Introduction
Upper eyelid blepharoplasty is one of the most common aesthetic surgical procedures and typically achieves a high level of patient and surgeon satisfaction. A meticulous appraisal of patient anatomy and expectation is a key prerequisite for achieving positive results. In this chapter, we review patient selection, the preoperative assessment, and key anatomical considerations. We also outline our surgical techniques and provide an overview of the postoperative period.
Anatomy
The facial soft tissue is divided into five continuous layers. These layers vary in structure and function depending on their location. The five layers are the (1) skin, (2) subcutaneous tissue (including superficial fat), (3) the musculoaponeurotic (mimetic) layer, (4) deeper fat layer (acts as a glide plane between the mimetic muscles above), and (5) deep fascial layer.
Brow and Upper Eyelid Anatomy
The brow and upper eyelid are intimately linked and should be considered as a continuous aesthetic unit. The brow consists of thicker hair-bearing skin. It spans the area above the bony orbital rim. At the arcus marginalis (corresponding to the position of the superior orbital rim), the subcilliary brow transitions into the upper eyelid. The only elevator of the brow is the frontalis muscle. The depressors of the brow include the corrugator supercilii muscle, the procerus muscle, and the orbicularis oculi muscle, which are found deep to the hair bearing skin of the brow. The frontalis muscle is absent laterally. With aging and the influence of gravity, the unopposed action of the orbicularis oculi contributes to lateral brow ptosis. The retro-orbicularis oculi fat (ROOF) fat pad is found deep to the frontalis and the orbicularis oculi, contributing to the volume of brow and upper lid.
Upper Eyelid Anatomy
Traditionally, the cross-section of the upper eyelid has been divided into two sections: the anterior and posterior lamellae, separated by the orbital septum. The anterior lamella includes the skin and the orbicularis oculi muscle. The orbicularis oculi muscle is formed of a thin sheet of concentric skeletal muscle fibers arranged as an oval sheet which covers the upper and lower eyelids, the inferior forehead and the upper midface. It is the only protractor of the eye. The muscle can be divided anatomically into two parts: the orbital (pars orbitalis) and palpebral (pars palpebralis) sections.
Fibers from the orbital portion are intimately connected to the corrugator supercilia, contributing to brow depression. The orbital septum is a thin connective tissue that originates at the arcus marginalis, descending inferiorly (in the upper eyelid) to fuse with the levator aponeurosis and tarsal plate.
Orbital fat is found posterior to the orbital septum. In the upper eyelid, it is separated into two compartments: the medial and central fat pad, separated by a layer of thin connective tissue and the trochlea. The two fat pads differ in appearance and origin. The medial fat pad is derived from neuroectoderm and appears whiter and denser than the central fat pad. The central fat pad is derived from the mesoderm and is sometimes referred to as the preaponeurotic fat pad. It provides volume to the central upper eyelid and overlies the levator aponeurosis. The lateral upper eyelid contains the lacrimal gland. Involutional changes of the lacrimal gland may include prolapse of the gland, requiring repositioning.
The posterior lamella is made up of the conjunctiva, the tarsal plate, and the upper eyelid muscle retractors (levator palpebrae superioris and levator aponeurosis (superiorly) and Müller muscle). The tarsal plates provide tectonic support for the upper eyelid and are formed from dense connective tissue. They contain the Meibomian glands and eyelashes follicles. The tarsal plate of the upper eyelid is larger than that of the lower lid. In the upper eyelid, it measures between 10 mm and 12 mm vertically at the mid-pupillary line and tapers in width across the length of the eyelid.
Aging of the Brow and Upper Eyelids
Involutional changes affect the bone and all five soft tissue layers of the face. At the microscopic level, changes occur to the various constituents of the extracellular matrix, including the loss of organization of collagen-elastin bundles, glycoproteins and glycosaminoglycans, which includes hyaluronan. In concert, these changes conspire to increase laxity and reduce elasticity in all the soft tissue layers of the face.
