasting results, these procedures
are not without inherent risks and postoperative recovery.
Fig. 9.24  Compensated brow ptosis – continuous obligatory frontalis muscle contraction to clear the periorbital tissues (and to affect comfortable and unobstructed forward
vision).
Fig. 9.23  (A) Preoperative and
(B) postoperative photograph demonstrating
tear trough augmentation with fillers.
A
B

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CHAPTER 9 • Blepharoplasty
proportion to the amount of skin removed. A small pretarsal
skin and muscle flap are dissected from the aponeurosis and
septum adhesion. After sharply disinserting the aponeurosis
from the tarsus, pretarsal fatty tissue can be removed to
debulk the pretarsal skin. Key components of the anchor
blepharoplasty include minimal skin excision (2–3 mm)
extending cephalad from the tarsus. A 1–2 mm sliver of
orbicularis must be removed in proportion to the amount of
skin removed. A small pretarsal skin and muscle flap are
dissected from the aponeurosis and septum adhesion. After
sharply detaching the septal extension from the tarsus, pret­
arsal fatty tissue can be removed to debulk the pretarsal skin.
Mattressed anchor sutures are placed connecting the tarsus
to the aponeurosis and pretarsal skin (Fig. 9.27). Finally, a
running suture approximates the preseptal skin incision.
Orbital fat excision
A relative excess of retroseptal fat may be safely excised
through an upper eyelid blepharoplasty incision. A small
septotomy is made at the superior aspect of the skin excision
into each fat compartment in which conservative resection of
redundant fat has been planned. The fat is teased out bluntly
and resected using pinpoint cautery. This fat usually includes
the medial or nasal compartment, which contains white fat.
Yellow fat in the central compartment is usually more super­
ficial and lateral. Gentle pressure on the patient’s globe can
reproduce the degree of excess while the patient lies recum­
bent on the operating room table (Fig. 9.28). Overall, under­
correction is preferred to prevent hollowing, which can be
dramatic and recognized as an A-frame abnormality.
The attenuated orbital septum may be addressed by using
selective diathermy along the exposed caudal septum.
Inflammation-mediated tightening can enhance septal integ­
rity. Septal plication aid is unnecessary and may induce a
brisk, restrictive inflammatory response.
Blepharoptosis
During upper blepharoplasty, with the septum open and the
aponeurosis and superior tarsus exposed, there is an ideal
opportunity to adjust the level of the aperture. Inappropriate
aperture opening can be due to upper lid ptosis or upper lid
retraction. It is not uncommon for there to be ptosis of only
the medial portion or retraction of only the lateral portion. A
surgeon should not hesitate to take advantage of this oppor­
tunity for repair. True ptosis repair involves reattachment of
the levator aponeurosis to the tarsus, with or without shorten­
ing of applicable structures (e.g., aponeurosis, Müller’s
muscle, and tarsus).32,33
Approximately half of all patients presenting for periorbital
aesthetic surgery have one brow that is several millimeters
lower than the other. Half of those have significant unilateral
ptosis on the side of the lower brow from the “mechanical
weight” of the excess skin. Half of those patients’ ptosis will
be corrected by manually raising the brow on the affected
side. The other half have true ptosis, which most likely has
gone undiagnosed because of overhanging tissue.
Surgical technique
There are a variety of techniques to address blepharoptosis
but they are outside the scope of this chapter. Oculoplastic
lid skin excision performed as standard procedure is both a
functionally and aesthetically harmful form of upper eyelid
blepharoplasty.
Simple skin blepharoplasty
Preserving orbicularis muscle and preaponeurotic fat has
been shown to enhance aesthetic outcomes for a variety of
presentations. Many who present for upper blepharoplasty
hope for a result that is aesthetically enhancing yet avoids a
“surgical appearance” or hollowed upper periorbital. Volume-
maintaining methods by preserving the orbicularis muscle
can be used to preserve or restore a youthful convexity of the
upper eyelid–brow junction. Excessive skin and facial soft-
tissue descent may rest more on the deflationary effects of
regional volume loss rather true, gravitational descent.
A youthful appearance is gained with maintenance or
enhancement of volume and a shorter pretarsal fold. Closure
of the skin ellipse after skin resection and orbicularis preser­
vation can improve supratarsal and infrabrow volume. The
effects of muscle preservation can be similar to results achieved
by soft-tissue filler. Muscle resection should be reserved for
patients with orbicularis redundancy or relative hypertrophy.
The primary indication for selective myectomy is upper eyelid
fold disparities and mild lid ptosis.
When skin-only excision is elected, it should occur above
the supratarsal fold or crease, leaving that structure intact.
This retains most of the definition of an existing lid fold. If
eyelid skin containing the crease is part of the excision, the lid
fold becomes ill-defined, indistinct, and irregular. The supra­
tarsal fold is located approximately 7–8 mm above the ciliary
margin in women and 6–7 mm in men. The upper marking
must be at least 10 mm from the lower edge of the brow and
should not include any thick brow skin. The use of a pinch
test for redraping the skin is helpful.
The shape of the skin resection is lenticular in younger
patients and more trapezoid-shaped laterally in older patients.
The incision may need to be extended laterally with a larger
extension, but extension lateral to the orbital rim should be
avoided if possible, to prevent a prominent scar (Fig. 9.25).
Similarly, the medial markings should not be extended medial
to the medial canthus because extensions onto the nasal side
wall result in webbing. At the conclusion of the case, the
patient should have approximately 1–2 mm of lagophthalmos
bilaterally. Fig. 9.26 displays the predictable, restorative out­
comes that can be achieved with skin excision alone.
Anchor (or invagination) blepharoplasty
Anchor blepharoplasty involves the creation of an upper
eyelid crease by attaching pretarsal skin to the underlying
aponeurosis. The advantage of an anchor blepharoplasty is a
crisp, precise, and well-defined eyelid crease that persists
indefinitely. Such lids are more desirable in women than in
men because they tend to glamorize the orbital region. The
disadvantage is that it is more time-consuming, requires
greater surgical skills and expertise, and encourages greater
frontalis relaxation as a result of more effective correction of
the overhanging pseudoptotic skin. It accomplishes that task
while minimizing upper lid skin removal.43
Key components of the anchor blepharoplasty include
minimal skin excision (2–3 mm) extending cephalad from the
tarsus. A 1–2 mm sliver of orbicularis must be removed in

313
Treatment/technique
Fig. 9.26  (A) Preoperative and (B) postoperative photograph depicting predictable results with simple skin excision blepharoplasty anchor technique in addition to levator
advancement with reinsertion into tarsus.
A
B
Fig. 9.25  Simple skin excision blepharoplasty. (A) Digital traction and light pressure by the
surgeon allow smooth quick incisions. (B) The skin may be elevated with the orbicularis
muscle in one maneuver, proceeding from lateral to medial. (C) The orbital septum is then
opened, exposing the preaponeurotic space. The underlying levator aponeurosis is protected
by opening the septum as cephalad as possible. (Adapted from Spinelli HM. Atlas of Aesthetic
Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:64.)
A
Incision
B
Skin and orbicularis muscle resection
Levator aponeurosis
Orbital septum
C
Pressure on globe causes
medial fat pad bulge
Central fat pad (preaponeurotic)
on levator aponeurosis

