Introduction
A predictable sequence of changes occurs in the face as we age. Early changes are barely discernible and few seek a surgeon’s help. Later, more obvious changes lead to a wide variety of cosmetic and functional surgical interventions. The eyelids are the focus for many seeking advice. However, the whole face is ageing and more subtle changes beyond the eyelids must also be addressed to achieve the best results. The youthful anatomy of the face and the sequence of involutional changes are described in Chapter 1 .
Blepharoplasty includes the removal or adjustment of skin, muscle and fat in varying proportions from the eyelids. Widely different techniques have been described. The choice depends on the assessment of the individual patient and the preference of the surgeon. This chapter describes one approach to blepharoplasty and the other facial changes beyond the eyelids. It aims to include enough basic information for other techniques to be evaluated. Alternative interventions such as skin resurfacing, botulinum toxin and fillers are not discussed in this chapter.
Before removing an apparent excess of skin or fat from the upper or lower eyelids a careful preoperative assessment is essential with the patient sitting. In addition to the ageing changes that affect everyone to varying degrees, other involutional changes may occur leading to lid malpositions – entropion, ectropion and ptosis. These also need to be assessed and may be corrected at the same time. The management of these is described in Chapter 6 , Chapter 7 , Chapter 9 .
Preoperative assessment
History
The problem for which the patient is seeking help must be clearly understood by both the patient and the surgeon. This discussion can be facilitated with photographs or a mirror. In addition, a history of dry eyes, blepharitis or other disease affecting the eyes is relevant and may influence the choice of operation.
Examination
The examination starts with a general assessment of the whole face from a distance to gain an overall impression.
Look at the upper lids and brows: is there excess skin in the lids, fat prolapse or ptosis? Are the brows ptotic and is this mainly lateral, medial or general?
Look at the lower lids and cheeks: is there excess skin or fat prolapse? Is there scleral show? Are the lateral canthi low? Is this associated with cheek ptosis, obvious nasojugal folds (the ‘tear trough deformity’), hollows accentuating the lower orbital rims (which may be called a ‘supramalar sulcus’) and deep nasolabial folds? Is there a general loss of tissue volume in the face?
Examine the lower face: jowls and webbing in the neck may require a full face lift. The patient may prefer to address these at the same time as any other surgery to the mid or upper face.
Examine the face from the side: assess the relative positions of the malar eminence and the anterior cornea. If the malar eminence is posterior to the cornea – a ‘negative vector’ – the support for the lower lid is weaker.
The detailed examination of the lids described in Chapter 3 should be recorded. Note other relevant findings as outlined above.
Examine the eyes: record the visual acuity – occasionally, changes in corneal curvature as a result of eyelid surgery may alter the uncorrected acuity. Look for disease of the lids, cornea or conjunctiva. Assess the tear production (see 3.18a , 3.18b , 3.18c ).
Discussion with the patient
Finally, discuss the patient’s expectations in detail so that the aims and likely result of the surgery are fully understood. Good communication and trust are essential. Describe what can be achieved and what cannot be achieved. Discuss relevant alternatives or additional treatments such as skin resurfacing, botulinum toxin or fillers. Explain possible side effects of any surgery, such as swelling, bruising and scarring and the risk of any complications. Take photographs and record your discussions for future reference. After the consultation it is helpful to send the patient a summary of the discussion and the agreed surgical procedures, if any, together with any limitations or potential complications.
Choice of operation
Most patients who consult an ophthalmic plastic surgeon have identified a problem with their eyelids. However, they may be unaware of contributory factors from elsewhere in the periocular region and face. The first decision is whether the patient requires blepharoplasty surgery alone or correction of other facial changes in addition.
Brow ptosis ( Section C )
If there is a significant brow ptosis this must be corrected ( Sect. C ) before the removal of any tissue from the upper lids.
Cheek ptosis ( Section D )
Significant cheek ptosis accentuates the nasojugal fold (‘tear trough deformity’), the lower orbital rim (‘supramalar sulcus’) and the nasolabial fold. It tends to drag the lower lid down, lengthening it vertically and accentuating scleral show. It is usually associated with downward and medial migration of the lateral canthus. A cheek lift (10.12, 11.9 ), combined with lateral canthal surgery, may be performed at the time of a lower lid blepharoplasty.
Upper lid blepharoplasty ( Section A )
The aim of upper lid blepharoplasty is to reduce the skin and any fat prolapse. Prominent brow fat, ptosis of the upper lid (10.2) and prolapse of the lacrimal gland (10.3) may be addressed at the same time.
