COSMETIC OCULOPLASTIC SURGERY

Upper Eyelid Blepharoplasty KEVIN I. PERMAN, M D The surgical removal of redundant upper eyelid skin along with the excision of prolapsed anterior orbital fat is one of the most popular elective cosmetic surgical procedures performed today. OBJECTIVE. To provide a brief overview of patient selection and upper eyelid blepharoplasty technique. CONCLUSION. Through careful patient selection and preoperative evaluation in addition to a thorough knowledge of eyelid and orbital anatomy, good outcomes from upper eyelid blepharoplasty can be obtained. J Dermatol Surg Oncol1992;18:1096- 1099. BACKGROUND.

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he surgical removal of redundant upper eyelid skin along with the excision of prolapsed anterior orbital fat is one of the most popular elective cosmetic surgical procedures performed Although first performed as far back as the 10th century, blepharoplasty has evolved into a sophisticated procedure with our increased knowledge of eyelid and orbital anatomy, along with our increased appreciation of the relationships between brow, facial, and eyelid contours. Today, the age range of blepharoplasty patients population seeking blepharoplasty consultation grows younger. More patients realize that the puffy hooded look of their upper lids is a function of heredity and not merely a sign of aging.

Basic Eyelid Anatomy The best way to appreciate upper eyelid anatomy is to divide it into tissue plane^.^ Working posteriorly they are: 1)skin, 2) orbicularis, 3) orbital septum, 4) preaponeurotic fat, 5)levator aponeurosis, and 6) tarsus and conjunctiva. The anterior portion of the upper eyelid is formed by the skin and orbicularis muscle. The orbicularis muscle is extremely vascular, and a source for the intraoperative bleeding seen during the procedure. Incisions for upper lid blepharoplasty are placed in the lid creases to conceal postoperation scars. The upper lid crease is roughly coinFrom the Department of Ophthalmic-Plastic and Orbital Surgery, Washington Hospital Center and Washington National Eye Center, Washington, DC. Address correspondence and reprint requests to: Kevin I. Perman, MD, 2021 K Street, Suite 312, Washington, DC 20006.

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cident with the superior border of the tarsus. The tarsus provides the connective tissue foundation to the upper lid; furthermore,this area marks the division between the pretarsal and preseptal orbicularsis muscle and the area where the fibers of the levator aponeurosis pass into the overlying pretarsal muscle and skin. The orbital septum separates the eyelid from the orbit. It originates at the orbital rim and usually inserts into the levator aponeurosis 3 to 4 mm superior to the superior tarsal border. The level of insertion will vary; for example, the level of insertion in the Asian population is lower down onto the anterior tarsal plate. Posterior to the orbital septum is the preaponeurotic fat, which serves as an important landmark for the levator aponeurosis. This is the fat that is partially removed during the blepharoplasty procedure (Figure 1).The fat is compartmentalized into central and nasal fat pads. The nasal fat pad is relatively lighter in color and closely associated with the palpebral artery. Laterally, the fat may be closely associated with a portion of the lacrimal gland." The gland has a more granular appearance than the fat with a firm consistency. It may be prolapsed forward and may require repositioning during the procedure but knowledge of its location is required to preclude inadvertant excision.6 Along with these basic anatomic points, surface anatomy is the key to preoperative evaluation. The upper eyelid margin normally crosses the cornea 2 mm inferior to the superior limbus. The normal palpebral fissure is 9 to 10 mm vertically when the eyelids are open. The contour of the orbits and brows should be noted as the brow level is usually just above the level of the superior orbital rim. These lid and brow levels are not exact and will vary from patient to patient and should be pointed out during the preoperative evaluation, where the patient's realistic expectations can be disc~ssed.',~

Preoperative Evaluation A complete eye examination should be a part of every presurgical work up, with attention to best-corrected visual acuity, corneal pathology, and tear production. A thorough history to reveal any evidence of dysthyroid ophthalmopathy, seventh nerve paralysis, dry eye syndromes, along with a history of systemic diseases includ-

0 1992 by Elsevier Science Publishing Co., Inc. 0148-0812/92/$5.00

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Figure 2. The orbital fat is shown as the preaponeurotic fat pad. Directly beneath are the levator muscle and aponeurosis.