314
SECTION I
CHAPTER 9 • Blepharoplasty
relatively retracted side can also reduce the need for formal
lid retraction surgery.38
The key components of formal lid ptosis correction include
correct identification of the distal extensions of the aponeurosis
and the orbital septal extension.12 The superior edge of the
tarsus is freed from any dermal or tendinous extensions.
Leaving a small cuff of filmy connective tissue (approximately
1 mm) on the tarsus will minimize bleeding from the richly
vascularized area. Ensure that there is complete hemostasis by
using a fine forceps cautery, lifting all lid tissues away from the
cornea and globe before cauterizing. Anchor the upper third of
the tarsus to the remaining levator with 5-0 silk suture, placed
surgeons advocate posterior approaches to ptosis correction
that rely on resecting Müller’s muscle and shortening the
posterior lamella.44 We will thus present our preferred tech­
nique for uncomplicated involutional ptosis. A ptosis repair
may be undertaken in combination with a skin excision upper
blepharoplasty. The difference is adjusting (or advancing) the
point of attachment of the levator aponeurosis to the tarsus.
There is a significant learning curve to performing a ptosis
repair, and even then, the ability to get perfect symmetry is
elusive.
In the setting of mild upper eyelid ptosis (approximately
1 mm), where the decision has been made to avoid a formal
lid ptosis procedure, selective myectomy of the upper eyelid
orbicularis can be performed to widen the lid aperture. The
amount of muscle to be resected depends on a host of factors,
including the severity of relative lid ptosis, brow position, and
fold disparity (Fig. 9.29). The orbicularis muscle is then
resected selectively using cautery that strips orbicularis
muscle from the underlying orbital septum. The amount of
resection is titrated depending on the amount of effect desired.
For 1 mm or less of relative upper lid ptosis, resection of at
least 3–4 mm of orbicularis is required. The effects are more
powerful the closer the resection is to the inferior edge of the
elliptical wound. No attempt is made to close orbicularis
muscle in this resection, which could increase the risk of
lagophthalmos. On the opposite side, which is likely retracted,
a slight ptosis can be induced by resecting a larger degree of
orbicularis and/or lowering the upper eyelid margin. Placing
the upper eyelid incision and crease 2 mm or higher on the
Fig. 9.27  Anchor blepharoplasty technique. Attaching the dermis of the pretarsal
skin flap to the superior aspect of the tarsus and to the free edge of the
aponeurosis. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular
Surgery. Philadelphia, PA: Saunders; 2004:69.)
Fig. 9.28  Simple skin excision blepharoplasty. (A) The medial fat pad may require
digital pressure to expose and grasp; however, care should be taken not to overly
resect fat when using digital pressure techniques. (B) Closure may then be
performed with a combination of interrupted and running intracuticular sutures.
(Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
Philadelphia, PA: Saunders; 2004:65.)
A
Medial fat pad removed
Whitnall’s ligament
Levator aponeurosis
B
Intracuticular running
suture
Closure
Interrupted sutures

315
Treatment/technique
techniques to maximize the aesthetic outcome and the other
towards more conservative techniques to minimize the risk of
complications. Although excellent aesthetic results can be
achieved with transcutaneous lower blepharoplasty, lid
retraction and ectropion are concerning complications.
Conservative excisional techniques center on the concept
of fat preservation. Transconjunctival lower blepharoplasty,
although more conservative, does not eliminate the risk of lid
malposition. An effective, lasting procedure should address
the extrinsic and intrinsic support of the eye, which is weak­
ened during the aging process.
In the classic concept of lower lid blepharoplasty, the
concern of the surgeon who resects lid fat is the difficulty of
estimating the correct amount of fat to remove.45 If this is not
done correctly, this miscalculation may lead to asymmetry,
hollowing, or a sunken lid appearance. Relative enophthalmos
is an obvious sign of aging because the volume of fat decreases
due to involution and herniation within the bony orbit. By
extension, rejuvenation proceeds by maintaining the fatty
volume and strengthening the globe’s extrinsic support by
canthopexy and orbicularis and midface suspension.
Transconjunctival blepharoplasty
Transconjunctival blepharoplasty is the preferred procedure
for fat reduction in patients without excess skin and with
as a horizontal mattress. The lid should be flipped to ensure
that the suture is not exposed posteriorly on the tarsus, which
could cause a troublesome corneal abrasion. The level of cor­
rection should be checked by having the patient open his/her
eye. Some coaxing helps the patient open the eye gently rather
than maximally, which the patient has been used to doing
consistently to compensate for ptosis. The patient should blink
frequently and look superiorly to ensure that the lid never rises
above the superior limbus. For cases under general anesthetic,
one should attempt to create one to two times the amount
of lagophthalmos relative to the preoperative ptosis.
If there is any medial or lateral retraction or ptosis, the
central suture should be repositioned medially or laterally as
many times as needed, with adjustment to a pleasing lid
height and contour. Both sides should be completed before the
suture is permanently tied. Once the desired lid height and
contour of both eyes are achieved, the patient should be asked
to open and close the eyes to ensure symmetry. Anchoring the
tarsus, dermis, and aponeurosis at the right level keeps the
pretarsal skin taut and flat, prevents lash eversion, and forms
a neat, crisp lid crease that will persevere for many years.
Lower lid blepharoplasty
Lower blepharoplasty has evolved substantially. There are
two trends in blepharoplasty, one towards more aggressive
Fig. 9.29  (A,B) Once the upper lid is incised, the levator may be modified (shortened/lengthened) in a number of ways, including simple plication. A suborbicularis skin
flap can also be developed allowing access to preaponeurotic fat. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders;
2004:69.)
A
Orbital septum
and underlying
(preaponeurotic) fat
Levator aponeurosis
B
Levator plication

316
SECTION I
CHAPTER 9 • Blepharoplasty
The lower lid retractors (capsulopalpebral fascia and infe­
rior tarsal muscle) and overlying conjunctiva lie directly
posterior to the three fat pads of the lower lid. A broad and
deep transconjunctival incision severs both conjunctiva and
retractors but typically should not incise the orbital septum,
orbicularis, or skin. The conjunctival incision is made with a
monopolar cautery needle tip at least 4 mm below the inferior
border of the tarsus – never through the tarsus (Fig. 9.30). A
good canthal position. A transconjunctival approach is less
likely to lead to lower lid malposition than is a transcutaneous
approach. It minimizes but does not eliminate postoperative
lower lid retraction; transection of the lower lid retractors can
cause a temporary rise in the lid margin, especially if they are
suspended during the healing period. Previously suspected
septal scarring through transconjunctival fat excision has not
been shown to significantly alter lid posture or tonicity.46
A
Retroseptal approach
Preseptal (suborbicularis) approach
Non-conductive retractor
Fig. 9.30  (A) The transconjunctival approach to the retroseptal space may be in one of two ways: preseptal or retroseptal. The preseptal route requires entry into the
suborbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum. This will allow direct visualization of the septum, and each fat pad can be
addressed separately in a controlled fashion. (B) A conjunctival stay suture is placed deep in the fornix and traction is applied superiorly while the lid margin is everted.
This causes the inferior edge of the tarsal plate to rise toward the surgeon. (C) The conjunctiva and lower lid retractors are incised just below the tarsal plate entering the
suborbicularis preseptal space. This plane is developed to the orbital rim with the assistance of the traction suture and a nonconductive instrument. (Adapted from Spinelli
HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:86.)
B
Conjunctiva is tented and secured with a stay suture
C
Conjunctiva is divided longitudinally
just below the tarsal plate
Orbital septum
Inferior tarsal plate

317
Treatment/technique
preseptal approach is obtained by entering the conjunctiva
above the level of septal attachment to the capsulopalpebral
fascia. A retroseptal approach involves a 1.5–2 cm incision
lower down in the fornix, and is typically used to excise fat.
There are differences of opinion about whether to leave the
transconjunctival incision open or to close it; however, it is
preferable to leave it open. Suturing the wound may trap
bacteria or cause corneal irritation. Conjunctival closure,
when it is elected, is simplified by a monofilament pull-out
Fig. 9.31  (A) The orbital septum may then be punctured and the inferior oblique muscle identified and preserved. (B) The fat pad may be addressed individually in
keeping with preoperative plans with either resection, repositioning, conservation, or any combination of the these techniques. (Adapted from Spinelli HM. Atlas of Aesthetic
Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:87.)
A
Lateral, central and medial fat pads (left to right)
Conjunctiva retracted superiorly
Inferior oblique muscle
Orbital septum opened
B
Reposition fat pads transconjunctivally
Remove fat pads if they bulge
suture that enters the eye externally, closes the conjunctiva,
and exits through the skin and is taped.
The incision through the conjunctiva and retractors gives
excellent access to the orbital fat. A 6-0 silk traction suture
passed through the inferior conjunctival wound and retracted
over the globe gives wide access to the orbital fat, even helping
to prolapse the fat into the wound. The thin film of synovium-
appearing capsule encasing the orbital fat is opened, releasing
the fat to bulge into the operative field (Fig. 9.31).

