eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Upper Lid

Author: Gregory Caputy, MD, PhD, Chief, Department of Plastic Surgery, Aesthetica Plastic and Laser Surgery Center of Honolulu
Coauthor(s): Bhupendra Patel, MD, FRCS, Professor of Ophthalmic Plastic and Facial Cosmetic Surgery, Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah School of Medicine
Contributor Information and Disclosures

Updated: May 31, 2009

Introduction

The procedure of upper eyelid blepharoplasty has changed dramatically in both understanding and performance over the last 20 years. Upper eyelid overhang and the resultant tired facies have led patients to seek correction for the last century. Understanding the dynamic anatomy of the upper eyelid and the palpebral crease allows tailoring the fold and eradicating the tired look in most patients. Given proper brow position (see Brow Lift, Periorbital Rejuvenation), the upper eyelid blepharoplasty is a mainstay of surgical rejuvenation of the orbital region.

History of the Procedure

Upper eyelid skin resection and fat resection from the 2 upper eyelid fat pockets have been performed for more than a century. In the last 20 years, skin and fat resection has decreased to avoid causing incomplete eyelid closure and dry eye symptomatology. A deeper understanding of the dynamic nature of the upper eyelid has led to invagination techniques, largely borrowed from the Asian double-eyelid procedure, to deliver a crisp upper eyelid fold at a height that is optimum for the patient.

Sayoc and Millard both have published static upper eyelid fold procedures for the Asian patient,^1,2 but Fernandez created the dynamic upper eyelid fold procedure largely used today.³ Extension of this procedure into the invagination or anchor blepharoplasty was largely the work of Flowers.⁴

Understanding the anatomy and physiology of the upper eyelid has recently made great strides in the "zipper" concept, as delineated and beautifully described by Siegel.⁵

Problem

Clearly differentiate upper eyelid dermachalasis from the myriad other problems of the upper eyelid that often are a component of upper eyelid aging. True dermachalasis is common, but often, all upper eyelid problems are treated with upper eyelid skin blepharoplasty, which is useful only for treating dermachalasis. Even with this problem properly diagnosed and differentiated from other periorbital problems, a better treatment is often found with an anchor blepharoplasty compared to simple skin resection or skin and partial muscle and fat resection.

Brow ptosis is the most common cause of upper eyelid fullness. Carefully assess brow position prior to planned rejuvenation of the periorbita. Please see the eMedicine text on brow lift (Brow Lift, Periorbital Rejuvenation) for a more detailed discussion of this topic. Aggressive treatment of the upper eyelid for the treatment of brow ptosis is inadequate and counterproductive and rarely leads to any marked improvement in the condition.

Upper eyelid ptosis also commonly is mistaken for upper eyelid dermachalasis and cannot be treated with simple upper eyelid blepharoplasty or anchor blepharoplasty. Repair the dehiscence or shortened levator muscle in individuals with good levator function but acquired or congenital ptosis. If ptosis requires correction, perform an anterior or posterior procedure (Fasanella-Servat or partial Mullerectomy to preserve conjunctival mucus-secreting glands).

The differentiation of low fold, lack of fold, and lacrimal gland ptosis and changing dogma in the treatment of upper eyelid fullness are discussed.

Frequency

Given sufficient time to age, essentially all individuals develop apparent upper eyelid skin excess. As mentioned above, differentiate this from numerous other conditions that add to the aged appearance of the upper eyelid.

An upper eyelid fold is present in approximately 50% of Asian patients, and this is often viewed as a more beautiful Asian visage than the heavy upper eyelid appearance of those born with no fold. In many instances, individuals are born with a fold that attenuates with time such that it becomes uneven or lacking. The object of upper eyelid fold procedures in Asian patients is not to create a more Caucasian-looking eye with a high eyelid fold. The goal is to create a more beautiful Asian eye, often with a low fold but without the excessive heaviness of the upper lid often present in those with no fold.

Etiology

Septal fat ptosis and ptosis of the lacrimal gland in the upper lateral area of the upper eyelid are caused by weakening of the retaining ligaments and septum. Classic upper eyelid blepharoplasty involved the aggressive resection of skin and fat. This often led, with aging and the fat atrophy that universally occurs in that process, to a sunken appearance of the upper lid area. This resulted in a skeletal appearance primarily caused by the iatrogenic decrease in fat in the area. The overresection of skin without proper brow fixation also led to the migration of heavier brow skin into the upper eyelid area, resulting in a worsened appearance. Often, resections were so aggressive that proper brow positioning could not be achieved without lagophthalmos and resultant dry eye symptomatology.

Pathophysiology

See Etiology for more information. As the aging process affects everyone, calling it pathologic is semantically incorrect.

In an Asian patient with an upper eyelid lacking a fold (congenital), often some degree of medial epicanthus also is present. The degree to which the medial epicanthus is hidden by the epicanthal fold determines whether correction is necessary. Medial epicanthoplasty is discussed in Treatment, but a small median epicanthus is also an ethnic trait, and complete removal in all instances can markedly change the appearance of the individual. Clearly discuss this preoperatively and plan the degree of correction if necessary.

