Key Points

•Aesthetic eyelid and periorbital surgery is a multidisciplinary field of cosmetic surgery.

•Ophthalmologists, oculoplastic surgeons, otolaryngologists, facial plastic surgeons, plastic surgeons, and dermatologists have contributed to the evolution of the field.

•Early surgical procedures focused on excisional or “subtractive” techniques.

•Our current understanding of periorbital and facial aging is that volume loss is one of the major factors leading to involutional changes.

physicians/surgeons with overlapping expertise in the treatment of the aging eyelids and surrounding regions. The evolution of how we approach and provide surgical options in this area could not be possible without the contributions of ophthalmologists, oculoplastic surgeons, facial plastic surgeons, otolaryngologists, plastic surgeons, and dermatologists. Their combined contributions have been a synergistic and collaborative movement that has resulted in a better comprehension of the appropriate techniques in periorbital aesthetic surgery. More importantly, this evolution has led to fewer surgical complications, better patient care, and improved

sive tissue excision, to prevent further volume depletion.

•Endoscopic surgical technology has become an essential part of forehead, eyebrow, and midface surgery.

•Neuromodulators and fillers are widely used for less invasive cosmetic improvement of the periorbital area.

1.1Introduction

The ancient Greek word aisthetikos describes a passion for that which is beautiful. It is this passion that has driven the evolution of aesthetic and reconstructive periorbital surgery. The treatment of “relaxed skin of the upper eyelid” was first described by Aulus Cornelius Celsus, a Roman encyclopedic, in his textbook De re Medica in 25–30 AD [1] (Fig. 1.1). Here, we have the beginnings of the numerous and varied contributions to the evolution of periocular surgery. Over the last 2,000 years, there have been great advances in the field, and it has been due to continued contributions from physicians, scientists, and scholars from a variety of disciplines. In the current age of medical subspecialization, there are many different

G.G. Massry (*)

Director, Ophthalmic Plastic Surgery, Spaulding Drive Cosmetic Surgery and Dermatology, Beverly Hills, CA, USA

e-mail: gmassry@aol.com

periorbital rejuvenation, and how these multidisciplinary contributions have allowed the field to evolve.

1.2Blepharoplasty

Blepharoplasty is derived from the Greek words blepharon, meaning eyelid, and plastos, meaning formed. It is one of the oldest described treatments of the aging face [2]. The first recorded surgical treatment of the eyelid was by a Spanish surgeon, Albucasis, a pioneer in the creation of surgical instrumentation, including cautery [3]. He described a crescent shaped partial thickness excision of upper eyelid skin using cautery in 1000 AD. About the same time in Baghdad, Ali Ibn Isa – who researched and described many ophthalmologic pathologic processes including the etiology of epiphoria and Vogt–Koyanagi–Harada syndrome (VKH) – described using two wooden bars to pinch excess upper eyelid skin for 10 days [4]. This led to tissue necrosis, and the subsequent removal of the resultant skin without a scar. Excess skin of the upper lids did not appear in the literature until Beers, a Viennese ophthalmic pioneer described it in 1792 [5]. The first illustration of the condition was published 25 years later in a subsequent edition of the text Lehre der Augenkrankheiten [6]. In 1818, a German ophthalmologist, Von Graefe, was the first to term blepharoplastik

Fig. 1.1 Aulus Cornelius Celsus was the first to describe treatment of relaxed skin of the upper skin in 25–30 AD

Fig. 1.2 Von Graefe is credited with coining the term blepharoplastik for excision of excess upper lid skin related to carcinoma

(blepharoplasty) for removal of excess skin of the upper lid for the treatment of eyelid carcinoma [7] (Fig. 1.2). The term has remained over the last 150 years.

In the first half of the nineteenth century, a number of Von Graefe’s contemporaries, including Mackenzie, Alibert, Graf, and Dupuytren, were also performing similar upper lid skin excisions [8–11]. In 1844, Sichel was the first to describe herniated fat in the upper lid, and later in the century Fuchs described the reformation of the eyelid crease [12, 13].