318
SECTION I
CHAPTER 9 • Blepharoplasty
trough deformities who have prominent medial fat pads are
excellent candidates.47 Access to the medial and central fat
pads is by the subciliary or transconjunctival incision.48 The
minor degree of lateral fat pad prominence is generally insuf­
ficient to affect any change with repositioning. A supraperios­
teal or a subperiosteal dissection for 8–10 mm caudal to the
inferior orbital rim permits tension-free placement. The fat
can be secured in place with interrupted absorbable sutures.
This technique can be used as an alternative to fat grafting or
filler injection. Patients must be warned that various degrees
of fat loss and hardening are possible. There is also a rare but
described possibility of restrictive strabismus related to
aggressive fat mobilization and fixation.
Plication techniques
The fundamental agreement among surgeons who practice
plication is that bulging of orbital fat is the major component
in most cases of eyelid aging deformity. The conclusion is that
most cases of baggy eyelids occur from a true herniation of
the orbital fat out of the bony orbit. Consequently, rejuvena­
tion centers on re-establishing the normal position of the
globe orbital fat. Plication offers the advantages of prevention
of depletion of the orbita, achievement of a homogeneous
and natural eyelid, avoiding local hollowing and sunken lid
appearance, and no risk of infraorbital hematomas. Access is
through a transcutaneous approach, which gives superior
exposure.
Orbital septum plication
In this procedure, the herniated septum is plicated and repo­
sitioned to its normal anatomic site within the orbit. The fat
is replaced in the retroseptal position to regain its original
anatomic integrity (Fig. 9.33). Three to four 5-0 polyglycolic
acid sutures are placed in a vertical fashion from medial to
lateral. The protruding fat pads are invaginated and the
integrity of the thin, flaccid septum is restored. Additional
support may be gained with septo-orbitoperiostoplasty varia­
tion.49 This technique plicates the flaccid septum and secures
it to the periosteum of the inferior orbital rim. Because of no
disruption of the eyelid anatomy occurs, complications of
Fig. 9.32  (A) Simple skin excision lower eyelid blepharoplasty. (B) Typical removal of redraped skin or skin–muscle from the lower lid, which can be the shape of an
obtuse triangle, with the largest amount sacrificed laterally.
A
B
Once fat is removed or repositioned through a transcon­
junctival incision, excess skin can be removed through a
subciliary position. Fat reduction may leave skin excess,
leading to wrinkling. A conservative “skin pinch” can be done
to estimate skin removal, or alternatively, skin can be tight­
ened by skin resurfacing with chemical or laser peels (Fig.
9.32). One should be careful not to incise the orbital septum,
which leads to increased postoperative retraction. This proce­
dure works particularly well when there is an isolated fat pad,
especially medially, accessed through a single stab incision
through the conjunctiva.
Transcutaneous blepharoplasty
A subciliary incision can be used to develop a skin flap or a
skin–muscle flap. With either method, pretarsal orbicularis
fibers should remain intact. For the skin–muscle flap, skin and
preseptal orbicularis are elevated as one flap, while with a
skin flap, the muscle and its innervation can be preserved.14
Periorbital fat, muscle, and skin can be addressed with either
approach. Once the plane deep to the orbicularis is entered,
dissection continues between the muscle and the orbital
septum down to the level of the orbital rim. Periorbital fat can
be excised through small incisions in the septum. The fat can
also be retropositioned using capsulopalpebral fascia placa­
tion, or it can be transferred into the nasojugular fold. Orbi­
cularis muscle fibers and skin can be excised at closure.
However, care must be taken with muscle excision, which can
lead to orbicularis denervation and lid malposition.
Orbital fat
The relative excess of orbital fat may be handled in several
ways. Most commonly, surgeons choose to excise the herni­
ated fat with meticulous attention to hemostasis. Additional
techniques exist to reposition the fat to create periorbital
harmony.
Orbital fat transposition
An alternative to excising prominent orbital fat is to redrape
the pedicled fat onto the arcus marginalis. Patients with tear

319
Treatment/technique
depressions, and shorten the lower lid-to-cheek distance. The
main steps include elevation of a skin muscle flap, release
of the orbicularis retaining ligament and resuspension of
the orbicularis – frequently after lateral canthopexy. Along
the entire infraorbital rim, the orbicularis retaining liga­
ment is divided. Additional medial dissection is performed
to release the levator labii when a tear trough deformity is
present.
related to lid malposition such as lid retraction, scleral show,
and ectropion are reduced.50
Capsulopalpebral fascia plication
Anatomical dissection suggests that the Lockwood suspen­
sory ligament descends with aging that leads to relative
enophthalmos and fat herniation. Moreover, simply plicating
the orbital septum, which is an acellular membrane with
little tensile strength, will not restore the globe’s position.
The capsulopalpebral fascia can be plicated to the orbital
rim either through a transcutaneous or a transconjunctival
approach. In the transcutaneous method, dissection is carried
out between the orbicularis and the septum down to the
orbital rim; the capsulopalpebral fascia is then sutured to the
orbital rim. In the transconjunctival method, the capsulopal­
pebral fascia is divided from the tarsus, and orbital fat is
retroplaced, its position maintained by suturing the capsulo­
palpebral fascia to the periosteum of the orbital rim using a
continuous running 6-0 non-absorbable suture. The conjunc­
tival gap of a few millimeters is allowed to re-epithelialize
(Fig. 9.34).51–53 One advantage of the transconjunctival
approach is the division of lower eyelid depressors, which
helps maintain the lower eyelid at an elevated level due to the
unopposed action of the pretarsal orbicularis. Several series
have shown this disruption does not interfere with lower
eyelid or globe function.49,51
Orbicularis suspension
Orbicularis repositioning can be used to eliminate hypo­
tonic and herniated orbicularis muscle, soften palpebral
Fig. 9.33  (A,B) Schematic representation of procedure for lower eyelid. Note that
only the inferior orbital septum is plicated and sutured to the inferior orbital rim.
(Adapted from Sensöz O, Unlu RE, Percin A, et al. Septoorbitoperiostoplasty for the
treatment of palpebral bags: a 10-year experience. Plast Reconstr Surg.
1998;101:1657–1663.)
A
Inferior orbital septum
Inferior orbital rim
Capsulopalpebral fascia
Protruding inferior orbital fat
B
Inferior orbital septum
Inferior orbital rim
Capsulopalpebral fascia
Fig. 9.34  (A,B) Suturing the lower capsulopalpebral flap to the arcus marginalis to
reduce and contain the herniated fat. (Adapted from Camirand A, Doucet J, Harris J.
Anatomy, pathophysiology, and prevention of senile enophthalmia and associated
herniated lower eyelid pads. Plast Reconstr Surg. 1997;100:1535–1538.)
A
Inferior orbital septum
Fascioseptal triangular space
B
Upper (ciliary) flap
Lower (ocular) flap made up
of conjunctiva inferior tarsal
muscle capsulopalpebral fascia

320
SECTION I
CHAPTER 9 • Blepharoplasty
drill bit) are placed 2–3 mm posterior to the lateral orbital rim.
The inferior and superior holes are separated by 5–10 mm to
allow suture separation and ligation (Fig. 9.38).
The vertical position of the lateral canthal suture is depen­
dent on eye prominence and pre-existing canthal tilt. Patients
with prominent eyes and negative-vector morphology are at
higher risk for lid malposition and require additional vertical
support of the lateral canthus. While the standard position
The skin muscle flap is draped in a superior lateral vector
rather than a pure vertical vector. Excision of skin and muscle
are performed by removing a triangle of tissue lateral to the
canthus, thereby minimizing the amount of tissue removed
along the actual lid margin. The lateral suspension of the
orbicularis is to the orbital periosteum. Lower lid support is
gained by resuspension of the anterior (skin and muscle) and
posterior lamellae (tarsus by canthopexy).
This technique is best suited for patients with scleral show,
lid laxity, and a negative vector, which put them at risk for lid
malposition in the postoperative period. Its drawback is that
it inherently disrupts the orbicularis, which may lead to
denervation. Mobilization of the levator labii muscles also
may put the buccal branch of the facial nerve at risk.
Canthopexy
As the lateral canthal tendon lengthens, it shortens the aper­
ture and allows the lid posture to drop to give the illusion of
excess lower lid skin as the tissues accordion inferiorly. With
restoration of the normal intercanthal axis tilt, lid tone, and
septal integrity, the appearance of excess skin and herniated
fat disappears with minimal tissue excision and, in many
patients, without the need for any muscle, skin, or fat excision
(Fig. 9.35).37,54
A lateral canthopexy can establish an aesthetically and
functionally youthful eyelid and reduce the incidence of lower
lid malposition and scleral show (Fig. 9.36). It has become an
integral part of a lower lid blepharoplasty and midfacelift­
ing.36 It is increasingly appreciated that good and long-lasting
surgical results in lower lid surgery are rarely possible without
an effective canthopexy.
A lasting canthopexy involves more than a simple stitch
into the periosteum. A properly executed canthopexy restores
the tone, posture, and tilt to the lower lid and serves as the
fulcrum point for rejuvenation of the entire midface. In addi­
tion, it raises the Lockwood suspensory ligament (and the
entire retinacular complex), lifting orbital structures upward,
reducing lower lid fat herniation, and reducing upper lid
hollowing – all an essential part of a youthful periorbital
restoration.
The degree of laxity predetermines the type of lateral
canthal support. A lateral canthopexy is recommended for
moderate lid laxity, which is considered <6 mm of lid distrac­
tion away from the globe. This technique takes advantage of
a bluntly dissected tunnel extending from the lateral upper
lid blepharoplasty incision into the lateral aspect of a lower
lid incision. Next, the lateral retinaculum and tarsal strap are
bluntly dissected off the periosteum 5 mm in both directions
(Figs. 9.4 & 9.37).
A double-armed 4-0 Prolene or Mersilene is used to suture
the tarsal plate and lateral retinaculum to the inner aspect of
the lateral orbital rim periosteum above Whitnall’s tubercle.
Periosteum is thickest at the superior and lateral orbital rim,
making it a secure suture site. The mattress suture is placed
through the periosteum within the lateral orbital rim to main­
tain the posterior position of the lid margin against the globe.
Bone canthopexy is technically possible through upper and
lower lid incisions but is technically demanding. Wide expo­
sure through a coronal browlift provides the ideal environ­
ment and access. Bone fixation gives a profoundly longer
lasting result than does periosteal fixation. Drill holes (1.5-mm
Fig. 9.35  (A) Attenuation with aging produces a descent of the lateral canthus.
(B) The end result is a lateral canthus that is linear or declined compared with the
medial canthus. As the lateral canthus sags, the intercommissure distance shortens
and the lower lid and inferior lateral septum become lax. This produces scleral
show, lid malposition, and orbital fat prominence laterally and tear drainage
problems. With restoration of the normal intercanthal axis tilt, lid tone, and septal
integrity, the appearance of excess skin and herniated fat disappears with minimal
tissue excision and, in many, without the need for any muscle, skin, or fat excision.
(Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
Philadelphia, PA: Saunders; 2004:35.)
A
-10 - 15˚
0˚
B
+10 - 15˚
0˚

