Fig.22.1 (a) Patient demonstrating the outcome of prior traditional subciliary blepharoplasty without volume restoration resulting in skeletonization of the inferior orbital rim. (b) Preoperative photo of a patient who

Fig.22.2 (a) A woman in her early 20s demonstrates the characteristics of a youthful periorbita. (b) Preoperative photo of a woman seeking periorbital rejuvenation. (c) Following skin-only upper lid blepharoplasty,

underwent browlift and upper blepharoplasty with removal of skin and fat. (c) Postoperatively, photo of the patient demonstrates skeletonization of the superior orbital rim and an exaggerated A-frame deformity

transconjunctival lower blepharoplasty with conservative fat excision, and fat transfer to the inferior orbital rim and midface. (b, c, Adapted from Carniol and Sadick [13])

22.2Analysis

It is useful to think of the eye as the centerpiece of the periorbital region, with the bone and soft tissue surroundings providing the frame in which it sits. Aging results in a deterioration of the frame’s integrity. The youthful periorbita, or frame, is soft and curvaceous, with an ample cushion of soft tissue hiding the underlying bony foundation. This voluminous base of tissue creates smooth transitions to the adjacent regions: the cheek, temple, and forehead (Fig. 22.3a). As age-related volume loss progresses, the facial contours and their resultant highlights and shadows change. This results in an older facial appearance dominated by shadows and harsh transitions between adjacent areas (Fig. 22.3b).

22.2.1 Lower Eyelid

Classically, the youthful lower eyelid (the lower frame of the eye) is indistinct from the cheek. The lid flows smoothly into the cheek forming a convexity ending inferomedially at the

nasolabial fold (see Fig. 22.3a). The span from lower lid to nasolabial fold is devoid of shadows and graced with a highlight at the apex of the cheek prominence. Volume loss along the inferior orbital rim exposes the bony orbital rim, creating a shadow that isolates the lower lid from the cheek (see Fig. 22.3b) [5]. The role of pseudoherniated lower lid fat in aging of the eye should not be overlooked. As this fat bulge increases, the concavity below, and the degree of shadowing, becomes more pronounced. The traditional surgical approach of merely removing fat from the lower lid reduces the depth of the concavity (and its associated shadow), but often has the deleterious effect of further unmasking the bony orbital rim. The result is a skeletonized and unnatural appearing eye that looks neither younger nor refreshed (see Fig. 22.1a). Rejuvenation should focus on restoring the soft, voluminous midfacial appearance where the lower lid flows smoothly into the cheek. This requires adding volume to the concavity at the lid–cheek junction and, when necessary, reducing the protrusion of pseudoherniated lower lid fat (see Fig. 22.2).

Although we are emphasizing volume restoration, our goal is not to completely discard traditional procedures, but

Fig. 22.3 (a) Young woman demonstrating the characteristic youthful lower lid: lack of pseudoherniated fat, minimal inferior orbital rim or midfacial volume loss, no separation of the lower lid from the cheek, and an uninterrupted convexity from lower lid to the nasolabial fold. (b) With advancing age, the combination of pseudoherniated lower lid

Fig. 22.4 (a) Preoperative photo demonstrating significant inferior orbital rim and midfacial volume loss. Despite appearing to have lower lid “bags”, the patient does not actually have prominence of the lower lid fat pads. (b) Following fat transfer to the inferior orbital rim, malar, and submalar regions, the appearance of “bags” under her eyes is eliminated without removing any fat. Of note, she did have concurrent rhinoplasty and her nasolabial folds were addressed at a separate setting with a hyaluronic acid-based filler

fat and volume loss in the inferior orbital rim creates a shadow demarcating the lid from the cheek. The single youthful midface convexity is broken by volume loss at the inferior orbital rim and malar septum. (b, Adapted from Lam et al. [1], used with permission)

rather to supplement them and to optimize results. In some cases, fat transfer alone will be adequate to accomplish this goal (Fig. 22.4). Other times, however, adding fat to eliminate the shadow effect is inadequate. When faced with the presence of prominent pseudoherniated fat, relying on volume augmentation alone can create an overinflated appearance to this area. These patients will best be served with supplemental conservative reduction of the relevant fat compartments (Fig. 22.5). Our procedure of choice for fat reduction is a transconjunctival lower lid blepharoplasty. This can be done at the same setting, just before or after the fat transfer.

