Upper Eyelid Blepharoplasty

49.1 Introduction

Aging of the upper periorbital region is often one of the first signs of aging noted by patients. The pathogenesis of upper lid aging is a process involving both soft tissue excess and volume loss. The goal of any facial rejuvenation procedure is to restore the individual’s youthful appearance – not to create morphologic change that is novel. Hence, successful rejuvenation of this region requires a thorough understanding of the aging process as well as how this process has affected the individual patient. Overall, there has been a trend away from aggressive removal of skin, muscle, and fat which had resulted in hollowing and skeletonization of the upper lid complex. Hollowing of the upper eyelid complex was seen in the postoperative period, which often left the patients looking older or simply “different.” The modern approach is to perform conservative excisional blepharoplasty targeted primarily at the excess upper eyelid skin coupled with some level of volume augmentation of the lateral eyebrow and infrabrow region. This translates to recreation of the youthful and health- ier-appearing upper eyelid region, which can be generally defined by a fullness of the soft-tissues without obvious skin excess. In this chapter, we evaluate the periorbital

A.M. Karam ( )

Carmel Valley Facial Plastic Surgery, 4765 Carmel Mountain Road, Suite 201, San Diego, CA 92130, USA

e-mail: md@drkaram.com

S.M. Lam

Willow Bend Wellness Center, Lam Facial Plastic Surgery Center & Hair Restoration Institute, 6101 Chapel Hill Boulevard, Suite 101, Plano, TX 75093, USA

e-mail: drlam@lamfacialplastics.com

aging process and how upper eyelid blepharoplasty can be used in addition to other treatments to restore the youthful structure of this area.

49.2 Periorbital Aging

The youthful upper eyelid has a minimal degree of eyelid skin excess [1]. The superior orbital rim and infrabrow region appears soft as a smooth layer of subcutaneous and submuscular fat exists over the contour of the bony orbital rim. The lateral aspect of the eyelid should be free of lateral hooding. The supratarsal crease should be clearly visible with a corresponding degree of lid show inferior to the crease. The degree of eyelid show varies even in youth. It varies most among Asian patients. There is no “norm” to measure the degree of eyelid show. With age, dermatochalasis gives way to skin redundancy which extends down below the supratarsal crease and shortening the preexisting eyelid show. As the volume of the peribrow region diminishes there is a descent of the lateral brow further contributing to lateral hooding. The infrabrow volume loss results in skeletalization of the superior orbital rim. In certain cases, there may be mild prolapse of the medial fat pad; however, this is often unmasked as a result of the regional volume loss.

49.3 Anatomic Considerations

In no other area of facial aesthetic surgery is such a fragile balance struck between form and function as that in eyelid modification. Owing to the delicate

nature of eyelid structural composition and the vital role the eyelids serve in protecting the visual system, iatrogenic alterations in eyelid anatomy must be made with care, precision, and thoughtful consideration of existing soft tissue structures. A brief anatomic review is necessary to highlight some of these salient points.

49.4 Musculature

Directly under the thin upper eyelid skin lays the orbicularis oculi muscle [2]. It is grossly defined as a relatively large, flat, elliptical muscle that encircles both the upper and lower eyelid. It covers the orbit but extends into the temple and eyebrow in the superior half and into the upper cheek on the lower half. In the upper eyelid it is comprised of the orbital and palpebral portions. The orbital portion is darker and thicker than the palpebral segments. Many fibers insert into the skin and subcutaneous tissues of the eyebrow, which in the lateral portion forms the depressor supercilii. This segment is partly responsible for pulling down the lateral brow and is often the target of neurotoxin injection. The thin palpebral portion of the muscle lies directly over the upper eyelids and is divided into the preseptal and pretarsal segments [2–4]. The transverse facial, supratrochlear, and supraorbital vessels supply the muscle. The innervation is derived from the temporal, zygomatic, and buccal branches of the facial nerve.

