Following suture removal, patients are instructed to avoid rubbing the eyelids as this may result in wound dehiscence. Patients should also be cautioned of hypesthesia below the incision line. As recovery progresses and patients return to the use of eyeliner, they may abruptly discover the hypesthetic lid margin, prompting an urgent call to the surgeon. The patient’s cornea is assessed and the presence of lagophthalmos or punctuate corneal staining should encourage the aggressive use of artificial tears and ointment until such time that it resolves. If the patient is doing well at the 1 week postoperative check, they are instructed to return for a final examination 6–8 weeks following surgery. Preand postoperative photographs are compared for every case and help the surgeon to refine their technique (Fig. 9.25).

9.11Complications

As mentioned previously, stand alone upper eyelid blepharoplasty in the hands of an experienced eyelid surgeon is a generallystraightforwardprocedure.Assuch,mostcomplications are not severe, respond to conservative care such as eyelid lubricants and reassurance, and are mostly self-limiting. These complications include prolonged bruising and swelling, mild lagophthalmos, exposure keratitis with dry eye symptoms, and lid tightness. Oral steroid can be used if swelling persists, and typically allow quick resolution. On rare occasion, vision threatening complications can develop, such as intraoperative or postoperative hemorrhage. Please refer to Chap. 11 for a detailed discussion of these issues.

Other, nonvision threatening, but more significant complications [11] include postoperative ptosis, wound issues, eyelid crease asymmetry, over or undercorrections, and allergic reactions to medications. Most cases of postoperative ptosis are related to edema and resolve over the first few weeks after surgery, with or without oral steroids. When ptosis persists, or is associated with reduced levator function, levator injury should be suspected. In these cases, the wound may require exploration to address muscular or aponeurotic lacerations. Wound infection, dehiscence, and epithelial suture cysts can occur. These are managed with antibiotics, resuturing, and cyst removal as needed. Eyelid crease asymmetry should be followed for 6 months, and only revised should it be an issue to the patient. Patients typically are more concerned with the symmetry of the pretarsal lid show (lid fold to lid margin distance) than with the height of the

crease. In either instance, skin re-excision or formal crease formation may be necessary. Undercorrection of skin removal requires re-excision, while overcorrection may require excision on the opposite side if excess skin exists. Finally, allergic skin and conjunctival reactions to topical medications can be very bothersome to patients. Treatment involves removing the offending medication and adding topical antiinflammatory agents as needed.

9.12Conclusion

Upper lid blepharoplasty can be a very satisfying surgical procedure for both surgeon and patient. With appropriate counseling, planning, and surgical technique, a very predictable result can be achieved. Recognizing that the eyelids are affected by other facial structures, and being sensitive to the effects of brow position, lid margin position, dry eyes, and lower lid laxity will help the surgeon to achieve the best results possible.

References

1.Dupuis C, Rees TD. Historical notes on blepharoplasty. Plast Reconstr Surg. 1971;47:246–51.

2.Miller CC. Cosmetic surgery: the correction of featural imperfections. 2nd ed. Chicago: Oak; 1908. p. 40–2.

3.Miller CC. Cosmetic surgery: the correction of featural imperfections. Philadelphia: FA Davis; 1924. p. 30–2.

4.Costaneras S. Blepharoplasty for herniated intraorbital fat: anatomic basis for a new approach. Plast Reconstr Surg. 1951;8(1):46–58.

5.Korn BS, Kikkawa DO, Hicok KC. Identification and characterization of adult stem cells from human orbital adipose tissue. Ophthal Plast Reconstr Surg. 2009;25:27–32.

6.Sang-Rog Oh, Weerawan C, et al. Analysis of upper eyelid fat pad changes with aging. San Francisco: ASOPRS; 2009.

7.Sires BS, Saari JC, Garwin GG, et al. The color difference in orbital fat. Arch Ophthalmol. 2001;119:868–71.

8.Morley AM, Malhotra R. Subconjunctival prolapse of the palpebral lobe of the lacrimal gland occurring in association with occult orbital fat herniation. Orbit. 2009;28(6):430–2.