In the early 1900, plastic surgeons began to focus on aesthetic eyelid surgery. In 1907, Conrad Miller, one of the modern day founders of plastic surgery, published the first textbook on cosmetic surgery, Cosmetic Surgery: The Correction of Featural Imperfections [14]. He included the first photographs of upper and lower blepharoplasty incisions. In his following textbook in 1924, he illustrated blepharoplasty incisions [15]. In 1911, Frederick Kolle, another early contributor to modern plastic surgery, elaborated on the value of preoperative markings for blepharoplasty skin excision [16]. In a series of publications in the 1920, Albert Bettman added to our understanding of blepharoplasty by detailing surgical techniques to reduce wound scarring (minimal tension, apposition of wound edges, timely removal of sutures) [17–19]. Interestingly, these early observations are still considered dogma today.

In the 1920, Julian Bourguet, a French surgeon, was the first to describe removal of herniated orbital fat from the upper lids, transconjuctival fat excision from the lower lids, and the importance of taking preand postoperative photographs [20–22]. Susan Noel, one of the first influential female aesthetic surgeons, included numerous preand postoperative photographs of cosmetic eyelid surgery in her 1926 textbook La Chirurgie Esthetique: Son Role social

[23]. She emphasized the importance of reviewing photographs with patients and is credited for highlighting the importance of the psychological issues related to cosmetic surgery. Even in the infancy of cosmetic surgery, Noel had theforesightandwisdomtoidentifythatphoto-documentation and patient psychology were basic tenets for successful surgical outcome.

Modern blepharoplasty techniques have focused on excision of variable amounts of skin, muscle, and fat. Costaneres first elaborated these techniques in a 1951 paper that also included a detailed anatomical description of the orbital fat compartments [24]. Costaneres also recognized the significance of the orbicularis muscle, including its excision, when necessary, as part of the scope of cosmetic eyelid surgery. In the 1950 and 1960, Sayoc, Pang, and Knou BooChai published on Asian upper lid blepharoplasty, including the formation of a double eyelid crease [25–27]. In 1970,

Sheen emphasized the role of the levator aponeurosis in eyelid crease formation (supra-tarsal fixation) [28, 29]. Dryden and Liebsohn then described levator advancement for simultaneous ptosis repair during blepharoplasty [30]. During this time, Smith, Patrelli, and Lisman elaborated on the surgical correction of lacrimal gland prolapse by suture repositioning for correction of temporal lid fullness [31, 32]. Over the next 20 years, the idealized goal for upper lid blepharoplasty was a high and deep lid fold. This was due in part to the contributions by Flowers and Siegel [33–35]. Today a high crease and deep fold in the upper lid have fallen out of favor. In 2002, Fagien reviewed current concepts of a fuller, more youthful appearing upper lid [36].

Increased interest in lower lid blepharoplasty surgery has primarily focused on preventing lower eyelid malposition and volume depletion, both inherent to the excisional surgery first described by Costaneras. The role of lower eyelid laxity as a predisposing factor for postsurgical eyelid malposition was first described by Edgerton in the 1970 [37]. Webster et al., Tenzel, and Kantzen et al. described lower lid horizontal shortening or canthal suspension techniques, which reduced the incidence of this aesthetic and functional complication [38–40]. Anderson and Gordy’s “tarsal strip” procedure [41] is noteworthy in that it has remained a mainstay in canthal suspension surgery until today. A number of less disruptive (more aesthetic) canthal suspension techniques have also been described to prevent eyelid malposition after lower lid blepharoplasty [42–46]. Fagien elaborated on the limitations of the lateral tarsal strip, including asymmetry, globe lid disjunction, canthal dystopia, and long-term shortening of the horizontal palpebral aperture. He advocated a lateral retinacular suspension (suture canthopexy) for reinforcement of the lateral canthus to enhance or maintain vertical lower eyelid position [47]. Shorr and colleagues described combined cheek lift, lateral canthal suspension, and posterior eyelid spacer grafting with hard palate mucosa, for correction of post-blepharoplasty cicatricial lower eyelid retraction [48–50]. His work demonstrated a means of raising the lower lid without skin grafting in appropriate patients. It also emphasized the need to assess and address when necessary, deficiencies in the anterior, middle, and posterior lamella of the lower lid to attain better outcomes.