The main function of the orbicularis is to serve as the sphincter of the upper and lower eyelids. The palpebral portion acts involuntarily to close the eyelids or reflexively to blink. The orbital portion is under voluntary control. When the orbital portion of the muscle contracts, it draws the skin of the cheeks and temple together resulting in crow’s feet and eyelid wrinkle formation. Neurotoxin is used to relax the contraction of the lateral portion of the orbital orbicularis to minimize crow’s feet formation.

49.5 Orbital Septum

Directly under the palpebral portion of orbicularis oculi muscle lays the orbital septum. This is a continuation of the periosteum of the orbit (periorbital) and

skull which extends over the eyelid. It is subdivided into an upper and lower portion. In the upper portion (above the tarsus), it divides the muscular compartment from the orbital fat compartment. The inferior portion fuses with the anterior part of the tarsus [3]. The insertion with the levator aponeurosis varies with ethnicity. In Asians, it inserts around 3 mm from the base of the eyelid margin while in westerners, it attaches higher around 8–10 mm, thus accounting for a higher eyelid crease.

49.6 Levator Palpebrae Superioris

Directly beneath the superior portion is the aponeurosis of the levator palpebrae superioris muscle. This is the main muscle responsible for the eyelid opening. It is powered by CN III. In addition, Mueller’s muscle which is deep to the tarsus is a smooth muscle responsible for 3–4 mm of eyelid opening. Beneath the orbital septum are the orbital fat compartments. Unlike in the lower eyelids, the upper fat compartments consist of only the medial and central compartments. In occasional cases, the medial fat pad may prolapse requiring surgical extraction. Removal of the central fat pads is rarely required, as it may often create an iatrogenic hollowing years later (A-frame deformity).

Beneath the inferior portion of the septum, lies the tarsal plate. In the upper eyelids, it typically measures 8–12 mm, unlike 4–7 mm in the lower eyelid. Beneath the septum about the tarsus lies the preaponeurotic fat, which when removed or retracted identifies the aponeurosis. The aponeurosis of the levator palpebrae superioris muscle attaches to the anterior portion of the tarsus, forming the superior palpebral fold. Weakening or dehiscence of the attachment results in eyelid ptosis.

49.7 Orbital Fat

Contained behind the orbital septum and within the orbital cavity, the orbital fat has been classically segmented into two discrete pockets (central and medial). Unlike the lower eyelid, a lateral fat pad does not exist [2–4]. Of these, the medial fat pad is more commonly seen to have mild prolapse. Similar to the lower eyelid, the medial pad has characteristic differences from its

other counterparts, including a lighter color, a more fibrous and compact lobular pattern, and a frequent association with a sizable blood vessel near its medial aspect. The orbital fat can be considered an adynamic structure because its volume is not related to body habitus, and once removed it is not thought to regenerate.

49.8 Preoperative Evaluation

Patient analysis is directed to understanding the patient’s desires and expectation, the etiology of the problem at hand, and development of the optimal treatment plan for the patient’s unique needs. The preoperative assessment of the anatomical characteristics must be directed at presence of:

1.Dermatochalasis or blepharochalasis (younger patients)

2.Volume status of the superior orbital rim and infrabrow region

3.Pseudoherniation of medial orbital fat

4.Glabellar lines and wrinkles

The treatment plan needs to include treatment of each of these potential anatomic issues.

In addition, a systematic and thorough preoperative assessment of blepharoplasty candidates is essential to minimize potential postoperative complications. Patients need to be specifically questioned about the history of dry-eye syndrome, hypertension, smoking, visual problems, ocular disorders (i.e., glaucoma), bleeding disorders, recent use of NSAIDS, aspirin, and other anticlotting medications. Appropriate workup is required depending on the patient’s history.

49.9 Ocular Assessment

Examination of the eyes should begin with an overall inspection. The eyelid should be assessed for symmetry (by noting palpebral fissure height and length), position of the upper eyelid margin with respect to the superior limbus, presence of eyelid ptosis, and lagophthalmus.