Lower lid blepharoplasty ( Section B )
Skin reduction is often not required in the lower lid, especially in younger patients. Fat alone may be reduced through a conjunctival approach (10.4). The skin approach allows skin and fat reduction (10.5) when indicated. Fat prolapse is addressed by excision or redraping (‘transposition’) of the fat (10.5.2). Laxity of the lower lid must be corrected (10.5.5) either as a separate procedure or at the time of blepharoplasty if scleral show or ectropion is to be avoided after lower lid blepharoplasty.
Choice of operation
Most patients who consult an ophthalmic plastic surgeon have identified a problem with their eyelids. However, they may be unaware of contributory factors from elsewhere in the periocular region and face. The first decision is whether the patient requires blepharoplasty surgery alone or correction of other facial changes in addition.
Brow ptosis ( Section C )
If there is a significant brow ptosis this must be corrected ( Sect. C ) before the removal of any tissue from the upper lids.
Cheek ptosis ( Section D )
Significant cheek ptosis accentuates the nasojugal fold (‘tear trough deformity’), the lower orbital rim (‘supramalar sulcus’) and the nasolabial fold. It tends to drag the lower lid down, lengthening it vertically and accentuating scleral show. It is usually associated with downward and medial migration of the lateral canthus. A cheek lift (10.12, 11.9 ), combined with lateral canthal surgery, may be performed at the time of a lower lid blepharoplasty.
Upper lid blepharoplasty ( Section A )
The aim of upper lid blepharoplasty is to reduce the skin and any fat prolapse. Prominent brow fat, ptosis of the upper lid (10.2) and prolapse of the lacrimal gland (10.3) may be addressed at the same time.
Lower lid blepharoplasty ( Section B )
Skin reduction is often not required in the lower lid, especially in younger patients. Fat alone may be reduced through a conjunctival approach (10.4). The skin approach allows skin and fat reduction (10.5) when indicated. Fat prolapse is addressed by excision or redraping (‘transposition’) of the fat (10.5.2). Laxity of the lower lid must be corrected (10.5.5) either as a separate procedure or at the time of blepharoplasty if scleral show or ectropion is to be avoided after lower lid blepharoplasty.
Upper lid blepharoplasty
Choice of operation
The level and security of the upper lid skin crease are important factors in the choice of blepharoplasty procedure in the upper lid. They determine the method of surgical closure of the lid (10.1). Whether or not the skin crease is satisfactory, the surgical approach required to remove excess skin, muscle and fat is the same (10.1).
At the same time orbital fat prolapse (10.1), ptosis of the upper lid (10.2), lacrimal gland prolapse (10.3) or prominent brow fat may be addressed. Lateral canthal tendon laxity may be corrected through the upper lid incision or through the lateral end of a lower lid incision (10.5).
Dressings after blepharoplasty
Eye pads may be applied for about an hour. They may then be removed and ice packs applied gently to the closed eyelids to reduce tissue swelling. If there is pain the pads must be removed immediately to exclude a compressive orbital haemorrhage.
10.1
Skin and muscle excision ( ) 
Note that upper lid blepharoplasty is often requested because of a low upper lid skinfold ( Fig. 1.1 ). Apart from excess upper lid skin, the level of the skinfold is influenced by two factors which must be assessed before blepharoplasty: the level of the skin crease and the level of the brow. Brow ptosis should be corrected before the removal of upper lid skin. The natural level of the skin crease may be low so that, even after safe removal of the maximum amount of skin, the lid fold is still too low. This can be corrected by setting the skin crease at a higher level during blepharoplasty.
10.1.1
Estimating skin excess
Pinch technique – assessing skin to be excised
Ask the patient to close both eyes. Using forceps based at the skin crease gently estimate the excess skin at a number of sites. Aim to remove just enough skin to leave the lid closed or, at most, to result in slight eversion of the lid margin. Mark the upper limit of the skin excision, staying high laterally. Join the upper and lower marks laterally with an oblique final mark.
Measurement technique – measuring skin to be retained
An alternative method to assess skin excess is to measure the skin to be retained rather than the skin to be removed. In an adult 21 to 22 mm of skin is needed to allow comfortable closure of the eye. Having measured upward from the lashes to mark the skin crease, measure downward from the brow to mark the upper limit of the skin to be excised. Together these measurements should total 21 to 22 mm. Remember that some patients pluck their brows so the true lower limit of the brow may be lower than the visible lower brow hairs. Ask patients if they pluck their brows. Often the skin quality of the true brow is different than the upper lid skin so the full extent of the brow can be estimated with reasonable accuracy.
