to the levator aponeurosis at the desired crease height. Ideally a crease suture is placed nasally, centrally, and temporally. The aponeurosis can also be engaged at these points in a running skin closure.

11.5.2 Skin

Asymmetry in the amount of eyelid skin after surgery results from preexisting asymmetries and/or disproportionate skin excision during surgery. This can be avoided with attention to preoperative differences between the two sides, and careful eyelid markings. If asymmetry of the amount of skin between the eyelids is significant or leads to an unacceptable cosmetic result, revision is appropriate.

11.5.2.1 Medical Management

Prior to performing any additional procedures, the surgeon should observe the patient and allow postoperative edema to resolve. Complete resolution of postoperative edema may take up to a full year depending on the invasiveness of the procedure(s) [44]. Aggressive postoperative icing and oral corticosteroids may hasten the resolution of edema. On rare occasion, an overresection of skin can lead to asymmetry and poor corneal coverage. In these instances, more immediate surgical intervention may be required to protect the cornea (see Sect. 11.5.5).

11.5.2.2 Surgical Correction

Surgical correction of asymmetry usually involves a quick “touch-up” skin excision from one eyelid. These are typically performed in the office under local anesthesia.

11.5.3 Fat

Asymmetric sculpting or excision of the upper eyelid fat pads can lead to an asymmetric cosmetic result between the eyes. As discussed previously, excessive removal of fat can result in deep superior sulci and an undesirable appearance. Overresection of the central fat pad often yields an abnormal configuration of the upper eyelid fold (A-frame deformity). When removing fat in upper eyelids, only the amount that protrudes anterior to the supraorbital rim when gentle pressure is applied to the orbit should be removed. Also, the amount of fat removed from each side should be monitored to ensure that symmetric amounts are being removed, or in the case of preoperative asymmetry, the desired amount of excision is accomplished.

11.5.3.1 Medical Management

11.5.3.2 Surgical Management

Additional fat excision is performed as with standard blepharoplasty. When there is a hollow sulcus from fat overresection, correction involves volume augmentation (as discussed previously) with filler or autologous or alloplastic material.

11.5.4 Brow Position

Brow ptosis or deflation can give the appearance of a blepharoplasty undercorrection, particularly in the temporal region (Fig. 11.18). A thorough preoperative evaluation should include noting brow position and counseling the patient on the limitations of stand-alone upper blepharoplasty if there is preexisting brow ptosis (which could become worse after surgery) and brow position is not to be concurrently addressed at the time of surgery.

11.5.4.1 Medical Management

If surgery has created new or worsening brow ptosis which is bothersome to the patient, surgical options should be discussed.

11.5.4.2 Surgical Treatment

The addition of a formal browlift (endoscopic, direct, etc.) or brow stabilization (browpexy through the blepharoplasty incision) can be added to any planned eyelid revision. If no further lid surgery is to be considered, an isolated brow lift can be suggested.

11.5.5 Undercorrection/Overcorrection

While not a “true” complication of upper blepharoplasty, surgical undercorrection can be an issue to the cosmetic patient. When referenced to blepharoplasty, the term undercorrection refers to inadequate skin, muscle, or fat removal. Undercorrection should not be confused with asymmetry

As with postoperative skin asymmetry, patience is critical before a revision is planned. At least 6 months should pass before another surgery is performed.

Fig. 11.18 Bilateral involutional brow ptosis. Pre-existing brow ptosis will limit the improvement seen with upper blepharoplasty if the brow position is not addressed concurrently