As a minimum, baseline ocular assessment should document visual acuity (i.e., best corrected vision if glasses or contact lenses are worn), extraocular movements, gross visual fields by confrontation, corneal

reflexes, the presence of Bell’s phenomenon, and lagophthalmus. If there is any question of dry-eye syndrome [5–7], a conservative approach must be taken and postoperative lubricating drops and ointment must be used as directed. In severe cases, the patient should be evaluated with Schirmer testing [8] (to quantify tear output) and tear film break-up times (to assess stability of precorneal tear film). Patients who demonstrate abnormalities in either or both of these tests or who have past or anatomic evidence that would predispose them to dry-eye complications should be thoroughly evaluated by an ophthalmologist preoperatively.

49.10 Operative Procedure

Upper eyelid blepharoplasty is an operation which is commonly performed to rejuvenate the upper eyelid region. Today, conservatism is favored and the surgical target is primarily excess eyelid skin. The underlying orbicularis oculi muscle and orbital fat are preserved in the vast majority of cases.

49.11Upper Eyelid Blepharoplasty Approach

The ideal candidate is a patient of any age that exibits redunent upper eyelid skin resulting in a reduction of the individuals aesthetic potential. In other words, is there enough skin excess that is negatively affecting the individuals appearance? If so, the patient may be considered a candidate for surgical excision of this skin excess. Younger patients affected by familial blepharochalasis often benefit from upper blepharoplasty in their 30s or 40s. Whereas the typical “aging face” patient may benefit from surgical excision in their 40s and beyond.

49.12 Preparation

While sitting upright, the patient is asked to look forward and to open and close their eyes. This helps to define the superior palpebral fold (or crease) which when present should be marked. This line represents the

inferior border of the skin excision. Placing the incision into the natural crease helps ensure that the incision will fall into the natural crease postoperatively minimizing the potential of “looking different” as well as optimizing scar placement. This inferior limb is extended slightly past the lateral canthus depending on the degree of lateral hooding present (Fig. 49.1). The more hooding, the longer the extension, so make certain to include the hooding into the excision. A crow’s feet wrinkle is chosen and the line is extended superiorly at an angle toward the lateral brow. The patient is then asked to close their eyes. With a nontoothed forceps the excess skin is pinched and marked (Fig. 49.2). Care is taken to avoid eyelid opening while pinching. This is essential in preventing postoperative lagophthalmus.

Fig. 49.1 Surgical markings along the supratarsal crease with an extension into a crow’s feet wrinkle to include lateral hooding

One percent lidocaine (Xylocaine) with 1:100,000 epinephrine to which is added a 1:10 dilution of sodium bicarbonate is then injected into the subcutaneous plane using a 30-gauge needle. Experience has demonstrated that this mixture affords analgesic effect while minimizing the sting of initial infiltration through alkalinization of the local agent. Care is taken to avoid injection into the underlying muscle. Typically 1–1.5 ml is sufficient. After waiting a full 10 min for vasoconstriction to occur, the outline of the incision is made using a 15 blade scalpel. Next, the skin is elevated off the underlying muscle using a scalpel. Hemostasis is then obtained using bipolar coagulation.

In cases in which a prominent medial fat pad is present, the skin over the medial aspect of the incision is retracted using a narrow double prong skin hook and the orbicularis is incised using scissors and the septum is penetrated. The medial fat pad which is lighter in color is exposed and expressed through the septal incision (Fig. 49.3). A fine-toothed hemostat is used to clamp the fat pad at its base. Prior to sharply excising the fat, bipolar is used to coagulate the fat above the clamp. Care is taken to remain conservative in order avoid postoperative hollowing. The incision is then carefully reapproximated using a running 6–0 Prolene suture; however, a variety of skin sutures and techniques can also be used. The key to a fine scar outcome is excellent approximation and limited wound tension (Figs. 49.4 and 49.5). Both eyes should then be irrigated with sodium chloride (Ophthalmic Balanced Salt Solution).

Fig. 49.2 Skin excess following pinching of the skin while the eyes are closed. If too much skin is pinched, then the eyes will open. This is an indication that too much skin excision is marked and the patient may be at risk for postoperative lagophthalmus

Fig. 49.3 The medial fat pad which is lighter in color is exposed and expressed through the septal incision. A fine-toothed hemostat is used to clamp the fat pad at its base prior to cauterization