9.Beer GM, Kompatscher P. A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthet Plast Surg. 1994 Winter;18(1):65–9.

10. Saadat D, Dresner SC. Safety of blepharoplasty in patients with preoperative dry eyes. Arch Facial Plast Surg. 2004;6(2): 101–4.

11. Schiller JD, Bosniak S. Blepahroplasty: conventional and incisional laser techniques. In: Mauriello JA, editor. Unfavorable results of eyelid and lacrimal surgery: prevention and management. Boston: Butterwoth-Heinemann; 2000. p. 3–26.

Key Points

•The upper eyelid blepharoplasty incision provides direct access to those brow, glabellar, and orbital structures that may contribute to brow ptosis and upper eyelid crowding and fullness.

•Adjunctive procedures that can be performed via the upper eyelid blepharoplasty incision at the same setting as blepharoplasty include internal brow fat sculpting and elevation, glabellar myectomy, and lacrimal gland repositioning.

•Internal brow elevation can be achieved by releasing the brow retaining ligaments (orbital ligament and the anterior leaf of the deep galea) that tether the brow to the lateral orbital rim. This allows the lateral and central brow to slide upward under the action of frontalis muscle. Internal brow fat pad sculpting lightens the brow tissues, further improving the position of the brow over the supero-lateral orbital rim.

•Although not as effective as those procedures that lift the brows from above, internal brow elevation and brow fat pad sculpting can be excellent options for those patients concerned with postoperative morbidity, operative time, and surgery costs. In addition, these procedures offer the advantage of ease of access as they are performed through the same blepharoplasty incision.

•Internal browpexy is performed by securing the brow to the periosteum above the orbital rim. This procedure is best used in patients with involutional brow ptosis, brow asymmetry, or even facial paralysis, who are concerned with the cosmetic result. Care must be taken to prevent skin dimpling and irregularities in brow contour with this technique.

D. Georgescu (*)

Clinical Assistant Professor, Wilmer Eye Institute, Johns Hopkins Medical Center, Baltimore, MD, USA e-mail: dan.oculoplastics@gmail.com

•To permanently improve the glabellar furrows and to elevate the medial brow, a glabellar myectomy can be performed by excising the corrugator and the depressor supercilii muscles via the upper eyelid blepharoplasty incision. The procerus muscle is undermined and stretched but not excised.

•We have found the trans-eyelid glabellar myectomy to be the most effective procedure for elevating the medial brow.

•The main complication of corrugator muscle removal is temporary damage to the supratrochlear nerves and the superficial branches of the supraorbital nerve. This results in transient anesthesia to the central forehead that usually resolves over a period of several months and should be discussed with the patients preoperatively.

•Corrugator and depressor supercilii muscle extirpation may be the best treatment for migraine and tension-type headaches originating in the glabellar region that are refractory to other treatment modalities.

•There are two surgical techniques utilized to correct lacrimal gland prolapsed at the time of blepharoplasty surgery: resection of the prolapsed gland and repositioning/resecuring the gland to the lacrimal fossa. Repositioning/resecuring of the gland is our favored technique, as it does not damage the gland parenchyma or the excretory ducts, which can result in dry eyes postoperatively.

10.1Introduction

Upper blepharoplasty is the most common eyelid surgery performed today. When a patient presents with excess tissue and heaviness in the upper eyelids, it is imperative that the surgical procedure chosen takes into consideration all factors that may contribute to the fullness of the upper lids. Factors which may aggravate upper eyelid appearance and heaviness include brow ptosis, glabellar muscle activity with secondary medial brow depression and rhytid formation, and lacrimal gland dislocation with associated temporal lid fullness.

Fig. 10.1 Preoperative clinical photograph of a 55-year-old man with brow ptosis and dermatochalasis, resulting in a tired facial appearance

When one, or all, of these deficits is present in association with dermatochalasis of the upper lids, they can be addressed simultaneously at the time of the upper blepharoplasty. Three adjunctive procedures: brow sculpting and elevation, glabellar muscle extirpation, and lacrimal gland repositioning can be performed through the same incision to improve upper eyelid cosmesis and function.