321
Treatment/technique
Fig. 9.36  (A) Preoperative and (B) 5-year postoperative photograph of a patient
with a lower lid blepharoplasty and canthopexy.
A
B
A
B
C
Fig. 9.37  (A–C) Periosteal canthopexy. The inferior ramus of the lateral canthal
tendon is secured and elevated to a raised position inside the orbital rim.
Tension-free suspension occurs with release of the tarsal strap and lateral orbital
thickening.
of the lateral canthopexy suture is most commonly at the
lower level of the pupil, patients with prominent eyes or
negative vectors require additional vertical positioning of
the lateral canthal support suture at the superior aspect of
the pupil.
Lateral canthoplasty, which includes surgical division of
the lateral canthus, is recommended for more significant
lower lid laxity, defined by lid distraction >6 mm away from
the globe. Lateral canthotomy, cantholysis of the inferior limb
of the lateral canthal tendon, and release of the tarsal strap are
performed. This dissection is followed by a 2–3-mm full-
thickness lid margin resection, depending on the degree of
tarsoligamentous laxity. The lateral commissure is carefully
reconstructed by aligning the anatomical grey line with 6-0
plain gut. Final fixation to the lateral orbital periosteum can
be as described above.
Midfacelifting
Patients will frequently complain that they would like the
lower skin to be smoother and tighter, the fatty pads to be
eliminated, and the tissues of the malar eminence to be fuller.
Midface descent occurs in the spectrum of periorbital aging,
clinically apparent in the fourth decade (Fig. 9.39). The

322
SECTION I
CHAPTER 9 • Blepharoplasty
Fig. 9.38  The canthopexy suture series for a two-layered canthopexy. (A) The
canthopexy suture fixating the tarsal tail into the drilled hole. (B) The second-layer
orbicularis suture. (C) Lateral sutures fix the lateral orbicularis to the deep temporal
fascia. (D) If a midfacelift is elected, an inferior drill hole can be made to fixate the
midface tissues. (E) Burying the knot into drill hole.
A
B
C
D
E
Fig. 9.39  (A) Preoperative and (B) postoperative photograph demonstrating the
benefit of midfacelift in the setting of blepharoplasty.
A
B
orbicularis muscle and suborbicularis oculi fat (SOOF)
descend in an inferonasal direction and, in conjunction with
descent of the malar fat pad, results in the fullness of the
nasolabial fold frequently seen with the aging face. This
inferonasal vector of aging also creates a visual lengthening
of the lower lids beyond the orbital margin. Lastly, relative
loss of soft tissue secondarily skeletonizes the inferior orbital
rim and zygoma, deepening the tear trough and diminishing
the malar prominence.55,56
The middle third of the face, or midface, lies between the
lateral canthal angle and the top of the nasolabial fold. It
includes the lateral canthal tendon, the medial canthal tendon,
the skin, fat, and orbicularis oculi muscle of the lower eyelids,
the suborbicularis oculi fat pad, the malar fat pad, the orbito­
malar ligament (orbicularis ligament), the orbital septum, and
origins of the zygomaticus major and minor muscles and
levator labii superioris. When evaluating the midface for
aesthetic surgery, all the structures listed above must be
considered.
The author’s preferred technique includes approaching the
midface through a transconjunctival incision. After reposi­
tioning or resection of orbital fat, the midface is elevated in a
supraperiosteal plane. The attachment of the orbicularis oculi
muscle to the orbital septum is preserved. Adequate release
of the remaining, lax orbitomalar ligament then permits malar
fat pad suspension in a superolateral vector to the lateral
orbital rim and temporoparietal fascia (Fig. 9.40). Canthopexy
is then performed to redrape lower eyelid skin and recreate a
youthful intercanthal angle. Finally, a skin-only resection of
the lower lid may be necessary to address any redundancy.
Postoperative care
All patients are advised to expect swelling, bruising, some
degree of ptosis, and tugging sensation on gazing upward.
Although complete recovery takes months, patients generally
look presentable approximately 2–3 weeks after surgery.
Surgical literature has not advocated compression bandag­
ing of the eyes after surgery. The concern is an undetected
retrobulbar hemorrhage that results in vision loss. However,
the reality is that the risk for hemorrhage, chemosis, and other
problems is more likely in an eye that has no compression.
Retrobulbar hemorrhage is likely to induce orbital pain, which
should never be ignored, alerting the surgeon to the potential

323
Postoperative care
Fig. 9.40  Midfacelift. (A) The arrow
in red depicts the plane of
dissection to the midfacial structures
in the cheek in a supraperiosteal
approach. (B) Wide undermining of
the periorbital ligamentous structures
and lateral retinaculum may be
transconjunctival or through the
upper blepharoplasty incision.
(C) Canthopexy and cheek
suspension then proceed
sequentially. SMAS, superficial
musculoaponeurotic system; SOOF,
suborbicularis oculi fat. (Adapted
from Spinelli HM. Atlas of Aesthetic
Eyelid and Periocular Surgery.
Philadelphia, PA: Saunders;
2004:129.)
A
B
Extent of sub-orbicularis muscle/
malar fat pad/SMAS undermining
Buccal fat pad
SMAS
Zygomaticus
Malar fat pad
SOOF
Orbitomalar ligament
Malar bag
Orbicularis oculi
Orbital septum
Orbital fat
Access via upper or lower blepharoplasty incision
C
Cheek flap is elevated and
sutured to deep temporal fascia or
periosteum of lateral orbital rim
Single mattress suture repair
vision-threatening complication. If one chooses not to use
gently compressive bandages, postoperative edema can be
reduced with cool compresses for up to 20 min intermittently
during the initial 36 h postoperatively. Patients are advised
against using frozen compresses directly over their face in the
setting of previous anesthetic use and pain medication.29
Additional recommendations include having the patient lie
in a semi-recumbent position while resting and to avoid
bedrest. Prescriptions for rewetting drops, Lacri-Lube, and
antibiotic ophthalmic ointment can be given to reduce the
incidence of exposure keratoconjunctivitis and dry eye symp­
toms in the immediate postoperative period. Patients are
permitted to shower the next day and use antibiotic ointments
as needed, for routine incisional care. Avoiding direct sun
exposure with sunglasses may reduce the severity of sunburn
and the formation of irregular, darkened pigmentation. It is