Involutional Changes to the Orbit
While involutional changes to the soft tissue are more apparent to the observer, there are also changes that occur in the bone. In a previous CT-based radiological study of 240 orbits, the bony orbital cavity was found to increase with age in women but not men. The central width of male orbits did not change with age, while that of the females increased (average difference = 2 mm). In males, at the anterior orbit, the central height increased, while the lateral and medial height did not change. The female orbits showed no changes in height with age. These results suggest that in males the inferior rim may move inferiorly and the lateral rim more posteriorly, with age. In both genders, there is a significant increase in fat volume with age (33% increase in males and a 29% in females). ,
Globe Position
The anterior globe position refers to the position of the globe within the orbit. It is typically measured as the difference between the most anterior portion of the cornea and the lateral orbital rim. It was previously thought that enophthalmos due to loss of soft tissue volume was a feature of aging. In more recent work, it has been suggested that this may not hold true for all patients and that some patients may in fact experience exophthalmos. , It is important to recognize the presence of a prominent eye, since removal or periorbital soft tissue in such cases can exacerbate the appearance of prominence and create an unfavorable appearance.
Preoperative Assessment
A good preoperative review includes an appraisal of the patient’s expectations and a discussion of what can be realistically achieved through surgery. In our experience, 90% of patients presenting with a complaint of “droopy” upper eyelids have a combination of brow ptosis and dermatochalasis. In such circumstances, a blepharoplasty done on its own may contribute to lateral brow descent and will produce unsatisfactory results. The preoperative review must also include a review of the patient’s previous medical and surgical history.
Medical History
A general medical history, taking into account potential general medical concerns that might have an impact on anesthesia or the postoperative period, should be taken. Most pertinent to upper eyelid blepharoplasty is the presence of dermal fillers. Given the rising popularity of such products, it is highly likely that patients presenting for an upper eyelid blepharoplasty will have a history of dermal fillers. Most dermal fillers are composed of cross-linked hyaluronic acid and are designed to imbibe fluid; this may lead to increased and prolonged swelling in the postoperative period. Patients should be counseled with regard to this.
Another consideration is the presence of dry eye syndrome. Some patients may experience worsening of their signs and symptoms following eyelid surgery. It is important to document the status of the cornea and tear film prior to surgery. If dry eye syndrome is present, optimization of the corneal surface using lubricants is recommended presurgery and postsurgery. Furthermore, avoiding resection of orbicularis oculi muscle may be prudent approach to minimize postoperative complications.
The Exam
The brow and upper eyelid should be evaluated as a continuous aesthetic unit. A detailed exam of the brow includes documentation of any asymmetry in the arch, shape, and contour. Further, the presence of rhytids on the forehead should be documented. Some patients may have a normal brow position that is maintained by frontalis overactivity. This group of patients will present with static forehead rhytids and should be examined with the forehead relaxed.
Examination of the upper eyelids should include documentation of excess skin, upper lid position, soft tissue volume within the upper eyelid sulcus and symmetry. Raising the patient’s eyebrows using the examiner’s hand can uncover hollowing of the upper eyelid sulcus and/or preexisting asymmetry or ptosis not previously seen.
A complete exam will also include assessment of globe position (oftentimes asymmetry may be related to exophthalmos/enophthalmos), visual acuity, facial nerve function, and levator function. The marginal reflex distance (MRD) is a critical preoperative measurement by measuring the vertical distance from the upper (MRD ) and lower (MRD ) eyelid margins to the center of the pupil. An MRD less than 2.5 mm indicates “ptosis” requiring the surgeon to consider functional ptosis repair in conjunction with upper blepharoplasty.
Surgical Planning
The supratarsal lid crease typically measures 8 to 10 mm for females and 6 to 8 mm for males in Whites. As a general guide, 21 mm of skin from the lid margin to the inferior brow should be conserved, however, in practice, the amount of skin removed should be tailored to each patient. The upper eyelid skin can be measured using calipers or a ruler when relaxed. Some physicians choose to pinch the upper eyelid skin. With this maneuver, observing for lid margin rotation or elevation helps to define the limits of excision.
Photography
Standardized preoperative photographs should be obtained for all patients. One should ensure the same lighting and aspect ratio for pre- and postoperative photographs. When done correctly, these will serve as excellent communication tools in the postoperative period. We prefer a photo with the patient looking straight ahead with a neutral facial experience and two photos on at 45° from either side.
Surgical Procedure
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Marking of the upper eyelid should be performed with the patient sitting upright and with the brow elevated. This will help to reveal the patient’s natural skin creases. On occasion, multiple creases may be found. Prior to marking, the skin should be cleaned using alcohol wipes and allowed to dry. Using a fine pen, the supratarsal crease is marked from the medial puncta to the lateral canthus. If no crease is seen or multiple creases are found, a new one may be marked according to gender and patient’s race. With multiple creases, adjunct procedures may be required ( Fig. 26.1 ).
