32 Revision Surgery for Blepharoplasty

Boaz J. Lissauer and Albert Hornblass

The upper eyelid crease is most commonly found 8 to 10 mm above the upper lid margin in occidental eyelids. The crease represents insertion of levator fibers in the pretarsal orbicularis and skin. The eyelid crease in Asians is only a few millimeters from the upper lid margin because the superior orbital septum inserts on the levator aponeurosis at the crease, close to the lid margin. The area of skin above the cilia in which the skin and underlying muscle are firmly attached to the tarsal plate is the pretarsal space. The visibility of the pretarsal space is dependent on the amount of skin overhanging the upper lid fold (dermatochalasia). The goal of upper lid blepharoplasty is restoration in the visibility of the pretarsal space, more so in females than in males (Fig. 32.1). If the medial canthus is covered by a nasal extension of the upper lid crease, this is termed an epicanthal fold. The lower eyelid crease is less well defined and represents the superficial insertion of the lower lid retractors. The crease is 4 to 5 mm below the lower eyelid margin and has a gradual temporal slope.

Skin and Muscle

The eyelid skin is the thinnest in the body and makes a sharp transition to the thick skin of the brow superiorly and the malar region inferiorly. The subcutaneous tissue in the eyelids is devoid of fat and has loose stroma and attachments to the underlying tissue. This explains the rapid accumulation of fluid in the pretarsal space during hemorrhage or acute allergic response, with an initial sharp demarcation line between the cheek region.

The orbicularis oculi muscle is deep to the dermis and is the protractor of the eyelids (closure muscle). It is divided into three regions: the pretarsal, preseptal, and orbital regions (Fig. 32.2).

The pretarsal orbicularis divides into two heads nasally. The superficial head passes anterior to the canaliculi and forms the anterior crus of the medial canthal tendon, inserting into the frontal process of the maxillary bone. The deep head inserts onto the posterior lacrimal crest (Horner muscle). This deep insertion provides a deep anchor and is responsible for the eyelids’ convex position on the surface of the globe. The preseptal orbicularis medially inserts into the anterior crus on the medial canthal tendon and temporally forms the lateral horizontal raphe. The orbital orbicularis nasally inserts into the medial canthal tendon, the nasal aspect of the frontal bone, and the inferomedial orbital margin. It then extends laterally around the lateral canthus without insertion into the lateral canthal tendon. The orbicularis muscle provides the lacrimal pump for drainage of tears into the nasolacrimal system. Weakening of the muscle can cause epiphora even in the presence of normal lid position.

Fig. 32.1 Cross-sectional anatomy of the upper eyelid.

Laterally, the pretarsal muscle is attached to the lateral orbital tubercle via the lateral canthal tendon. The preseptal and orbital orbicularis travel along the orbital rim and pass the lateral canthal angle to attach to the zygoma.

Fig. 32.2 Orbicularis oculi muscle.

In the lower eyelid, the septum fuses with the lower eyelid retractors 4 to 5 mm below the tarsal plate, then attaches to the inferior border of the tarsus of the lower lid. In the upper eyelid, the septum fuses with the levator aponeurosis superior to the tarsal plate, ~10 mm above the eyelid margin in occidental eyelids. In Asians, the orbital septum inserts to the levator aponeurosis anterior and inferior to the tarsal plate only a few millimeters from the eyelid margin (Fig. 32.3).

Preseptal and Postseptal Eyelid Fat Compartments

The preseptal eyelid fat pad extends in a submuscular plane from the brow region inferiorly beneath the preseptal orbicularis of the upper eyelid. In the upper eyelid posterior to the orbital septum are two fatty compartments. The preaponeurotic fat pad lies anterior to the levator aponeurosis, temporal to the trochlea, and medial to the orbital lobe of the lacrimal gland. Nasal to this fat pad is the nasal fat pad of the upper lid just beneath the trochlea. These fatty deposits can be discerned by their color; the preaponeurotic fat pad is yellow, whereas the nasal fat pad is white.

