Patient Selection
The goal of cosmetic upper eyelid blepharoplasty in the Caucasian patient is usually to improve appearance by reducing the gravitational and age-related redundancy, descent, and herniation of the upper eyelid tissues. Many other age-related changes also exist but are much more difficult to address. These include loss of skin elasticity, flaccid skin and orbicularis, eyelash thinning and shortening, pigmentary changes, loss of subcutaneous and eyebrow fat, descent of the lid crease and fold, and textural skin surface changes. One should examine and document common concurrent conditions including eyelid ptosis.
Patient selection considerations ( Figs 10.1 & 10.2 ):
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primary problem is redundant upper eyelid skin, orbicularis, and oftentimes, fat
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no significant eyelid margin malposition
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satisfactory eyebrow position
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satisfactory lacrimal gland position.
The margin reflex distance (MRD) obtained with eyebrows manually raised (referred to as MRDb) is highly predictive of the post-blepharoplasty MRD. Balloting the globe while lifting the eyebrow and examining the superior sulcus helps determine which fat pads should be resected. Any pre-existing eyebrow ptosis, eyelid ptosis or nasal webbing should be documented and emphasized to the patient ( Figs 10.4 & Figs 10.5 ). While the brows are manually raised (and the superior sulcus is examined for evidence of herniating nasal and preaponeurotic fat pads) one should also search for lacrimal gland prolapse ( Fig. 10.6 ). Finally, the extent of lateral hooding and retro-orbicularis oculi fat (ROOF) should be noted.
Search for lagophthalmos by having the patient passively close their eyelids as if sleeping ( Fig. 10.7 ). Slit-lamp corneal evaluation, rose Bengal or fluorescein epithelial staining or Schirmer tear help screen for dry eye patients. An ocular examination including Bell’s phenomenon testing and cranial nerve VII testing may help document any pre-existing ophthalmic pathology. At this point, the surgeon should have a clear understanding of the patient’s expectations, surgical risk factors, and underlying anatomic eyelid changes. With this information, the surgeon may now proceed to negotiate a surgical plan that safely meets the patient’s needs and expectations.
Laser Instruments, Safety, Selection, and Parameters
Useful instruments include a millimeter ruler, 0.3mm toothed platform forceps, needle holder, stitch scissors, and hemostat. Metal globe shields or guards will be needed. Bipolar or other cautery device is also necessary. Since there is a combustion hazard associated with CO 2 laser use, the patient should be draped with wet cloth towels. The superb hemostasis achieved by the CO 2 laser is due to the zone of coagulative and thermal injury created by the laser ( Fig. 10.8 ).
Please see Chapter 11 for discussion of CO 2 laser parameters and laser safety.
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Focused spot size of 0.3mm or less
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Wattage setting usually around 6–7W
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Continuous wave or pulsed setting
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Articulated arm beam delivery
Surgical Steps
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1. Mark the proposed upper eyelid crease
When marking the eyelid skin for excision, always remember that the inferior border of the skin incision usually becomes the postoperative eyelid crease. If the inferior incisions are misplaced or asymmetrical, then the final results will be askew. Therefore, careful initial skin markings are critical. In Caucasian eyelids, the inferior incision is usually marked 9 to 11mm superior to the central eyelid margin, 4mm superior to the upper punctum, and 6mm superior to the lateral canthal angle ( Figs 10.9 & Figs 10.10 ). These markings are usually lower in Asian or Oriental eyelids and higher when one desires a higher lid crease and fold. The female eyelid usually has a higher arched crease compared to the male eyelid. In the Asian eyelid, be certain that the incision height and curvature is a natural extension of any pre-existing epicanthal folds. The eyelid crease (and inferior marking) usually curves somewhat downwards as it extends towards the medial canthus and lateral canthus.
