5.1 Introduction

Along with being the aesthetic centerpiece of the face, the eyelids are responsible for protecting and framing one’s vision. Aging changes related to skin quality and upper facial volume often result in skin descent and potential obstruction of one’s visual field (Fig. 5.1 a).

Nonsurgical treatment options for upper eyelid skin descent include eyebrow depressor muscle botulinum toxin and hyaluronic acid fillers to lift and fill the upper eyelid–brow complex and are addressed elsewhere in this book. This chapter focuses on the most common surgical procedure for improvement of upper eyelid skin descent, upper blepharoplasty, a technique centered around the artful removal and shaping of upper eyelid skin and soft tissue.

Traditional goals of blepharoplasty have been the elimination or minimization of excess eyelid tissue. This led to a largely subtractive procedure, removing skin, orbicularis muscle, and orbital fat, and placement of a relatively high eyelid crease, resulting in a postsurgical appearance (Fig. 5.2). Upper blepharoplasty technique has evolved in parallel with our understanding of the etiologies of the aging face. The importance of soft tissue volume in the youthful face supports the preservation of upper eyelid preaponeurotic fat during blepharoplasty surgery. The relative prominence of medial fat in the aging upper eyelid has been shown in observational studies and may be related to a higher concentration of stem cells ^{1 ,​ 2} (Fig. 5.1). This finding supports selective medial fat removal or repositioning. With the intent of minimizing worsening preexisting dry eye symptoms, in 2007, Dresner et al revealed that upper blepharoplasty with preservation of the orbicularis muscle did not lead to an increase in dry eye symptoms. ³ The patients were also found to have an improvement in postsurgical cosmetic appearance and eyelid blink function. Minimizing trauma or excision to the orbicularis muscle remains one of the most important components of modern upper blepharoplasty surgery.

Failure to identify concurrent blepharoptosis secondary to malfunction or malposition of the levator aponeurosis or eyebrow descent may limit the success of upper blepharoplasty. Treatment of blepharoptosis and eyebrow ptosis can be performed concurrent with upper blepharoplasty as described here and is addressed in other chapters of this book.

5.2 Goals of Treatment

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  Functional improvement of superior field of vision when the excess skin causes field loss.

  
  
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  Improved cosmesis.

  
  
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  Preservation of a natural appearance.

  
  
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  Preservation of normal blink and eyelid function.

  
  
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  Relief from frontalis contraction and compensatory eyebrow elevation.

  
  
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  Patient satisfaction, optimized by preoperative expectation management.

5.3 Risks

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  Vision loss from orbital hemorrhage.

  
  
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  Temporary lagophthalmos.

  
  
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  Temporary eyelid edema.

  
  
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  Worsening dry eye.

  
  
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  Undercorrection.

  
  
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  Overcorrection.

  
  
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  Visible scar.

  
  
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  Wound dehiscence.

  
  
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  Acute or delayed infection. ⁴

5.4 Benefits

When performed correctly, patients undergoing upper eyelid blepharoplasty can expect an improvement in their superior visual field, improvement in the sensation of heaviness from upper eyelid skin, lessened need for chronic frontalis and eyebrow elevation, and improved cosmesis.

5.5 Informed Consent

All patients should be informed of the risks as described above and that, as with any surgery, every patient may heal differently and results are never guaranteed. Surgery should never proceed without a signed consent from the patient or guardian acknowledging an understanding of the risks, benefits, and alternatives to surgery.

5.6 Indications

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  Upper eyelid skin resting on or below eyelashes.

  
  
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  Superior visual field obstruction that improves with elevation of eyelid skin.

  
  
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  A displeasing facial aesthetic.

5.7 Contraindications

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  Upper eyelid skin deficiency from previous blepharoplasty.

  
  
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  Suspicion for cutaneous periocular malignancy and need for possible rotation flap or skin graft.

  
  
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  Upper eyelid descent secondary to levator aponeurosis dehiscence and minimal upper eyelid skin (Fig. 5.3).

  
  
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  Unrealistic patient expectations.