Upper Eyelid Blepharoplasty

Key Points

•Upper blepharoplasty is one of the oldest described treatments of the aging face.

•Surgery is commonly performed to improve both appearance and field of vision.

•A detailed knowledge of eyelid function and anatomy is critical to achieving appropriate surgical outcomes.

•The preoperative evaluation should focus on identifying patients not suitable for surgery as a result of ocular pathology (dry eye, etc.) or unrealistic expectations.

•Preoperative brow ptosis and true eyelid ptosis must be pointed out to the patient.

•To achieve the best surgical results a brow lift and ptosis repair are added when necessary.

•While surgery is generally straightforward, complications can be severe and lead to significant discomfort and visual compromise.

•Complications are avoided with appropriate patient selection and surgical technique.

•In experienced hands, upper blepharoplasty surgery is a very rewarding procedure.

procedure. The procedure is relatively straightforward and safe, is performed by physicians in many specialties, and yields high patient satisfaction. However, when performed improperly and poor outcome is attained, more than appearance can be affected. Patients may experience significant discomfort, visual difficulty, and dissatisfaction. When this occurs in functional surgery, it may be tolerated until resolution is achieved. Conversely, when surgery is cosmetic in nature, the postoperative expectation is high and the patient less forgiving. As most aesthetic facial surgeons consider this a “bread and butter” procedure, and because it is so commonly performed, mastering the technique is essential. In addition, there are a host of reasons for which patients pursue blepharoplasty and it is incumbent upon the surgeon to identify patient expectations and determine if they can be met.

In this chapter I will review the essential components of the preoperative evaluation of the blepharoplasty patient. In addition the surgical technique will be reviewed in detail. Finally, the postoperative care for patients undergoing the operation and the common complications encountered will be described.

9.1Introduction

Initial historical reference to upper eyelid blepharoplasty dates back to the tenth and eleventh centuries [1], when the functional impairment of eyelid skin relative to vision was recognized. The first cosmetic references to the procedures were described in the early part of the twentieth century [2, 3]. It was not until the 1950s that the traditional techniques of upper lid blepharoplasty that are still used today were described in detail [4]. In contemporary times, upper lid blepharoplasty has become an accepted and common cosmetic

A.D. Morton (*)

Director of Oculoplastic and Facial Reconstruction, Eye Care of San Diego, San Diego, CA, USA e-mail: admorton@aol.com

9.2Anatomic Eyelid and Periorbital Considerations

The anatomy of the eyelids and periorbital structures is discussed in Chap. 2. The eyelid surgeon is well advised to review normal anatomy prior to performing eyelid surgery. In brief, the upper eyelid is composed of skin and orbicularis muscle, the orbital septum, two fat compartments, the levator muscle and aponeurosis, Mueller’s muscle, tarsus, and conjunctiva (Fig. 9.1). The skin overlying the septum is loosely attached to underlying tissue, is generally above the eyelid crease, and is the skin which becomes redundant with age and is excised in surgery. The pretarsal skin is firmly attached to underlying tissue, is below the crease, is not excised during surgery, and forms the pretarsal lid platform of the eyelid.

Fig. 9.1 Key anatomic components of the upper lid

Just posterior to the orbital septum are the nasal and central (preaponeurotic) fat pads of the upper lid. These fat pads differ in color and constitution (see Chap. 2) [5–7] which may give rise to the typical involutional changes seen in the eyelids. The preaponeurotic fat is a critical landmark in surgery. The fat pad may be debulked as needed, and it directly overlies the levator aponeurosis (the main eyelid elevator), a structure which must be preserved in surgery. Posterior to the levator muscle and intimately associated with it is Mueller’s muscle, the accessory (and sympathetically driven) eyelid elevator. Unlike the lower eyelid, the upper lid does not have a third (temporal) fat pad. If fullness is present in this area, consideration should be given to an anteriorly displaced or translocated lacrimal gland [8, 9]. This should be addressed by repositioning the gland into its associated fossa, not excision, as to avoid potentially significant postoperative dry eye complications. The tarsus is the cartilaginous skeleton of the upper lid and provides it with rigid support. Its superior edge is the general location of the eyelid crease, and it acts as the anchor point for the levator aponeurosis.