324
SECTION I
CHAPTER 9 • Blepharoplasty
sensation, burning, secretions, and frequent blinking. Pre-
existing dry eyes may be aggravated by postoperative lagoph­
thalmos. Ocular protection can achieved medically with
liberal use of corneal lubricants.
Additional complications such as lower lid malposition,
lagophthalmos, undercorrection, asymmetry, and iatrogenic
ptosis all require careful observation and photographic
documentation. Reoperation should be performed no earlier
than 3 months later. Secondary blepharoplasty can range
from simple office-based procedures to extremely challenging
interventions.
Special considerations
Non-surgical enhancement
The ability to surgically enhance the eye is a powerful tool
that is amenable to expedited healing and future enhance­
ment to the eye by using the growing armamentarium of
non-surgical technology, including the ability to perform
composite blending or stacking of surgery with fillers, lasers,
and energy-based tissue tightening.57
If we consider the previously mentioned cosmetically
desired youthful, appealing eye, we must look at smooth
eyelid skin, adequate volume around the eye, and enhanced
lower lid tone. The use of off-label hyaluronic filler injection
to the tear trough and nasojugal area can significantly enhance
a post-lower blepharoplasty result.58,59 Further, the use of
Juvederm Voluma for midfacial volume restoration has been
shown to enhance the appearance of 52% of tear troughs with
isolated filler injection to the midface.60 In addition, we have
utilized hyaluronic acid filler to the infrabrow in those recov­
ering upper blepharoplasty patients who have relative fat
atrophy to the region. We have advocated waiting at least 3
months in the postoperative period and giving detailed
informed consent to the off-label nature of this filler injection
in the upper and lower eyelid. We also prefer the use of blunt
cannula around the eye, as has been advocated in the
literature.58
The ability to resurface the upper and lower lid skin with
laser resurfacing post-surgery can reduce a surgeon’s ten­
dency to over-resect eyelid skin that is atrophic. Ablative laser
resurfacing to the upper and lower eyelid can be done at the
time of surgery or years later to enhance surgical results,
adding a third dimension to the eye. We find that the laser-
based solutions help to prolong the life of the result and are
useful to soften existing scars around the eyes.
There are also expanded roles of micro-focused ultrasound
or radiofrequency to tighten the lower lids. This application
to boost tone to a lax lower lid and enhance blending of the
lower lid cheek junction as well as adding tone to the lateral
aspect of the upper eyelid post surgery. At The Few Institute,
we advised the application of radiofrequency to the lower lids
postoperatively in patients with significant edema and/or
preoperatively in more involved surgical cases. In these cases,
radiofrequency is started at 1–2 weeks after surgery. In cases
that are more than 3 months post-surgery, with persistent fat
protrusion or relative laxity, the ability to apply micro-focused
ultrasound or radiofrequency can lead to reduction/
elimination of postoperative fat protrusion. Our approach has
been to apply radiofrequency-based energy over the course of
also suggested that patients refrain from using contacts and
to minimize the use of prescription eyeglasses.30
When no canthopexy is performed, half-inch Steri-Strips,
retracted superiorly, are applied as a “cast” (with benzoin or
Mastisol for security). This treatment tends to reduce lid
retraction. Alternatively, a Frost suture placed in the lower lid
margin and fixed to the brow suspends the lid during early
healing. Temporary medial or lateral limbus tarsorrhaphies
were previously popular after aggressive skin excision
blepharoplasty techniques. These sutures were primarily used
to minimize chemosis during the first 48 h. Discomfort,
restricted vision, and secondary office visits for suture removal
have led to their limited use today. However, the best support
during healing is a secure extended canthopexy.46
Complications
Even the most carefully planned procedures will have a small
percentage of complications. The possibility of such complica­
tions and a realistic appraisal of likely outcome should be
discussed with the patient before surgery.
Asymmetry is common postoperatively and can be caused
by edema, bruising, and asymmetric sleep posture, but it also
predictably follows undiagnosed preoperative asymmetry,
including mild ptosis, made worse by the weight of postop­
erative edema. Patients should be advised that no reopera­
tions are indicated before 8 weeks, and then only if the lids
have stabilized and no edema or bruising is seen. The need
for reoperations is infrequent, but when ptosis or exophthal­
mos is involved, incidence increases significantly to 10–30%.46
Retrobulbar hemorrhage is the most feared complication of
eyelid surgery. Any complaint of severe orbital pain needs to
be examined immediately, especially that of sudden onset.
Acute management involves immediate evaluation, urgent
ophthalmologic consultation, and a return to the operation for
evacuation of the hematoma. Medical treatments, in addition
to operative exploration, include administration of high-flow
oxygen, topical and systemic corticosteroids and mannitol.
Acute loss of vision mandates bedside suture removal and
decompressive lateral canthotomy. Hospitalization with head
elevation and close observation may be necessary to supple­
ment the described measures.29 Peribulbar hematoma, in
contrast, does not threaten vision. It usually results from
bleeding of an orbicularis muscle vessel. Small hematomas
may resolve spontaneously, though larger hematomas can be
evacuated in the office.
Visual changes, including diplopia, are generally tempo­
rary and can be attributed to wound reaction, edema and
hematoma. Any damage to the superficial-lying oblique
muscles can be permanent and lead to postoperative strabis­
mus. Conservative management is recommended; refractory
cases should be referred to an ophthalmologist.
The most common complication after blepharoplasty is
chemosis. Disruption of ocular and eyelid lymphatic drainage
leads to development of milky, conjunctival, and corneal
edema. Chemosis can be limited by atraumatic dissection,
cold compresses, elevation, and massage. It is usually self-
limited and resolves spontaneously, though prolonged che­
mosis can be treated with topical steroids.
Dry eye symptoms are also frequently cited in the postop­
erative phase. Patients may complain of foreign body

325
Special considerations
293% increase in the number of African-American patients
who underwent cosmetic plastic surgery between 1997 and
2004.63 The awareness of the benefits of cosmetic plastic
surgery is becoming ever-present to a patient population that
transcends cultural and racial boundaries.
African-American patients pursuing eyelid rejuvenation
have preconceived notions and concerns distinct from their
Caucasian counterparts, thereby demanding a different surgi­
cal strategy. African Americans are twice as likely as Cauca­
sians to be afraid of losing their ethnic identity and 10 times
as likely to choose a surgeon with special interests in ethnic
plastic surgery. There are several features that make the
African American eye ethnically unique. The lateral canthus
is cephalad to the medial canthus in great frequency. In addi­
tion, there is a tendency for a more oval, Asian-like palpebral
aperture, as opposed to the more rounded Caucasian palpe­
bral fissure. The supratarsal fold distance tends to be shorter
than in the Caucasian eyelid but longer than the Asian eyelid.
The lateral orbit and cheek skin is more sebaceous, and there
is a decreased tendency toward rhytid formation. Finally,
African Americans tend to be poor candidates for lower eyelid
resurfacing because of pigmentation risk. The preferred surgi­
cal approach includes canthopexy to restore lateral canthal
position, preservation of the majority of orbicularis to restore
supratarsal contour, and avoidance of cephalad malposition
of the upper eyelid incision to preserve limited pretarsal
show. These subtleties are discussed preoperatively, often
with the aid of youthful photographs, to appropriately plan
surgery.25,64
The unique characteristics of the Asian blepharoplasty will
be thoroughly discussed in Chapter 10.
4–6 sessions, applied weekly, with sessions lasting 10–15 min
per time.
Male blepharoplasty
In the United States, 16% of blepharoplasties are performed
on men, and blepharoplasty is the second most common
cosmetic surgery performed on male patients.61 Men tend to
seek out blepharoplasty more for functional reasons than
women, but this difference has become less and less distinct
in recent years. A more natural look is preferred, and the
“operated look” will not be tolerated well by most male
patients. Men typically do not use cosmetics, so all scars must
be carefully concealed. This also makes male patients subop­
timal candidates for laser resurfacing. The lateral incision
should rarely be extended beyond the later orbital rim. In men
with heavy brows, resection of upper eyelid skin only will
result in profoundly ptotic brows. Therefore, one should
consider combined brow surgery with upper blepharoplasty.
Many men are reluctant to have cosmetic surgery to correct
brow ptosis, so careful preoperative counseling is needed to
prevent a dissatisfied patient with worse brow ptosis postop­
eratively.30,62 Often, conservative eyelid resection is all that is
required.
Blepharoplasty in people of color
Patients who identify themselves other than Caucasian now
account for 27% of all cosmetic procedures. Hispanics, African
Americans, and Asian Americans have seen a steady rise in
their market share over the last 10 years. According to the
American Society for Aesthetic Plastic Surgery, there was a
12. Flowers RS, Nassif JM, Rubin PA, et al. A key to canthopexy: the
tarsal strap. A fresh cadaveric study. Plast Reconstr Surg.
2005;116:1752–1758. Flowers and colleagues detail the anatomy of the
lateral orbital retinaculum and highlight the importance of full dissection
to achieve a tension-free canthopexy.
14. Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
Philadelphia, PA: Saunders; 2004.
15. Zide BM. Surgical Anatomy Around the Orbit: The System of
Zones. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins;
2006.
17. Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid anatomy:
introduction of the septal extension. Plast Reconstr Surg.
2006;117:65–70. This cadaveric and histologic study identifies an
extension of the orbital septum that must be identified and spared when
performing a levator advancement for blepharoptosis.
21. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of
the ligamentous attachments of the lower lid and lateral canthus.
Plast Reconstr Surg. 2002;110:873–884.
26. Hirmand H. Anatomy and nonsurgical correction of tear trough
deformity. Plast Reconstr Surg. 2010;125:699–708.
30. Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in
aesthetic upper blepharoplasty. Plast Reconstr Surg. 2004;3:32e–42e.
This continuing medical education article provides a concise description of
upper eyelid aging and a step-by-step guide to popular rejuvenation
techniques.
36. Flowers RS. Canthopexy as a routine blepharoplasty component.
Clin Plast Surg. 1993;20:351–365.
45. Mendelson BC. Fat preservation technique of lower-lid
blepharoplasty. Aesthet Surg J. 2001;21:450–459. Results shown in
Mendelson’s article demonstrate the safe, reproducible outcomes of a
skin-only blepharoplasty and help swing the pendulum away from
aggressive, fat-excisional techniques.
46. Codner MA, Wolfi J, Anzarut A. Primary transcutaneous lower
blepharoplasty with routine lateral canthal support: a
comprehensive 10-year review. Plast Reconstr Surg.
2008;121:241–250.
64. Few JW. Rejuvenation of the African American periorbital area:
dynamic considerations. Semin Plast Surg. 2009;23:198–206. Few’s
survey-based study shows that one must prioritize a patient’s ethnic
identity and heritage when approaching the periorbital area in African
Americans.
Access the complete reference list online at

