Upper lid blepharoplasty performed without correction of a lax or ptotic eyebrow results in postoperative residual upper lid folds and a narrowing of the spacing between the eyebrow and eyelashes (brow–lash distance). The goal of upper lid blepharoplasty is to remove redundant skinfolds and produce a clear strip of skin above the eyelash line (the eye-shadow space in females).
The following eyebrow procedures are available in conjunction with upper lid blepharoplasty:
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Internal browpexy is performed through the upper blepharoplasty incision for correction of laxity in the lateral third of the brow.
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Endoscopic-assisted eyebrow forehead lift is used more commonly in females for the nasal two-thirds of the brow and glabellar area
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Direct eyebrow lift is used, generally, in males. It involves direct skin incision over the area above the brow ( Fig. 5.1A & B ).
Figure 5.1
(A) Male patient with brow ptosis and voluntary compensation of frontalis muscle.
Figure 5.1
(B) Surgical closure of a direct eyebrow lift.
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Temporal forehead lift (lateral brow lift) is used for the lateral third of the brow when there is severe skin laxity lateral to the brow, beyond the lateral orbital rim.
It is important, when performing upper lid blepharoplasty, for the surgeon to produce an aesthetically pleasing upper eyelid in the patient, but also to use techniques that prevent lagophthalmos of the upper lid, which may cause postoperative exposure symptoms. To achieve this, one may think of the procedure as a three-dimensional reconstruction and reanchoring of the subcutaneous tissues, including orbicularis, orbital septum, preaponeurotic and nasal fat pads, as well as repair of prolapsed lacrimal gland and repair of dehiscence, with very selective and limited skin excision. Figure 5.1C–H shows examples of variation in upper eyelid crease.
Figure 5.2 shows a schematic representation of a cross-sectional view of an upper eyelid with presence of a natural crease.
Generally, females desire a higher lid crease and a more well-defined eye-shadow space and crease than do males. Men, in general, do better with a parallel crease. Adjunctive eyebrow procedures are commonly needed in patients seeking upper lid blepharoplasty. It is possible to produce the goal of crease formation and fold clearance with minimal skin excision when adequate brow stabilization and debulking of the upper lid are performed.
Surgical Technique
At the mid portion of the upper lid crease, the upper lid is anesthetized through skin subcutaneously with no more than 2mL of 2% Xylocaine with 1:100 000 dilution epinephrine, through a 30-gauge needle. The anesthetic solution is lightly massaged several times to spread it evenly across medially and laterally. After 2 minutes to allow for vasoconstriction to set in, the surgical field is draped. A corneal protector is applied. I prefer to inject the nasal fat pad quadrant only after I have reached the preaponeurotic space, with an open view.
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Avoid using large-gauge needles during injection.
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Avoid any repeated passage through the orbicularis layers to reduce the chance of bleeding.
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Inject slowly, from a perpendicular orientation over the central preseptal area of the orbicularis; then massage to both sides.
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Use diluted Xylocaine mix (see Chapter 3 ), or use bicarbonate supplement to decrease stinging sensation from the acidity of the full-strength injection.
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Regional nerve block is often unnecessary, as some patients are bordered by transient torsional diplopia and ptosis from involvement of the levator muscle and superior oblique tendon.
Pitfalls Designing the skin excision
The central position of the upper lid crease is marked centrally at 8.5 to 10mm above the lashes in females, in a semicircular configuration. Medially, it tapers down to 5mm from the lashes and may angle upward in the vicinity of the upper punctum. Laterally, the crease line is carried to about 6mm from the lash line and then the marking is angled upward, pointing toward the end of the brow.
In men, I prefer to mark the crease centrally at 8–9mm, and in a parallel shape. The medial extent of the lower line of incision is about 7mm and the lateral extent about 8mm from the lash line, rendering it more of a parallel crease shape.
For Asians, the existing crease is measured. The central height of the tarsus is similarly measured by everting the tarsus. If the two measurements are identical, the patient’s original crease line is used as the lower marking for incision. If the current crease measures more than the central tarsal height, this author prefers to transcribe the tarsal height measurement onto the skin side as a yardstick to the proper height for the new crease.
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Allow adequate amount of time for anesthetic solution to spread out and egress; this will reduce the tissue distortion.
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If the tissues are marked before injection, one tends to make an excessively high incision and often inadvertently injure the levator. This can cause cicatricial lagophthalmos on downgaze as well as upgaze.
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The use of hyaluronidase (Wydase), when available, is a helpful adjunct towards achieving the correct incision height and ultimately the crease height.
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In men, the crease looks best if it is close to and along the superior tarsal border.
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Avoid excessive fat removal, especially in men, as it will exaggerate the sulcus.
Pitfalls For marking the upper line of the skin excision ellipse, the bunching technique is used only at the lateral canthus. The proper amount of bunching in this area should show some slight eversion of lashes. One may maximize the skin excision laterally and should minimize the skin excision centrally and nasally. Any lagophthalmos in the upper lid is poorly tolerated if it occurs in the central or nasal portion of the lid. One way of ensuring symmetry in the final upper lid crease position is to measure the distance of the superior line of incision from the brow hairs above.
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The superior line of the ellipse should be measured from the inferior edge of the brow hairs and generally is located at the juncture of the thick and thin skin of the upper lid ( Fig. 5.5 ). Equal distances from the upper line of incision to the brow hairs will give even creases postoperatively if the brow positions are symmetrical on both sides.