The eyelid crease is an anatomic structure essential to blepharoplasty surgery. The creases of the two lids should be symmetric. In occidental eyes, the lid crease generally forms between 8 and 12 mm above the lash margin. This varies and is a function of where the levator aponeurosis and orbital septum fuse, and at what level the distal levator fibers adhere to the skin. The levator aponeurosis attaches to the anterior surface of the tarsus and sends slips of tissue forward through the orbicularis muscle to the pretarsal skin. This creates a pull on the eyelid skin and the formation of the crease (Fig. 9.2). The level at which the orbital septum fuses with the levator aponeurosis limits descent of preseptal fat into the eyelid and defines the eyelid crease. In the Asian eyelid, the septum fuses much lower on the levator allowing descent of the eyelid fat. This blunts the anterior fibers of the levator aponeurosis from which adhering to the skin, and creates a low or nonexistent lid crease (Fig. 9.3).

Fig. 9.2 The levator aponeurosis attaches to the anterior surface of the tarsus and sends slips of tissue forward through the orbicularis muscle to the pretarsal skin (dotted black line). This creates a pull on the eyelid skin and the formation of the crease

Fig. 9.3 In the Asian eyelid, the septum fuses much lower on the levator allowing descent of the eyelid fat. This blunts the anterior fibers of the levator aponeurosis from adhering to the skin and creates a low or nonexistent lid crease. Also note that the Asian eyelid has a preseptal fat pad, normally absent from the Caucasian eyelid, which also (in addition to lower riding postseptal fat) adds fullness to the lid

Normally, the eyelashes are directed anteriorly so as not to obstruct the visual axis. With advancing age, the crease elevates, reducing its support of lash position (the attachments of the levator to the skin/orbicularis), and advancing dermatochalasis mechanically rides on the lashes. These events may redirect the lashes into the visual axis adversely effecting vision and appearance. In addition, the overhanging lid fold can trap bacteria and skin debris, inducing blepharitis. These issues can be addressed surgically with tissue debulking and crease reformation when necessary.

The position of the brow is important in performing appropriate upper lid blepharoplasty. In general, the male brow is flat and sits just at, or slightly above, the orbital rim. The female brow is arched above the orbital rim and slopes inferio-laterally out over the lateral canthus (Fig. 9.4). Significant horizontal rhytids of the forehead suggest

compensation for brow ptosis. Patients subconsciously will elevate their brows to reduce the weight on the eyelids and improve super temporal visual fields. This compensation can be negated by eyelid surgery resulting in postoperative brow ptosis (Fig. 9.5).

9.3Assessing Patients’ Concerns

The initial consultation may be the most important part of the surgical relationship. It is incumbent upon the surgeon to understand the concerns and goals of the patient. The following questions will help to reveal the patient’s intentions and assess how reasonable their goals are:

•How is it that I can best help you?

•What is it that you would like to change?

•How do you feel your eyelids affect your appearance or vision?

•Are there any life circumstances that effect your decision to proceed with surgery now?

A mirror held by the patient will encourage them to accu-

rately demonstrate areas of concern. Patients are encouraged

to describe what they wish to change and not comment on the surgical procedure they feel is needed. Prospective patients often arrive with preconceived notions on how their aesthetic goals will be realized and these should be carefully reviewed and corrected if necessary.

It is difficult with instruments or fingers to demonstrate expected outcomes. A Q-tip or bent paperclip can be utilized to indent the lid crease and elevate redundant skin to simulate the intended result. Patients should be cautioned as to the accuracy of these techniques. Ideally, the patient is photographed directly before the consultation so that a series of standard photographs are available for reference. A moderately sized flat screen monitor positioned for shared viewing is ideal (Fig. 9.6). Areas of concern can be enlarged for greater clarification during the discussion. Digital morphing programs are available to simulate postoperative results, but increase the risk for unrealistic patient expectations. A portfolio of preand postoperative photos of actual patients demonstrates true results and speaks to the surgical skills of the surgeon.