10.1.2
Excision of excess skin and orbicularis muscle
The skin and orbicularis muscle may be excised as one layer or as two layers.
Skin and muscle excised as one layer
To excise the skin–muscle excess as one layer incise around the marks and deepen the incision to include the orbicularis muscle. Remove both layers together to expose the underlying orbital septum, leaving it intact.
Skin and muscle excised separately as two layers
To excise the skin–muscle excess in two layers remove the marked skin first, exposing the underlying orbicularis muscle, and then excise a strip of muscle, 5 to 6 mm wide, from the lower wound edge to expose the orbital septum. Excise more muscle if there is a marked excess.
10.1.3
Fat excision
Excision of the skin and orbicularis muscle exposes the superior border of the tarsal plate, the lower part of the levator aponeurosis and the orbital septum. Press gently on the closed eye or lower lid to accentuate any prolapse of fat from the central and medial fat compartments. Fat excision, if any, should be conservative. Many patients do not need fat excision. It can be removed either through small buttonhole incisions in the orbital septum or through a wide incision which opens the septum fully.
Fat excision through septal buttonholes
To excise fat through buttonholes make small holes by spreading sharp pointed scissors and prolapse the fat. Apply fine curved artery forceps and excise redundant fat without traction. Cauterise the cut edge and then remove the forceps and apply more cautery before allowing the fat to fall back into the orbit.
Fat excision through open septum
Alternatively, open the septum fully and excise excess fat as described previously. Reduce the central (preaponeurotic) fat pad separately from the medial fat pad which is in a separate compartment medially.
10.1.4
Correction of ptosis or lacrimal gland prolapse
If there is upper lid ptosis (10.2) or lacrimal gland prolapse (10.3), these should now be corrected.
10.1.5
Skin closure
If the natural deep fixation of the skin crease to the levator aponeurosis ( Diag. 1.16 ) has been weakened, either through ageing or during the surgery, it must be restored. This can be done with deep fixation sutures from the skin (9.1h, 10.1v,w) or with sutures that fix the orbicularis muscle to the aponeurosis before closing skin directly to skin. If the deep fixation is intact at the end of blepharoplasty surgery, as it is in many younger patients, the skin can be closed with simple skin to skin sutures (10.1x,y); 7/0 absorbable or nonabsorbable sutures may be used.
The most serious early complication of upper lid blepharoplasty is orbital haemorrhage. It is uncommon and occurs following the excision of orbital fat. If persistent, the pressure of the resulting haematoma may threaten vision. Blindness, however, is very rare. This complication can be prevented by avoiding traction on the orbital fat during fat excision and by careful attention to haemostasis. A serious haematoma occurring during the hours following surgery should be evacuated by reopening the lid. If this is ineffective cut through the full thickness of the lower lid laterally to relieve the intraorbital pressure.
Discomfort in the eyes from exposure is not uncommon in the first weeks after blepharoplasty but it should settle with no more than topical lubricants. More serious complications of exposure, such as corneal ulcers, are rare.
Milia occasionally form along the skin crease. They may be removed individually if they do not disappear within a few months.
Webbing may occur between the upper and lower lid scars if they are closer laterally than 4 mm. A Z -plasty (see 2.23 ) may be needed to correct the web.
Altered pigmentation may occur in the scars. In time this usually improves.
10.2
Ptosis correction ( ) 
The ptosis associated with an eyelid requiring a blepharoplasty will almost always be of the aponeurotic disinsertion type.
The preaponeurotic fat pad is exposed. Excise excess fat from the central and medial fat pads if necessary (see 10.1o,p ). Dissect the attenuated aponeurosis from the tarsal plate and then separate it from Muller’s muscle for 7 to 8 mm. Identify healthy aponeurotic tissue by inspecting the anterior and posterior surfaces of the aponeurosis; it is whiter and thicker than the attenuated aponeurosis immediately superior to the tarsal plate.
Advance the healthy aponeurosis to the tarsal plate and secure it with a temporary suture. Check the lid level by asking the patient to look up and down. If it is low the aponeurosis may need to be advanced further by placing the suture at a higher level.
When the level of the lid is satisfactory place two further sutures in the aponeurosis to achieve a natural lid margin contour. Close the lid with deep fixation as described in 10.1v,w .
10.3
Lacrimal gland prolapse
Expose the orbital septum over the lateral half of the upper lid and identify the lacrimal gland laterally, deep to the septum. Open the septum over the prolapsed gland and expose the superior orbital rim anterior to the lacrimal gland fossa.