325.e1
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skin-only blepharoplasty and help swing the pendulum away from
aggressive, fat-excisional techniques.
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325.e2
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59. Hirmand H. Anatomy and nonsurgical correction of the tear trough
deformity. Plast Reconstr Surg. 2010;125:699–708.
60. Jones D, Murphy DK. Volumizing hyaluronic acid filler for midface
volume deficit: 2-year results from a pivotal single-blind
randomized controlled study. Dermatol Surg. 2013;39:1602–1612.
61. American Society of Plastic Surgeons. Gender Distribution: Cosmetic
Surgery 2008. Arlington Heights, IL: American Society of Plastic
Surgeons; 2010. Available at: <
Media/stats/2008-top-5-male-cosmetic-surgery-procedures-
graph.pdf>.
62. Flowers RS. Periorbital aesthetic surgery for men: eyelids and
related structures. Clin Plast Surg. 1991;18:689–729.
63. American Society of Plastic Surgeons. Cosmetic Demographics 2008.
Arlington Heights, IL: American Society of Plastic Surgeons; 2010.
Available at: <
cosmetic-procedure-demographics-ethnicity.pdf>;
demographics-ethnicity.pdf>.
64. Few JW. Rejuvenation of the African American periorbital area:
dynamic considerations. Semin Plast Surg. 2009;23:198–206. Few’s
survey-based study shows that one must prioritize a patient’s ethnic
identity and heritage when approaching the periorbital area in African
Americans.

SECTION I • Aesthetic Surgery of the Face
10 
Secondary blepharoplasty: Techniques
Glenn W. Jelks, Elizabeth B. Jelks, Ernest S. Chiu, and Douglas S. Steinbrech
SYNOPSIS
■ Serious complications of primary blepharoplasty surgery are rare, but
should they occur, can be difficult to correct and be potentially
disastrous.
■ Some serious complications that develop early, such as corneal
exposure, require aggressive treatment, but lesser complications such
as minor lid malpositions should be dealt with after time has passed to
allow for scar maturation.
■ The eyelids can be divided into four anatomic zones.
■ Upper eyelid problems include ptosis and lid retraction. An
understanding of Hering’s law is necessary to diagnose the problem
responsible for lid level asymmetry.
■ Lower lid malposition is a common problem after primary
blepharoplasty and is due to an interplay between the patient’s unique
orbital and eyelid anatomy, and the cicatricial forces. There are a
number of predisposing factors.
■ Lower lid evaluation should address the presence of cicatricial
contraction, a vector analysis of the globe in relation to the malar
eminence, a soft-tissue–bone distance at the lateral canthus,
tarsoligamentous integrity (distraction and snap tests), lower lid
eversion, and the level of the malar fat pad.
■ Lower lid malposition can be treated with various methods, including a
wide variety of canthopexy and canthoplasty procedures, vertical
spacer grafts, and midface elevation. In severe cases, a combination
of modalities is often indicated.
Introduction
Each year, over 170 000 people in the United States have a
blepharoplasty operation.1 These operations are generally
very successful with a high level of patient satisfaction. Suc­
cessful operations are the result of thorough preoperative
evaluation, skillfully performed customized surgical proce­
dures, uneventful anesthesia, proper surgical venue, and
individualized postoperative management. Although rare,
complications and unfavorable results may occur following
blepharoplasty. It has been estimated that the complication
rate following blepharoplasty is 2%.2–21 Minor complications
are temporary and self-limiting with minimal visual distur­
bance or aesthetic consequence (Box 10.1). Major complica­
tions are definitely undesirable and potentially disastrous.
They include visual loss, fixed eyelid deformities, corneal
decomposition, and significant aesthetic compromise (Box
10.2). In addition, an apparent technically successful opera­
tion may produce a very unhappy patient.
Once the complication is discovered, a careful and thor­
ough evaluation of the patient’s anatomical deformity and its
prognosis is essential. If impending visual compromise is
apparent, early emergent intervention may be warranted.
Most lid malpositions are temporary and resolve within 4–6
weeks postoperatively. It is important to protect the cornea
during this time. If the lid malpositions aggravate and con­
tribute to corneal decompensation, they should be corrected
as soon as possible. However, lid malpositions that do not
compromise visual function may be corrected after scar matu­
ration. In general, a delay in secondary surgical procedures to
address the problem is recommended. Secondary surgery is
more predictable in a surgical environment that is less inflam­
matory. Better results are obtained if secondary surgery can
be postponed for at least 6 months and preferably 1 year
following the initial surgery.
The effect of blepharoplasty procedure complications on
patient and physician can be profound. When the results of
an elective aesthetic surgical procedure are suboptimal, the
patient usually becomes more difficult to manage. It is easier
to manage a dissatisfied patient when there has been a thor­
ough preoperative discussion of risks resulting in a signed
informed consent to the procedure. It is imperative to have a
handwritten note by the operating surgeon in the patient’s
chart documenting the explanation of the proposed surgical
procedures including any risks or complications to their
surgery. In addition, the alternatives to surgery should be
discussed.22

327
Introduction
The easiest complication to avoid is failure to recognize a
pre-existing condition that would increase the likelihood of
an unfavorable result from standard blepharoplasty (Box
10.3).23–26 Pre-existing conditions include: (1) medical or oph­
thalmological conditions that may increase the risk of visual
impairment; (2) morphological variants that predispose the
patient to post-blepharoplasty eyelid malpositions; (3)
Once a complication occurs, more time and effort by the
physician and his support staff will be required. This often
translates into arranging for more frequent office visits. The
physician must devote more time to help the patient through
this disappointing situation. Reassurance by the surgeon in
the face of temporary complications will aid in patient accep­
tance of prolonged healing.
General
Retrobulbar hemorrhage without visual loss
Pupil changes
Glaucoma
Extraocular muscle disorder
Corneal changes
Exposure
Keratitis
Erosion
Ulcer
Refractive
Astigmatism
Edema
Tear film abnormality
Basement membrane disorder
Lacrimal disorder
Dry eye
Epiphora
Tear film abnormality
Reflexly stimulated tears
Tear distribution abnormalities
Lid margin eversion
Lid retraction
Lid ectropion
Lid entropion
Lid paresis
Tear drainage abnormalities
Punctal eversion
Obstruction of nasolacrimal system
Lid paresis
Dacryocystitis
Conjunctival changes
Chemosis
Prolapse
Incarceration
Hemorrhage
Eyelid malposition
Upper eyelid
Ptosis
Retraction
Contour change
Marginal rotation
Lower eyelid
Scleral show
Lid retraction
Lid paresis
Marginal rotation
Ectropion or entropion
Eyelid deformities
Hematoma
Epicanthal folds
Cysts
Wound separation
Eyelid numbness
Eyelid discoloration
Scars
Loss of eyelashes
Inflammatory conditions
Infectious
Cellulitis
Abscess
Hordeolum
Chalazion
Blepharitis
Non-infectious
Allergic
Chemical
Blepharitis
BOX 10.1  Minor blepharoplasty complications
(From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed). Complications and
Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing;
1992.)