To ensure an accurate assessment of patient goals, it is useful to conclude with a review statement such as, “I hear

Fig. 9.6 A flat screen computer monitor is used to project the patients photos. Areas of concern can be visualized from full face, oblique, and side view images. Representative preand postoperative images from consenting patients can be shared

you saying that you would like to accomplish the following.” The patient confirms understanding and the accuracy of communication is verified. It cannot be overemphasized that time spent carefully listening and explaining the course of events, recovery phase, and risks of surgery, is crucial and should never be rushed. Not every patient is a candidate for surgery. This is the time to identify mismatches in expectations and reality and politely decline to participate if necessary.

9.4Patient History

Prior to consultation the patient completes the history form. This is an opportunity to discover and assess key relevant medical information before surgery. The information is reviewed with the patient during the interview. A thorough discussion of medications, especially those that increase intraoperative bleeding time, should be obtained. Anticoagulation for various maladies is becoming more and more common as the patient population lives longer. The risk of stopping these agents versus the risk of intraoperative bleeding with their continued use must be carefully assessed and reviewed with their primary physician. This is an elective surgery which should not create undo risk to the patient.

The patient is questioned about chronic systemic diseases and autoimmune processes. Patients with increased periorbital edema and prominent eyes or swelling should be evaluated for thyroid-related orbitopathy. A history of dry eye or frequent artificial tear use should be solicited.

A careful record of drug allergies and medication sensitivities should be obtained. Anesthesia complications during prior surgeries should be noted. In all but the healthiest of patients, it is advisable to request a medical clearance from the patient’s primary physician.

9.5Patient Examination

A careful and thorough preoperative examination is essential to attaining a good surgical result and a vital reference should postoperative problems develop. The surgeon must be careful to ensure that preexisting problems are documented and not credited postoperatively to the surgical procedure they perform.

With all eyelid surgery, the patient’s best-corrected visual acuity should be recorded. The presence of an afferent pupilary defect, ocular misalignment, or limitations in ocular motility is noted. Standardized eyelid measurements are very useful and necessary to document preand postoperative findings. These should include the vertical palpebral fissure measurement from upper lid margin to lower lid margin (typically 10 mm). Levator excursion is measured by immobilizing the brow with the thumb and measuring the excursion from full down-gaze to full up-gaze. Normal levator function is 15 mm of excursion. This is an especially important measurement in the presence of true eyelid ptosis. The lid crease height is measured by having the patient look down and measuring from the lid margin to the lid crease. A normal Caucasian crease is approximately 10 mm, and significantly lower in Asians. Pretarsal show is measured in primary gaze from the inferior aspect of the lid fold to the lid margin. This is an important measurement in blepharoplasty surgery as it defines the visible lid platform after surgery. Negative numbers can be used to represent a lid fold that hangs below the lid margin. The margin reflex distance (MRD) is measured as the distance from mid-pupil to the lid margin with the patient fixating in primary gaze. This can be measured for both the upper (MRD1 - an assessment of ptosis) and lower eyelid (MRD2 – assessment of lid retraction or sclera show). If ptosis is noted, neurological disease must be ruled out (Myasthenia Gravis, Horner’s syndrome, etc.) before proceeding (see Chap. 12). The term “pseudo MRD” can be used to measure the distance from the hanging lid fold to mid-pupil in cases where the fold drops below the lid margin. These “pseudo” measurements can also be applied to the vertical palpebral fissure. Also important is an assessment of orbicularis oculi strength. The patient is asked to close the eyes with force. The examiner then attempts to open the eyes. This should be difficult when lid strength is normal. The strength is measured from 1 to 4, with 4 being normal and decreasing numbers gradations of weakness. Even with conservative skin excision, patients may develop reduced lid closure after surgery. This can be related to preexisting muscle weakness which can be exacerbated by the trauma of surgery. Finally, the Bells’ phenomenon can be assessed. This is globe supraduction (elevation) that occurs with lid closure. It is a normal protective mechanism of the cornea. If this is deficient, patients are at greater risk of postoperative exposure