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Figure 2 . 4)This 58-year-old man underwent upper lid blepharoplasty. The small element of brow ptosis was discussed preoperatively, but B) the patient was pleased with the brow and opted for blepharoplasty alone.

ing hypertension, diabetes, and blood dyscrasias may avoid potential intraoperative and postoperative complications. The interview must include all medicines taken regularly for any reasons. Many patients do not consider aspirin or aspirin products to be "true" medicines, yet dangerous complications can ensue unless their use is discontinued 2 to 3 weeks prior to surgery and in the postoperative period. The brow and lid levels should be examined and discussed with the patient. There may be a need to correct a ptotic brow or eyelid in conjunction with the blepharoplasty or as a separate procedure. Blepharoptosis (low eyelid margin level) is addressed by some form of shortening of the levator aponeurosis or Miiller's muscle. Although beyond the scope of this article, it is of the utmost importance for the neophyte blepharoplasty surgeon to understand that a ptotic eyelid cannot be corrected by skin excision a l ~ n e . ~ , ' ~ Brow ptosis may be addressed as a separate procedure either prior to or after the blepharoplasty; however, its presence must be revealed to the patient, especially with

Figure 3. A crescent shaped skin muscle flap has been elevated. The curvature of the Pap follows the crease.

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regard to how it influences the blepharoplasty procedure and the h a 1 postoperative appearance (Figure 2). Finally, potential complications of the procedure should be discussed with the patient. By covering the rarer complication such as anesthetic and visual compromise and the more common complications such as ptosis, lid retraction, and the need for minor revisions, the patient will be able to make a more realistic decision about surgery. The best informed patients are the most appreciative patients, even in the face of complications."

The Procedure Photographs are taken during the preoperative consultation. They are taken with the patient sitting up; any other position may influencelid level and skin and fat contours. The actual procedure is most often performed under local anesthesia or local anesthesia with intravenous sedation. This allows the patient to open the eyelids during the procedure, aiding the surgeon in establishing sym-

Figure 4 . The anterior orbital fat is held back by the orbital septum.

Figure 5 . The orbital septum has been incised nasally. A knuckle of fat protrudes forward.

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2992;18:1096-1099

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B Figure 6. 4) Pre- and B) postoperative photos of a 63-year-old female, 5 days postblepharoplasty.

metry of eyelid height and contour. Cardiac blood pressure and pulsoximetry monitoring are usually performed. Infiltrative anesthesia is accomplished with 2% lidocaine with 1: 100,000 epinephrine mixed with hyaluronidase (Wydase).The use of hyaluronidase allows for even distribution of the anesthetic and will minimize postinjection tissue distortion. Approximately 1.5 to 2 mL of solution is injected subcutaneously in each lid. Ten minutes are allowed to elapse after the injection prior to marking the tissue. This elapsed time is necessary for the best hemostatic effect of the epinephrine. It is during this time that the face is prepared and draped for the procedure.'? The skin markings are crucial. The first markings are at the level of the lid crease. Three key landmarks should be the upper lid puncta, the pupil, and the lateral canthal angle. These will help in comparing the right and left upper lids. The lid crease outline should not be carried to the nose so as to avoid an epicanthal fold. The lateral extent of the line must arch superiorly to encompass the lateral hooding so often seen in these patients. The lateral line may extend beyond the lateral orbital rim but should be far enough away from the canthal angle to avoid webbing, especially if a lower lid blepharoplasty is to be performed at the same time. The superior line of marking