328
SECTION I
CHAPTER 10 • Secondary blepharoplasty: Techniques
prevention, diagnosis, and management of complications
in the post-blepharoplasty patient. Although malposi­
tion of both the upper and lower eyelid are presented,
a particular emphasis is placed on unnatural distortion
of the lower eyelid, as these are the most common types
of defects encountered. If re-volumization is considered,
then the pertinent anatomy will also need to be borne in
mind.27
anatomical variations that may be accentuated after eyelid
skin, muscle, and fat removal; and, most importantly, (4) the
psychological status of the patient and assessment of their
expectations of surgery. The presence of a pre-existing condi­
tion does not preclude cosmetic blepharoplasty; however, the
surgical timing, venue, and technique may have to be altered.
The following discussion contains relevant informa­
tion regarding anatomical zones of the eyelids as well as
Visual loss or alteration
Globe penetration
Retrobulbar hemorrhage
Glaucoma
Extraocular muscle disorder
Corneal
Exposure
Ulcer
Filaments
Scar
Neovascularization
Refractive
Astigmatism
Tear film abnormality
Contact lens intolerance
Basement membrane disorder
Permanent eyelid deformities and functional disorders
Lacrimal disorders
Dry eye
Epiphora
Tear film abnormalities (reflexly stimulated)
Tear distribution abnormalities
Lid eversion
Lid retraction
Ectropion
Entropion
Tear drainage abnormalities
Lid paralysis
Medial punctal eversion
Obstruction of nasolacrimal system
Eyelid malpositions
Upper eyelid
Ptosis
Retraction
Contour changes
Margin abnormalities
Lower eyelid
Scleral show
Retraction
Laxity
Paralysis
Margin abnormalities
Ectropion
Entropion
Eyelid deformities
Palpebral aperture asymmetry
Unveiled pre-existing condition
Iatrogenic
Upper eyelid fold
Asymmetric
Absent
High
Low
Multiple
Epicanthal folds
Cicatrix
Inadequate fat removal
Excessive fat removal
Suture tunnels
Dermal pigmentary changes
Festoons
Malar pads
BOX 10.2  Major blepharoplasty complications
(From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed). Complications and
Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing;
1992.)

329
Corneal protection
result of blepharoplasty procedures will be discussed in
detail.
Corneal protection
In both primary and secondary surgery of the eyelids and
orbital region, protection of the cornea is essential. Specially
designed, protective contact lenses should be routine (Fig.
10.3).29 Colored lenses are preferred as they filter bright oper­
ating light if the procedure is performed under local anesthe­
sia, and they are also less often inadvertently left on the cornea
postoperatively. The contact shell prevents desiccation and
inadvertent corneal injury by an instrument or gauze. In order
to avoid postoperative corneal abrasions, deep sutures on or
near the conjunctival surface should be placed in such a
manner that the knots are buried in the tissue or placed
externally. A continuous buried suture that may be pulled out
Anatomical zones
To facilitate complete and thorough anatomical analysis, the
eyelids are divided into zones (Fig. 10.1).23,28 Zone 0 includes
the ocular globe and orbital structures behind the arcus
marginalis, posterior lacrimal crest, and lateral retinaculum.
Zones I and II include the upper eyelid and lower eyelid,
respectively, from the lateral commissure to the temporal
aspect of canalicular puncti. Zone III is the medial canthus
with the lacrimal drainage system. Zone IV is the lateral reti­
naculum. Zones I–IV are further subdivided into structures
that are anterior (preseptal) or posterior (postseptal) to the
orbital septum. Zone V includes the contiguous periorbital
structures of nasal, glabella, brow, forehead, temple, malar,
and nasojugal regions which merge with zones I–IV (Fig.
10.2). The diagnosis and management of upper eyelid (zone
I) and lower eyelid (zone II) complications that occur as a
Pre-existing conditions
Medical conditions
Hypertension
Diabetes
Bleeding disorders
Inflammatory skin condition
Asthma
Sulfite allergy
Venous thrombosis
Cardiac disorders
Atherosclerosis
COPD
Emphysema
Sleep apnea
Ophthalmological conditions
Amblyopia
Diplopia
Strabismus
Glaucoma
Corneal disease
Eyelid disorder
High myopia
Contact lens wearer
Retinal disorders
Uveitis
Dry eye
Tear film dysfunction
Refractive surgery
Morphology
Negative vector
Malar hypoplasia
High myopia
Small orbital volume
Horizontal lid laxity
Involutional
Cicatricial
Ectropion
Entropion
Anatomical variations
Tear trough deformity
Malar pads
Festoons
Cheek–lid interface deformity
True ptosis
Look ptosis
Frontalis spasm
Corrugator hyperactivity
Crow’s feet
Punctal eversion
Ectropion
Entropion
Psychological
Realistic outcome expectations
Ability to deal with vision loss, deformity
Body dysmorphic disorder
Body image
BOX 10.3  Prevention of blepharoplasty complications: preoperative evaluation

330
SECTION I
CHAPTER 10 • Secondary blepharoplasty: Techniques
attachments of the levator aponeurosis to the subcutaneous
tissue of the eyelid. Above the lid fold, the aponeurosis does
not attach to the preseptal or orbital subcutaneous tissue, and
the overhanging skin forms a fold. Inferior to the lid fold there
are levator attachments to the subcutaneous tissue overlying
the tarsus. In the Asian patient, the orbital septum inserts
more inferiorly onto the distal expansion of the levator apo­
neurosis, which allows more preaponeurotic fat to descend
into the upper eyelid and the resultant lower eyelid crease.
Blepharoplasty in Asians requires the identification of subor­
bicular fat. Dissection through this fat layer provides access
to the orbital septum and the retroseptal (preaponeurotic) fat.
Ptosis and lid retraction are conditions that alter the palpe­
bral aperture by affecting the anatomic position of the upper
eyelid. Localization of any major eyelid pathology facilitates
after healing is particularly useful in the approximation of
tissue over the cornea. Skin grafts should not be placed in the
conjunctival sac if they are to be in contact with the cornea;
only conjunctival or other mucosal tissue is tolerated by the
cornea.
Upper eyelid
Upper eyelid malposition: evaluation
and management
A thorough evaluation of the upper eyelid (zone I) level is
facilitated by dividing the structure into anterior, middle, and
plural lamellae (Table 10.1). The anterior lamella is composed
of upper lid skin and orbicularis muscle. The middle lamella
is composed of the tarsus, levator mechanism, orbital septum,
and fat. The posterior lamella consists of the conjunctiva. The
palpebral aperture is primarily influenced by the upper eyelid
levels (Fig. 10.4). The palpebral aperture usually varies in
shape, size, and obliquity due to hereditary, racial, traumatic,
or other acquired situations. The surrounding bony orbital
anatomy, the internal orbital volume, and the integrity of the
eyelids, with their muscular and tarsoligamentous supports,
are some of the factors that influence the palpebral aperture
(Figs. 10.5 & 10.6). It is also influenced by the relative amount
of associated periorbital skin, fat, and soft tissues. Unique
individual combinations of eyelid and orbital anatomy can
cause variations in the palpebral aperture (see Fig. 10.4).30
The eyelid fold position should also be evaluated. In the
occidental patient, the upper eyelid fold is normally 8–10 mm
above the lid margin. This corresponds to the superior
Fig. 10.1  Surgical zones of the eyelids and periocular structures. Zone I, upper
eyelid; zone II, lower eyelid; zone III, medial canthal structures including the
lacrimal drainage system; zone IV, lateral canthal area; zone V, periocular
contiguous area – glabella, eyebrow, forehead, temple, malar, nasojugal and nasal
areas. (From Spinelli HM, Jelks GW. Periocular reconstruction: a systematic
approach. Plast Reconstr Surg. 1993;91:1017–1024.)
I
II
III
IV
V
V
Fig. 10.2  Topographic anatomy of the eyelids and cheeks. (1) Superior eyelid fold;
(2) inferior eyelid fold; (3) malar fold; (4) nasojugal fold; (5) nasolabial fold.
(Modified from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed). Complications
and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical
Publishing; 1992.)
1
2
4
3
5
Fig. 10.3  Corneal protective shields manufactured with a steep central radius of
curvature and a flat peripheral radius of curvature. This configuration prevents direct
contact. Colored lenses are preferred as they filter bright operating light if the
procedure is performed under local anesthesia, and they are also less often
inadvertently left on the cornea postoperatively. (From Jelks GW, Jelks EB.
Blepharoplasty. In: Peck GC (ed). Complications and Problems in Aesthetic Plastic
Surgery. New York, NY: Gower Medical Publishing; 1992.)

