The goal of aesthetic plastic surgery is rather simple: correct the undesirable conditions for which a surgeon has been consulted and avoid the telltale signs of surgery. This objective is best accomplished by accurately identifying the combination of issues that are responsible for the appearance of aging eyelids. Moreover, the surgeon must use the correct combination of rejuvenation procedures to create more youthful appearing eyelids. In an article coauthored with Dr. James English in 1988, I described a number of safeguards that tend to preserve naturally appearing eyes following lower lid blepharoplasty. These points are crucial in ensuring success with this approach.

During the preoperative consultation, a surgeon has an opportunity to identify conditions that may herald a potential problem postoperatively. The strength of the lower lid hammock and any preoperative scleral show should be noted and pointed out to the patient. Photographic documentation of the preoperative state is also essential.

As a rule, blepharoplasty tends to improve the sags and bulges but does not remove wrinkles in the skin around the eye. If wrinkling of the skin is noted at the time of consultation, the surgeon should advise the patient of the potential for a skin resurfacing procedure (chemical exfoliation or laser resurfacing) to provide additional improvement. In most cases, skin resurfacing is performed from 8 to 12 weeks following blepharoplasty. When transconjunctival adipose tissue removal is performed or when a skin-muscle technique is used, skin resurfacing may be performed at the time of blepharoplasty. Patients should be duly informed of the potential risks of combining these procedures.

The two principal approaches to removing excessive tissues in the lower lid are the skin flap technique and the skin-muscle flap technique. When bulging infraorbital adipose tissue needs to be addressed—without the presence of redundant skin—a transconjunctival approach may be considered. The correct diagnosis determines which technique is used in each individual patient.

Presence of an atonic or hypotonic lower lid should be noted, and this would require performing a pentagonal full-thickness wedge resection of the lower lid. For best results, the surgeon should place the center-most portion of pentagon (and resulting scar) at the lateral margin of the limbus.

In the preoperative holding room, the appropriate blepharoplasty skin incisions are outlined with a skin-marking pen. Once the patient arrives in the operating room—and after conscious sedation anesthesia is instituted—lidocaine (1%) with epinephrine (1:100,000) is injected into the surgical areas, taking care not to injure underlying structures.

If performed in conjunction with lower lid blepharoplasty, the upper lid is corrected first. After excision of excessive upper lid skin and removal of any adipose tissue pads needed, a tacking suture is placed at a point that coincides with the lateral canthus to anchor the inferior edge of the upper lid defect to the upper edge. This maneuver tends to stabilize the lateral canthal region in its new position. Once the upper lid blepharoplasty is complete, the lower lid skin incision is made with a no. 15 blade. This incision should be placed with traction on the lower lid in the first lower lid skin crease (approximately 4 to 6 mm below the free border of the lash margin) (Fig. 3.1). The incision, which is carried only through skin, begins a few millimeters lateral to the punctum medially and courses laterally just past a vertical line dropped from the lateral canthus. At this point, the incision curves inferiorly and laterally 4 to 6 mm following a naturally occurring relaxed skin tension line (Fig. 3.2). Doing so, results in a more aesthetically pleasing postoperative scar.

In a skin flap procedure, undermining is carried inferiorly to the edge of the infraorbital rim. Access to the adipose tissue pads is achieved by dividing the fibers of the orbicularis oculi muscle approximately 5 to 6 mm cephalad to the rim.

In skin-muscle flap procedures, a small curved Iris Scissor is used to spread and penetrate the orbicularis oculi muscle laterally (Fig. 3.3). A blunt scissor is then used to undermine the entire skin-muscle flap to a point just cephalad to the infraorbital rim (Fig. 3.4). Once the undersurface of the orbicularis oculi muscle has been freed from the orbital septum, one blade of the scissor is placed in the previously created pocket beneath the muscle. The other blade of the scissor is placed externally along the initial skin incision. A beveled incision through the orbicularis oculi muscle and subcutaneous tissue is completed with the blades of the scissors (Fig. 3.5). Since the skin-muscle flap is selected in those patients with minimal skin redundancy, the flap is reflected allowing for visualization of the orbital septum (Fig. 3.6).

Bulging adipose tissue pads can be more accurately removed by incising the overlying orbital septum while placing gentle digital pressure on the globe (Fig. 3.7). This maneuver causes the excessive adipose tissue


to bulge through the orbital septum for easy amputation. Unless patients are under general anesthesia, prior to excision, the base of the adipose tissue stalk is injected with local anesthetic (without epinephrine) (Fig. 3.8). The stalk is then generously cauterized with bipolar cautery (Fig. 3.9). Only the portions of adipose tissue that exude easily through the defect in the orbital septum are removed (Fig. 3.10).