17 Upper Blepharoplasty
Upper lid blepharoplasty is not just about removing excess skin and fat. Achieving a satisfactory functional and aesthetic result after upper lid blepharoplasty can only be attained by understanding the anatomical changes that are responsible for the objectionable features causing symptoms, and by understanding how those features are addressed to leave a more youthful and normally functioning upper eyelid.
Removal of excess skin with or without removal of prolapsed fat in the upper eyelids to improve visual function and cosmesis.
Removal of redundant eyelid skin and contouring of prolapsed fat as needed eliminates the physical barrier of these tissues overhanging the visual axis, allowing for improvement in visual function and an increase in the superior visual field.
Upper eyelid blepharoplasty also improves the cosmesis of heavy, tired-appearing eyelids.
Patients should expect improvement in the redundancy of the upper eyelid skin with a more visible and defined eyelid crease and a decrease in visible fat prolapse. Patients should be aware that there will be a scar hidden along the upper eyelid crease. When surgery is properly performed, patients should expect to maintain normal eyelid function with complete closure of the eyelids.
17.4 Key Principles
In youth, the upper lids are typically full. For some, very little of the tarsal platform is visible, while in others there is a larger visible area below the lid crease and above the upper eyelid lashes. With aging, the upper lid skin tends to lose elasticity and may stretch. The crease may become less defined. The preaponeurotic fat and medial orbital fat may prolapse into the lid (Fig. 17‑1). These fat compartments may be modified during blepharoplasty surgery. There is a trend toward being conservative in any modification to the preaponeurotic fat in an effort to not hollow out the upper lid sulcus area and instead to maintain youthful volume. 1
Laterally, the orbital lobe of the lacrimal gland may also prolapse anteriorly into the lid (Fig. 17‑2). It is important to recognize the lacrimal gland as such in order to avoid mistaking it for prolapsed fat and excising it (i.e., there is no “lateral” fat pad in the upper eyelid). The lacrimal gland may be resuspended into the bony lacrimal gland fossa via the upper blepharoplasty incision.
In addition, there may be dehiscence or detachment of the levator aponeurosis resulting in upper lid ptosis (Fig. 17‑3). Removing redundant skin may be enough for some patients to regain a normal upper eyelid position, but other patients will require formal correction of eyelid ptosis (such as levator repair) to achieve their goals of improving superior field of vision or creating a more aesthetically pleasing upper eyelid configuration.
Brow ptosis is quite common and results in additional redundancy of skin over the upper lids, especially temporally (Fig. 17‑4). It is important to identify brow ptosis during the preoperative clinical evaluation and make the patient aware of its contribution to excess eyelid skin, as patients often lack this insight. Concurrent correction of brow ptosis should be considered at the time of upper blepharoplasty.
It is common to consider blepharoplasty as the removal of excess skin and fat from the upper lid. However, a better way to approach this procedure may be to focus on how much tissue is left behind rather than how much is removed. It is critical to leave adequate tissue to allow for eyelid function and closure. Optimizing the fine line between adequate tissue removal and safety is key to successful surgery.
Underlying baseline asymmetry of facial anatomy is the norm, albeit to varying degrees among individuals. 2 This must be noted and discussed preoperatively. While surgical maneuvers can serve to ameliorate certain degrees of underlying preexisting asymmetry, patients should be counseled that there is a tendency for some return of asymmetry during healing and that underlying bony asymmetry, etc. is not corrected via blepharoplasty.
Desire for cosmetic improvement of excess skin and prolapsed soft tissues of the upper eyelids.
Desire for improved visual function by relieving the obscuration of the superior visual field caused by redundant upper lid tissues.
Upper eyelid blepharoplasty should not be performed in cases of baseline severe dry eye disease that is not well-controlled or in cases of lagophthalmos. A tenet that all eyelid surgeons must remember is that the main purpose of the eyelids is to protect the eye. The lids must be able to open, close, and blink. Any surgical procedure aimed at improving either function or aesthetics must not compromise the ocular protection provided by the lids. Even a small amount of lagophthalmos or incomplete blinking may result in corneal exposure and pain (Fig. 17‑5).
Patients who are anticoagulated for any reason, such as medications or thrombocytopenia or other disorders of clotting, should undergo blepharoplasty with caution, especially if the orbital septum is to be opened for fat debulking or levator repair, due to the risk of orbital or retrobulbar hemorrhage that may be sight-threatening if unrecognized or inadequately treated.