The effects of gravity and aging work at least as much on the brows and the forehead as they do on the eyelids. It is common for patients to have brow ptosis, dermatochalasis, and eyelid ptosis simultaneously (Fig. 10.1). A typical, yet preventable error of aesthetic eyelid surgeons is failing to recognize the brow ptosis component when evaluating patients with upper eyelid dermatochalasis, herniated fat, and eyelid ptosis [1–6].

In the presence of significant brow ptosis, upper eyelid blepharoplasty performed alone can result in further lowering of brow position and worsening of brow ptosis. This occurs as the distance between the two structures is narrowed, and because the action of the frontalis muscle, the main elevator of the brow, is reduced as the forehead no longer has the stimulus to raise the brows in order to clear the superior field of vision [2, 7–9]. In addition, blepharoplasty, performed alone in the setting of brow ptosis, may lead to excessive skin excision. This can drag the thick skin of the brow into the upper eyelid, impairing lid dynamics and narrowing the space between the eyelashes and the brow hairs. This can worsen the appearance and make future brow lifting difficult [3, 10].

Understanding the pathophysiological mechanisms associated with brow ptosis is critical in determining the best surgical correction [7–9, 11–16]. This provides the framework for attaining the best cosmetic and functional results. Agerelated brow ptosis does not occur in isolation. It is part of the general aging process of the upper face. The soft tissues of the forehead, skin, frontalis muscle, galea, and fat, slide

downwards with time, as they lack deep attachments to the underlying periosteum. This causes the brows to fall, a process further influenced by an imbalance between the depressor and the elevator muscles of the brow.

Internal brow sculpting and elevation is not as effective as the direct, open coronal or endoscopic brow lift. However, with appropriate patient selection, good brow elevation can be achieved, which makes it a useful adjunctive procedure to blepharoplasty [11–17].

Often times, brow ptosis may have a significant medial component associated with heavy glabellar rhytids. When necessary, weakening the glabellar musculature may benefit the final outcome. The medial brow is depressed by the corrugator, procerus and depressor supercilii muscles, and to some degree by the medial segment or the orbicularis oculi muscle [2, 11–13]. Medial brow depression is seen clinically as frowning. People who frown frequently develop hypertrophy and hypertonicity of these depressor muscles with resultant downward slanting of the medial brow. This is seen in both men and women, although more commonly in men, and in those who spend considerable time outdoors and use the brows to protect their eyes from the sun. Corrugator muscle contraction produces vertical furrow lines in the glabellar region while procerus muscle contraction is responsible for the horizontal glabellar lines. Depressor supercilii muscle contraction adds inferior displacement of the medial brow. For those patients concerned with vertical furrowing and medial brow ptosis, glabellar myectomy can be performed at the time of upper eyelid blepharoplasty to enhance cosmetic results. This consists of extirpating the corrugator and depressor supercilii muscles and elevating the procerus muscle from its deep ligamentous attachments in the glabellar area. This procedure can be performed best via the upper eyelid blepharoplasty incision due to excellent access and visualization of these muscles.

Finally, in patients presenting with temporal upper eyelid fullness, a prolapsed lacrimal gland can sometimes be found at the time of blepharoplasty. This finding is typically involutional in nature and is seen in approximately 10% of patients at the time of surgery [18–20]. Less frequently, a prolapsed lacrimal gland can be seen in congenital ptosis, thyroid eye disease, lacrimal gland tumors, lacrimal gland inflammation, trauma, and infection. A prolapsed lacrimal gland can be resuspended to the periosteum inside the superolateral orbital rim via the blepharoplasty incision, to decrease the temporal fullness and enhance the cosmetic result.

In this chapter, we will elaborate on these three surgical procedures: internal brow fat sculpting and elevation, glabellar myectomy, and lacrimal gland repositioning, which can be performed at the time of blepharoplasty to improve the outcome of eyelid surgery. All three procedures have the advantage of being performed via the blepharoplasty incision. This not only cuts down on costs and operative time but also increases patient acceptance and cosmetic results.