The incidence of lower lid malposition has significantly decreased with the repopularization of the transconjunctival lower lid blepharoplasty by Tomlinson and Hovey in 1975 [51]. In 1989, Baylis and colleagues further elaborated and refined the technique [52]. In 1991, Kamer and Mikaelian described a simple skin pinch excision as an adjunct to transconjunctival lower blepharoplasty surgery to address excess skin [53].

Fat preservation and repositioning in lower lid blepharoplasty was first described by Loeb and later modified by Hamra and Goldberg in an effort to prevent postoperative

orbital skeletonization (hollowing) and improve the tear trough deformity (nasojugal groove) [54–56]. Volume augmentation/preservation with fat has been a paradigm shift away from traditional excisional blepharoplasty. Sydney Coleman pioneered the technique of fat grafting in the periorbital area to restore volume deficiencies [57]. Massry recently presented results of combined fat repositioning and grafting for effacement of the tear trough and orbitomalar groove [45]. In addition to modifications in lower lid blepharoplasty surgical techniques, and an awareness of the importance of volume restoration, creating a smooth contour between the lower lids and cheek requires modification of the midface (discussed later) [58].

1.3Forehead Lift

In contemporary times, there is a clear understanding of the relationship of the forehead and brows to the eyelids. Historically, however, this relationship has been generally overlooked. In 1919, Passott was one of the first to describe excising multiple skin ellipses from the face for lifting of the brow, midface, and neck [59] (Fig. 1.3). Lexer also recognized the aesthetic importance of the brow. He performed early brow lifts by excising an ellipse of skin from the forehead [60]

Fig.1.3 Early elevation of the brows through elliptical excisions. (Adapted from Passot [59])

(Fig. 1.4). In 1929, the coronal browlift technique was described by Hunt in New York [61] (Fig. 1.5). Shortly afterwards, Claoue dissected the forehead in an attempt to get a better lift of the brow, and Fomon published an article describing subcutaneous dissection before transection of the pericranium [62, 63]. Passot also described the use of a supraciliary brow incision for the correction of brow ptosis, and Vinas clarified the relationship of the coronal incision and the change to a patient’s hairline [60, 64]. In the 1960 and 1970, he described using a pretrichial incision for high foreheads and coronal incisions for patients with average forehead

Fig. 1.4 Early approaches for browlifting included a direct excision of ellipse of skin from the forehead. (Adapted from Lexner [60])

height. He was revolutionary in advocating release of fibrous attachments in the glabellar and supraorbital regions.

Modern browlifting has gradually changed since George Brennan repopularized the bi-coronal lift in 1980 [65]. In 1991, Flowers stressed the true importance of the brow position in regards to periorbital rejuvenation [66]. He advocated that lifting a ptotic brow in select cases would result in a better aesthetic outcome than excision of tissue from the upper lid. Internal fixation of the brow was first described by McCord and Doxanas in 1990. This procedure, termed “Browpexy,” was described to address mild temporal brow ptosis [67]. It is performed at the time of blepharoplasty, through the same eyelid crease incision, and is minimally invasive. Anderson and others have reported on modifications of the initial description to improve outcome [68–70].

In 1992, Isse was the first plastic surgeon to describe the use of an endoscope for brow rejuvenation [71]. Many modifications of the “endoscopic brow lift” have been described since its introduction. Ramirez was integral in modifying the technique and defining surgical landmarks with the aid of the endoscope [72]. Different planes of dissection have been advocated and remain controversial [73]. In addition, various methods of brow fixation have been described, including the use of bolsters, v–y scalp closure, externalized or buried permanent/resorbable devices anchored to calvarium, and drilled tunnels in calvarial cortex [74–86]. There is general agreement that temporal fixation is best achieved by securing the superficial to deep temporal fascia with suture. Otherwise, cost, operative time, and potential complications such as allopecia, scarring, and palpation of, or pain, from the anchoring device have dictated surgeon preference. While no single suspension mechanism has proved superior, most surgeons agree that the optimal elevation of the brow complex requires complete release of the arcus marginalis and all the attachments of the brow depressors [87, 88].