Malar mounds present a uniquely difficult problem, and a full discussion of their management is beyond the scope of this chapter [1, 6]. Patients who have malar mounds or edema preoperatively should be made aware of the complexity of

their issue. Otherwise, they may only become aware of their existence postoperatively. Patients should be counseled that no procedure will predictably get rid of malar mounds and that, when present, the goal is to both minimize their appearance and avoid exacerbating them. During volume restoration, the malar mounds should be worked around in order to minimize trauma and prolonged postoperative edema. Despite a careful approach, patients with prominent malar mounds should understand that they might have a prolonged postoperative course requiring oral or intralesional steroids.

22.2.2 Upper Eyelid

The youthful upper lid-brow complex should have soft rounded contours. As with the youthful lower lid, which is

Fig. 22.5 (a) Preoperative photo demonstrating the presence of significant pseudoherniated fat in all lower lid compartments combined with volume loss across the inferior orbital rim. (b) Following transconjunctival blepharoplasty to reduce medial, central, and lateral lower lid

Fig. 22.6 Type 1 upper eyelid structure. (a) This woman in her early 20s demonstrates the youthful Type 1 upper lid. There is a convexity from brow to lid fold and a small separation between lid fold and lash line. (b) This illustration demarcates the narrow space between the two parallel lines: the inferior aspect of the lid fold (red) and the lash line (blue)

fat pads combined with fat transfer to the inferior orbital rim. Of note, an upper lid blepharoplasty was performed simultaneously removing only skin, not fat

seamlessly joined with the adjacent midfacial units, the upper lid should have a similar relationship with its surroundings (the brow and temple). The soft tissue cushion overlying the superior orbital rim (SOR), which provides volume, also elevates the brow off of the orbital rim. As volume loss progresses, the gentle curves are lost and become dominated by harsh shadowing between the upper lid and brow (just as we see between the lower lid and cheek). Temporal volume loss will also contribute to an older and less healthy periorbital appearance. Before detailing the specific goals for obtaining a natural, youthful upper lid, we need to recognize that there are two primary variants of upper lid architecture that are very distinct. The analysis and rejuvenation plan will be different for each type of upper lid.

The first, and more common, type of upper lid (Type 1) is characterized by a full convexity running from the lid crease inferiorly to the brow above (Fig. 22.6a). The bony prominence of the SOR is completely masked by the soft tissue

cushion underlying the brow. The distance between the upper lid crease and lash line is minimal (usually only several millimeters); with these two “lines” running parallel to one another (Fig. 22.6b). Age-related volume loss, although affecting the entire upper lid-brow complex, is more significant in the medial half of the upper lid in the area just below the brow. This can be partly attributed to the presence of the lacrimal gland, under the lateral portion of the SOR, which reduces skeletonization in that area. The predominance of medial upper lid volume loss creates what is referred to as an “A-frame” deformity. The overall effect of upper lid volume depletion is to unmask the bony SOR, creating a concavity and shadowing between the upper lid crease inferiorly and brow superiorly (Fig. 22.7). The progression from soft curves and highlights to harsh angles and shadowing is responsible for the aged appearance.

In the Type 1 eyelid, volume loss contributes to the development of upper lid hooding. Patients will often complain of a

Fig. 22.7 Aging in the Type 1 upper eyelid structure. A high school yearbook photo (a) of an 18-year-old woman demonstrating the typical appearance of a youthful Type 1 upper lid. (b) The same woman, now in her early 40s, demonstrates the effects of aging, dominated by volume

loss, on the upper lid. Loss of upper lid volume causes skeletonization of the superior orbital rim and a visible concavity between the brow and upper lid fold. Additionally, she demonstrates the A-frame deformity due to greater loss of medial volume.

Fig. 22.8 The lateral fold of upper lid skin, particularly when draped out during examination, is nearly abutting the lash line. Despite the obvious volume deficit in the central half of the upper lid (A-frame deformity), failure to address the skin redundancy will likely lead to a dissatisfied patient

“flap of skin” sitting on the lid. The question that must be answered in evaluation is whether this “extra skin” is secondary to loss of skin elasticity and/or loss of volume. The answer is found in comparing the patient’s old photos to their current status. During the examination, it is helpful to drape out the upper lid skin to see what actual separation remains between lid fold and lash line. When compared to pictures of themselves

when younger, this distance will be either the same, greater, or less. If the distance has narrowed, meaning the skin is draping onto the lash line, then skin removal will be a necessary component of upper lid rejuvenation. The patient in Fig. 22.2b,c demonstrates this type of upper lid aging without volume loss. Preoperatively, the upper lid skin is draping onto the lash line. Following upper blepharoplasty with isolated skin removal, the gap between lid and lash line is restored as is the parallel relationship between these two lines. In comparison, some Type 1 upper eyelids will have a partial decreased distance between lid and lash line in combination with volume loss (Fig. 22.8). If the distance between lid and lash line has increased due to volume loss retracting the upper lid superiorly, then volume addition is essential. When this volume is restored, thereby reinflating the upper lid, the appearance of a flap is addressed without having to remove skin (Fig. 22.9). If there is minimal change, the patient will probably benefit from a combined approach of skin removal and volume augmentation. Caution should be taken in this last group of patients to not aggressively remove skin (Fig. 22.10). This can result in an increased distance between the lid fold and lash line, which does not represent a more youthful appearance.