delineates the extent of skin to be resected. The superior line may be judged visually or by variations of a pinch test. Forceps are used to pinch what is felt to be the amount of skin to be resected. Excess skin is pinched until the upper lid lashes just begin to evert or there is 1 to 2 mm of eyelid opening. With the marking completed, a #15 blade is used to incise the outlined skin. Downward traction of the lid is accomplished by the assistant with a forceps grasping of the lid margin skin or by traction suture through the tarsal plate. Either way, the downward traction protects the levator aponeurosis during the skin-muscle flap elevation, thus reducing the risk of intraoperative levator injury and postsurgical ptosis. With elevation of a full skinmuscle flap, the orbital septum is now directly seen (Figures 3 and 4). The septum is opened along its entire length (Figure 5). This maneuver is carried out as the assistant accomplishes mild retropulsion of the globe causing the anterior orbital fat to come forward. This helps with identification of the septum, especially for the novice surgeon. The fat is excised in a graded fashion; only prolapsed fat is excised. Deep orbital excision is to be avoided. Careful attention to the medial fat pad and lateral inspection

Figure 7 . 4) Pre- and B) postoperative photos of a 42-year-old 3 months postblepharoplasty.

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J Dermatol Surg Oncol 1992;18:1096- 1099

of the lacrimal gland for its position should be camed out. Hemostasis is accomplished with monopolar cautery. Clamping of orbital fat is rarely necessary; in fact, clamping causes increased traction of posterior orbital vessels, resulting in possible avulsion and orbital hemorrhage. Avoidance of clamping of fat and careful attention to cautery of bleeding orbiculus vessels are key maneuvers to achieving hemostasis. Closure is camed out with a running 6-0 or 7-0 nylon, prolene, or mild chromic suture. Lid crease formation is dictated by the previous preoperative evaluation with the patient whether male or female, Asian or European.13,14A deeper, higher crease may be accomplished by supratarsal fixation; a maneuver where a small amount of the levator aponeurosis is included in the skin muscleclosure. A more subtle, natural appearance will be attained by simple skin-muscle closure15(Figure 6, 7). The operative field is dressed with antibiotic ophthalmicointment and ice compresses. Compression dressings are to be avoided because they may mask developing complications. Pain is managed with nothing more than acetaminophen. The sutures can be removed in 2 to 3 days.

References 1. McCord CD, Tanenbaum M. Oculoplastic Surgery. New York: Raven Press, 1987.

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2. Putterman A. Cosmetic Oculoplastic Surgery. Orlando: Grune and Stratton, 1982. 3. Jelks G, Zide B. Eyelid and Orbital Anatomy. New York Raven Press, 1985. 4. Shorr N, Cohen MS. CosmeticBlepharoplasty.Ophthalmol Clin N Am 1991;4:17-33. 5. Gradinger GP. Cosmetic upper blepharoplasty. Clin Plast Surg 1988;15:289-97. 6. Smith B, Petrella R. Surgical repair of prolapsed lacrimal glands. Arch Ophthalmol 1978;96:113-4. 7. McCord CD, Doxanos, MT. Browplasty and browpexy: an adjunct to blepharoplasty. Plast Reconstr Surg 86:248- 54. 8. Lemke BN, Stasior OG. The anatomy of eyebrow ptosis. Arch Ophth 1982;100:981-5. 9. Leone CR. Management of the blepharoplasty patient with ptosis. 1988;19:515- 22. 10. Wilkins RB, Patipa M. The recognition of acquired ptosis in patients considered for upper eyelid blepharoplasty. Plast Reconstr Surg 1982;70:431-4. 11. Mahaffey PJ, Wallace AF. Blindness following cosmetic blepharoplasty-a review. 1986;39:213- 21. 12. Neuhaus RW. Tips for local anesthesia in blepharoplasty. Ophthalmic Surg 1988;19:525-6. 13. Bov-Chai K. Some aspects of plastic (cosmetic) surgery in Orientals. Br J Plast Surg 1969;22:60-65. 14. Doxanos MT, Anderson RL. Oriental eyelids: anatomic study. Arch Ophthalmol 1984;102:1232-8. 15. Sheen JH. Supratarsal fixation in upper blepharoplasty. Plast Reconstr Surg 1974;54:424-31.

Upper eyelid blepharoplasty.

The surgical removal of redundant upper eyelid skin along with the excision of prolapsed anterior orbital fat is one of the most popular elective cosm...
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