331
Upper eyelid
Fig. 10.4  (A) Normal palpebral aperture. The upper eyelid is normally 1–2 mm below the superior corneal limbus. (B) Ptosis is seen when the upper eyelid level is below
that seen in (A), interfering with the superior visual field. (C) Lid retraction is seen when the elevation of the upper lid is at or above the superior corneal limbus. (Modified
from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed). Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
Normal
B
Ptosis
C
Lid retraction
the delineation of corrective procedures. The most commonly
seen upper eyelid complications requiring secondary correc­
tion are ptosis and lid retraction.
Ptosis
Ptosis is the abnormally low level of the upper eyelid.30–33
Ptosis of the upper eyelid can result from damage to the
levator complex during retroseptal dissection by direct
trauma, hematoma, edema, or septal adhesions.30,34–40 The
normal upper eyelid level covers 2–3 mm of the superior
limbus or lies at the level midway between the superior edge
of a 4-mm pupil and the superior corneal limbus (see Fig.
10.4). Preoperative variations in upper eyelid levels may result
from the level of alertness, pharmacologic agents, direction of
gaze, size of the ocular globe, orbital volume, visual acuity,
and extraocular muscle balance.30 Occasionally, unrecognized
ptosis manifests itself in the postoperative blepharoplasty
patient. Review of the preoperative examination records and
medical photography usually reveals the etiology. When no
presenting condition can be documented, a surgical misad­
venture is implicated in the etiology.
Mechanical ptosis due to postoperative edema is symmetric
and transient and usually resolves spontaneously within
48–72 h. A hematoma in the retroseptal space can cause
impairment of levator muscle function, maintaining the upper
eyelid in a ptotic position. Resorption of the hematoma may
produce secondary fibrosis of the levator with persistent
ptosis. Attempts to create high upper eyelid supratarsal folds
involve fixing the skin muscle edges to the levator aponeuro­
sis. This can lead to tractional ptosis if the lid fold is placed
too high. The medial and lateral retinaculae become tense and
lower the upper lid level. Treatment consists of observation
and massage of the upper eyelid. If ptosis persists more than
several weeks, removal of the supratarsal fixation sutures is
necessary. Ptosis may also occur when adhesions develop
Table 10.1  Secondary blepharoplasty candidate evaluation: upper eyelid
Anterior lamella
Lagophthalmos
Absent
Present
Skin
Normal
Abnormal
Over-resection
Excess
Scars
Normal
Abnormal
Position
Quality
Lid fold position
Normal
Abnormal
High
Low
Absent
Multiple
Lash position
Normal
Abnormal
Palpebral aperture
Symmetric
Asymmetric
Middle lamella
Lid levels
Equal
Ptosis
Retraction
Unilateral
Physiologic
Bilateral
Thyroid
Cicatricial
Bell’s
Mechanical
Cicatricial
Involutional
Levator function (measurement)
0–3 mm
3–10 mm
>10 mm
Fat
Normal
Abnormal
Excess removal
Retention
Posterior lamella
Palpebral conjunctiva
Normal
Abnormal

332
SECTION I
CHAPTER 10 • Secondary blepharoplasty: Techniques
palpebral apertures at the midpupillary line. The amount of
levator function in millimeters is measured whenever ptosis
is diagnosed, in order to plan a surgical correction. The test
is performed by examining the upper eyelid excursion from
complete downgaze to upgaze, while blocking any contribu­
tion to upper eyelid elevation by the eyebrow (Fig. 10.7).
Asymmetric or absent lid creases must be identified, because
asymmetry can be accentuated with standard blepharoplasty
techniques. The vertical dimensions of the palpebral apertures
at the midpupillary line are also measured.24
Aponeurosis disinsertion, or dehiscence, is the most
common form of acquired ptosis. The typical clinical presen­
tation is a mild (1–2 mm) to moderate (2–3 mm) case of ptosis
associated with thin upper eyelids, high lid folds, and good
levator excursion (Figs. 10.8 & 10.9).30 The levator muscle
originates from the apex of the orbit and passes anteriorly,
becoming aponeurotic at the superior orbital margin to insert
onto the anterior two-thirds of the anterior tarsal surface.
Some fibers of the aponeurosis extend to the orbicularis fascia
to attach to the dermis of the upper eyelid, forming the upper
lid crease. The anterior orbital fat removed during upper
blepharoplasty lies posterior to the septum and anterior to the
levator aponeurosis. Inadvertent penetration or detachment
injury to the levator aponeurosis can occur during removal of
the preseptal orbicularis oculi muscle or retroseptal fat (see
Fig. 10.9A).
This condition is repaired by levator exploration and
advancement of the aponeurotic structures to the anterior
tarsus.34–40 Patients with levator detachment should be
repaired by levator advancement to the anterior tarsus. The
Fasanella–Servat40 technique and its various modifications
(Fig. 10.10), or variations of a tarso-mullerectomy are also
excellent approaches to correct minimal ptosis.
Retraction
Lid retraction of the upper eyelid is an elevation of the upper
eyelid margin above the superior corneal limbus. Lid retrac­
tion may be unilateral or bilateral, giving the patient a staring
appearance and the illusion or accentuation or exophthalmos.
Excessive skin removal from the upper eyelid may result in
lagophthalmos and lid retraction which prevents complete
closure of the eyelids (Fig. 10.11A). Varying amounts of lid
margin eversion may also be present (Fig. 10.11B). Surgical
correction requires release of the retraction through applica­
tion of a retro- or preauricular full-thickness skin graft (Fig.
10.11C,D).39–44
Adhesion, fibrosis, and foreshortening of the midlamellar
structures of the upper lid (levator aponeurosis, orbital
septum, and tarsus) can cause upper eyelid retraction (Fig.
10.12A). Treatment requires surgical release of the adhesion,
levator aponeurosis recession, interpositional fascial grafts,
and lid traction sutures, which should establish a minimal
amount of ptosis of the involved lids (Fig. 10.12B).29,39–44 Sub­
sequent ptosis correction by a levator aponeurosis advance­
ment or partial tarso-mullerectomy usually produces an
acceptable result (Fig. 10.12C).29,39,45
Hering’s law
Retraction in the upper eyelid may also present as a result of
ptosis in the contralateral eye (Fig. 10.13). This type of retrac­
tion can be explained by Hering’s law of equal innervation,46
between the orbital septum and the levator aponeurosis at a
level higher than the original septal origin.
Ptosis is classified as mild at 1–2 mm, moderate at
2–3 mm, and severe at ≥4 mm.4,23,30 The amount of ptosis is
documented by measuring the vertical dimensions of the
Fig. 10.5  Sagittal section through the upper eyelid showing the relationship of the
orbicularis oculi muscle, septum orbitale, levator palpebrae superioris, and Müller’s
muscle. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and
associated structures. In: McCarthy JG (ed). Plastic Surgery. Philadelphia, PA: WB
Saunders; 1990:1671.)
Müller’s muscle
Levator tendon
Attachments
to tarsus
Cul-de-sac of
conjunctiva
Tarsus
Attachments
to skin
Skin
Obicularis
Orbital septum
Fig. 10.6  Sagittal section illustrating the structures of the upper eyelid, including
the levator muscle, its aponeurosis, and its relationship with Müller’s muscle and
the septum orbitale. (Modified from Jelks GW, Smith BC. Reconstruction of the
eyelids and associated structures. In: McCarthy JG (ed). Plastic surgery.
Philadelphia: WB Saunders; 1990:1671.)
Müller’s smooth muscle
Levator aponeurosis
Lateral horn of
levator aponeurosis
Conjunctiva
Lateral rectus
Lateral canthal tendon
Superior rectus
Globe
Levator
Tarsus
Skin
Obicularis
Orbital septum