In the lower eyelid there are three fat pads. The inferior oblique muscle divides the nasal and central fat pads. The central and lateral fat pads are divided by a fibrous septum anteriorly but connected in the deep tissue posteriorly (Fig. 32.4).

Complications of Blepharoplasty

Complications of Upper Blepharoplasty

The most common complication of cosmetic blepharoplasty is dissatisfaction with the surgical results. The easiest way to avoid this complication is by spending time during the preoperative visit explaining to the patient what can be expected. Preoperatively, the patient must be advised of all potential cosmetic outcomes of upper blepharoplasty. including under- and overcorrection, high eyelid creases, asymmetry, nasal tension lines, suture milia, superior sulcus deformity, and feminization of the male upper eyelid. The patient must have realistic expectations even if the procedure progresses as planned. More importantly, the patient must be advised of the functional complications that require surgical revision, including ptosis, hematoma, lid lag or the inability to close the eyelids when sleeping, exposure keratopathy, and vision-threatening retrobulbar hemorrhage.

Complications of Lower Blepharoplasty

Common complications of lower blepharoplasty are fewer and more accentuated than those of upper blepharoplasty. Cosmetic and functional complications include lower lid malposition, retraction with scleral show (Fig. 32.5), ectropion, lagophthalmos, bowing deformity, injury to the inferior oblique muscle, worsening of rhytides, improper orbital fat excision, accentuation of the tear trough deformity, and orbital hemorrhage.

The eyelid crease, as previously mentioned, represents the insertion of the levator fibers into the pretarsal orbicularis and skin. To lower the crease surgically, a new blepharoplasty incision should be placed at the desired lid crease height (usually 8–10 mm superior to the eyelid margin). The incision should be carried down through the orbicularis muscle and orbital septum to the levator aponeurosis. If required, a skin–muscle flap and herniated orbital fat may be removed. The incision is then closed with interrupted sutures. The sutures reestablish the new lid crease, as each suture pass incorporates the inferior incisional skin edge and a bite of levator aponeurosis and then the superior skin edge, imbricating the aponeurosis within the skin closure. This allows the upper eyelid skin to slightly hang over the closed incision, re-creating the upper eyelid crease. It should be stressed that taking too much skin laterally in reoperations should be avoided, as it will pull the eyebrows inferiorly.

Asymmetric upper eyelid creases are also encountered after blepharoplasty; this asymmetry is more easily corrected by elevating the eyelid crease that is too low (Fig. 32.5). The distance from the lid margin to the lid crease in the eye that is not to be repaired is measured. An ellipse of skin is marked on the eyelid to be repaired above the existing lower eyelid crease, with the inferior incision placed at the same height as the lid crease measured on the opposite eye. The marked ellipse is then excised as a skin–muscle flap along the horizontal length of the eyelid, and levator aponeurosis adhesions are separated from the previous lower eyelid crease. The incision is closed in a similar manner as mentioned above, with interrupted sutures incorporating the levator aponeurosis into the newly repositioned eyelid crease. The inferior and superior incisional suture passes should be orbicularis and skin together, enhancing the lid crease (Fig. 32.6).

Nasal Tension Lines

Nasal tension lines or nasal webbing can be avoided with a W or M incision configuration; however, mechanically created nasal tension lines can also occur during incision closure (Fig. 32.7). This can be prevented primarily if tension is noted at the time of suturing. The first pass of the running suture should be placed lateral to the most nasal incision angle (~4 mm), taking a bite of skin and orbicularis inferiorly, then the levator aponeurosis, and then in a parallel vector through skin and orbicularis superiorly (instead of at a meridianal angle). This creates lateral tension on the upper nasal eyelid skin, reducing tension lines. No sutures should be placed medial to the first pass of the running suture. If tension lines are still present, remove the first stitch of the running suture and place it even more temporally, again leaving the incision open nasal to the running suture.

Suture milia are incisional cysts at the area where the suture passes into the skin (Fig. 32.8

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