In the upper lid, even more so than the lower, obtaining natural volumized results depend as much on preserving volume (upper lid fat), as it does on restoring volume. It is the rare patient that has significant upper lid pseudoherniation of fat. When present, it is most commonly seen in the medial. However, we believe that this generally represents a “pseudopseudo herniated fat.” Most likely, there is deflation above the fat at the superior medial orbital rim, thereby creating a relative fat protrusion. This fat pocket should be surgically reduced in the rare circumstance that volume addition alone along the SOR will not sufficiently mask its presence.

Fig. 22.9 (a) This patient demonstrates the loss of volume, which not only creates the upper lid concavity, but also gives the appearance of a “flap of skin” despite a more than adequate distance from the lid fold to lash line. (b) Following volume augmentation to the upper lid, staying

Fig. 22.10 (a) This patient with a Type 1 upper eyelid initially complained of the appearance of upper lid hooding, emphasizing the appearance of the visible flap of skin. (b) Following upper lid blepharoplasty, with removal of skin (no fat removal). Although there was slightly less skin draping, the end result was an increase show of pretarsal skin and

inferior to the brow, the youthful convexity from brow to lid fold is restored. Additionally, by inflating the upper lid, the appearance of a redundant skin flap has been reduced

a persistent appearance of a flap of upper lid skin. (c) After volume augmentation, filling the concavity between the medial half of the brow and the upper lid fold, the natural youthful appearance of the upper lid was restored. Filling the concavity inflated the skin flap and removed the shadow between lid fold and superior orbital rim

The central fat compartment should almost never be reduced. Further deflation, by surgical removal of fat, will magnify (or create) the upper lid concavity that is seen in the aged eye. Again, the goal of upper lid rejuvenation in these patients should focus on restoring a parallel line between the lid fold and lash line, creating a small pretarsal platform (pretarsal skin show) and forming a convex contour from lid crease to brow without skeletonization of the SOR (see Fig. 22.9). Traditional brow lifts and upper blepharoplasty that remove excess skin and fat do little to achieve these goals. These interventions are more likely to result in creating the impression of someone who had plastic surgery.

The second, and less common, upper eyelid (Type 2) is characterized by a natural concavity in the gap between brow and lid. The outline of the SOR is visible but, in youth, is

softened due to soft tissue padding (Fig. 22.11a). In contrast to the Type 1 lid, the lid fold to lash line relationship is less central in defining the appearance. There is often a greater distance separating these two landmarks. The more important relationship in the Type 2 upper eyelid is that of the lash line and the shadow under the SOR. In contrast to the Type 1 eyelid where the lid and lash line run parallel to each other, the Type 2 eyelid demonstrates a parallel relationship between the lash line and the SOR shadow (Fig. 22.11b). These two “lines” appear as stacked semicircles. As these individuals age, volume loss occurs across the entire SOR, again more medial than lateral.

As with Type 1 upper lids, the Type 2 patients will often demonstrate an “A-frame” deformity as a result of the disparate eyelid volume loss. The natural evolution of the Type 2

Fig. 22.11 (a) The youthful Type 2 upper lid has visible definition of the superior orbital rim, but it is not skeletal due to adequate soft tissue cushioning. (b) In these patients, the important linear relationship is between the superior orbital rim (red line) and the lash line (blue line); these two lines are parallel to each other and there is no A-frame deformity. This is in contrast to the Type 1 upper lid in which the height of the lid fold is more variable and not integral in defining the age of the person

Fig. 22.12 (a, b) Baseline photo of a woman with a Type 2 upper lid showing the skeletonization of the superior orbital rim. The relatively greater volume loss medially clearly demonstrates the A-frame deformity.

(c, d) Following augmentation along the entire superior orbital rim, the appropriate relationship of superior orbital rim and lash line is reestablished and a healthier and youthful Type 2 lid is achieved

eyelid, particularly in a thin individual, is that of a skeletonized and unhealthy appearance. Although the youthful Type 2 upper lid is normally concave, the progressive age-related volume loss creates a deep upper lid sulcus, significant

shadowing, and a more pronounced concavity. Loss of soft tissue surrounding the SOR leads to a harsher appearance as bony definition is revealed (Fig. 22.12). In these individuals, there is no reason fat should be removed from the upper lid.