Mild dacryoadenitis may occur. It may take several weeks to settle spontaneously. The gland may prolapse again.
Lower lid blepharoplasty
Choice of operation
Removal of excess skin is required much less frequently from the lower lid than the upper lid. Patients younger than about the age of 50 often do not need skin excision. If there is definite excess skin, consider a skin-muscle flap blepharoplasty (10.5). If it is minimal, a simple skin ‘pinch’ technique, as in the upper lid (see Fig. 10.1c ), can be used either alone, or in combination with a conjunctival approach fat reduction.
Fat prolapse (‘pseudoherniation’) in the lower lid may be addressed by fat excision, ‘redraping’ or a combination of both. If no skin needs to be removed, the conjunctival approach is appropriate (10.4). Fat excision should be conservative – there is a risk of later hollowing of the lower lid if too much fat is removed. It is preferable to ‘redrape’ at least some of the prominent fat by opening the septum and fixing the fat over the lower orbital rim. The repositioned fat reduces, but usually does not eliminate, the hollowed profile of the lid-cheek junction along the lower orbital rim. To assist in improving this profile the lax septum may be separated from the orbital rim at the arcus marginalis and ‘reset’ at a slightly lower position on the inferior orbital rim 10.5i–l .
Skin excess in the malar region of the cheeks, cheek festoons, may be excised locally without the need to dissect a full skin–muscle flap from the lid.
If a cheek lift may be needed the technique of lower lid blepharoplasty is modified ( Section D , 11.9 ). Malar bags, subcutaneous swellings in the malar region, are more difficult to correct but may improve to some extent during skin–muscle blepharoplasty.
Canthal tendon laxity causes horizontal lower lid laxity and must be corrected ( 10.5n–r , 7.2 ). Tightening the lid may be combined with elevation of the canthus if it has migrated inferiorly. A graded approach is adopted. If the laxity in the lid and the migration of the canthus in a downward and medial direction are mild, a simple plicating suture (10.5n–r) is inserted between the tarsal plate, or a stab wound at the outer canthal grey line, and the lateral canthal tissues. If the changes are more marked a lateral tarsal strip is preferred ( 7.2 ). Marked changes require relocation of the whole lateral canthal tendon to a higher level on the lateral orbital rim (10.5s–w). In exceptional circumstances the lateral canthus may need to be supported with a periosteal flap ( 16.5 ). These techniques all reduce lid laxity and, to a limited extent, the tear trough deformity and may raise the lower lid margin.
It is occasionally necessary to correct medial canthal tendon laxity ( 7.7 , 7.8 , 7.15 ).
10.4
Transconjunctival lower lid blepharoplasty
This technique is suitable for fat excision or redraping without skin excision.
Carefully assess the fat to be removed noting any asymmetry between the two lower lids. Retract the lower lid and inject 2% lignocaine with 1 : 100,000 adrenaline deep to the conjunctiva along the lower fornix. Incise the fornix a few millimetres inferior to the lower border of the tarsal plate. This can be done with scissors or a monopolar cutting cautery needle tip on a low setting, for example the Colorado Micro Dissection needle or the Ellman Surgitron. Direct the cut just inside the lower orbital rim. A more anteriorly placed cut will, instead, reach the orbicularis muscle (see Diag. 1.15 ). This offers an alternative approach to the fat – dissect inferiorly between the orbicularis muscle and the septum to reach the inferior orbital rim and enter the fat compartment by disinserting the arcus marginalis. However, the fornix approach is more direct and is simpler. It also avoids an incision into the septum and the risk of septal scarring and contraction.
Open the fat pockets widely. There is a larger medial fat pad – which is subdivided into a medial and a central fat pad – and a smaller lateral fat pad. Gently separate the central and medial fat pads until the inferior oblique muscle is visible (see 1.8 and Diags 1.14 , 1.15 ). This muscle must be identified before any fat is excised and care must be taken during the rest of the procedure to avoid damage to the muscle.
Gently dissect around the fat pads to allow further prolapse. Excise redundant fat without traction having applied fine curved artery forceps. Cauterise the cut edge and then remove the forceps and apply more cautery before allowing the fat to fall back into the orbit. To estimate how much fat to excise in the supine patient, gently press on the globe through the closed upper lid. The residual fat should just reach the level of the orbital rim. Repeat this with the lower lid in position and check for visible residual fat prolapse in each of the fat compartments. Avoid excessive fat excision which might leave a hollowed lower lid postoperatively. The aim is to achieve a natural fullness and symmetry between the two lower lids.