Presentation

The best approach is to begin with a large area and then narrow to specifics. The following format may be followed:

• When a patient reports a tired look and desires correction of the upper eyelid, confirm the problem and that its correction will lead to a happy patient. Other than in cosmetic surgery, a patient diagnosing the problem and telling the physician which correction is required is unusual. Asking the patient to disclose what bothers him or her about his or her appearance and then diagnosing the cause and discussing appropriate correction(s) is best. Few patients request an appendectomy; rather, they present with abdominal pain, nausea, and progressive symptomatology. The physician must diagnose the problem. Similarly, many patients present with heavy upper eyelids. The physician must diagnose if the true problem is brow ptosis, ptosis, lacrimal gland ptosis, blepharochalasis, or another problem.
• Directly check the position and fixation of the brow. Is a component of ptosis leading to the upper eyelid heaviness? Are crow's feet present that will not be corrected with upper eyelid blepharoplasty but are a major concern to the patient? Proper brow position varies in individuals and by gender. Discuss this with the patient. Diagnose exophthalmos if present and perform exophthalmometry if necessary. Exclude systemic causes. Surmise the symmetry and shapes of the bony orbit and incorporate them into the facial gestalt.
• Once the diagnosis has been narrowed to an upper eyelid problem, an anatomic evaluation is suggested.
  • Skin of the upper eyelid: Is it texturally in need of improvement? Is much epidermal etching present, or is the dermis creased as well? Are growths or pigmentary changes present that need to be addressed? Has heavy brow skin encroached on the upper eyelid?
  • Support of the upper eyelid: Is the orbicularis muscle overactive or a tick present? Is the lid fold well defined along its length? Are the folds even for both eyes vertically, horizontally, and in depth? Do the eyes close evenly both gently and forcefully?
  • Ascertain the presence of preaponeurotic or septal fat ptosis. Is fullness present throughout the upper eyelid or proximally? Is excess fat present in the medial or lateral fat compartment? If so, how much?
  • The upper eyelid should occlude only 1-2 mm of the iris. Is ptosis present? Is the eye opening evenly on both sides? Is lid retraction present? If ptosis is present, are anhydrosis and meiosis present as well?

The discussion of secondary problems, although common, is complex and vast and is not included in this article. The associated procedures of corrugator supercilii excision, procerus excision, and lateral epicanthoplasty and/or epicanthopexy are considered beyond the discussion of upper eyelid problems.

Indications

The primary indication for upper eyelid blepharoplasty is the patient's desire to improve his or her appearance. In rare instances, upper eyelid skin occludes peripheral vision, and some insurance carriers are willing to contribute to operative costs to improve the condition after visual field examination and mapping are performed. Rarely, a component of brow ptosis is absent in these patients.

The indications for upper eyelid procedures in the Asian patient merit further discussion. The intent of the procedure is to create a more beautiful Asian eye, not to create a Caucasian-appearing eye. The author has had parents bring in 5-year-old children for the procedure, and, although he declined to perform the procedure, the author believes individual practitioners should decide whether they consider this a congenital defect or a cosmetic variance.

Relevant Anatomy

A discussion of anatomy is important. The change in how this procedure is performed was caused largely by a better understanding of anatomy through the dissection of fresh versus preserved cadavers. Understanding the 4 layers that contribute to the fascial framework of the upper eyelid is imperative.

The first, the orbicularis (superficial) fascia, is immediately beneath the skin and orbicularis muscle. The orbicularis muscle acts as the sphincter for the palpebral fissure. It must slide over the orbital septum. This fascia is elastic, and grasping it at surgery actually can lower the brow and lower forehead.

Just deep to this is the inelastic orbital septum. This second layer is the deep fascia of the upper lid and acts to retain the orbital fat. It is continuous with the periosteum of the orbit. It joins with the levator aponeurosis to form a sling for the orbital fat.

The third layer is the levator aponeurosis, which is deep to the fat pad. Some patients have varying amounts of fat in each layer; use the fascia in anatomic place finding. The main function of the levator is to elevate the lid, but it has attachments to each layer of the lid and a direct connection to the pretarsal (conjoined fascia), which is the last layer. This layer is spread thinly on the face of the tarsus and is the attachment for both the orbicularis muscle and the levator palpebra muscle. Thus the orbital septal fascia and the levator aponeurosis join in a conjoined fascia a variable distance from the tarsus.

A number of anatomic differences exist between an Asian patient's upper eyelid, which does not have a fold, and a Caucasian patient's upper eyelid. The levator aponeurosis/conjoined fascia extensions to the skin tend to be weak or nonexistent. The preaponeurotic fat pad tends to be thicker. Trichiasis often is present because of the constant downward force on the eyelashes from the overhanging upper eyelid skin. The skin also can be thicker, occasionally because the patient used tiny pieces of tape to form a fold and constantly irritated the skin.

Contraindications

No contraindications exist to a properly conceived and performed upper eyelid blepharoplasty in the typical patient. Approach lagophthalmos with caution, since no skin should be resected, but other corrections can be performed with the procedure. Multiply operated upper lids can present a formidable challenge to those inexperienced with the changing anatomy from previous surgery. The patient's attitude and expectations must be appropriate and reasonable. The patient's general health is always a consideration, but the procedure is minimally invasive, and, when performed alone, it can be performed readily with local anesthetic unaugmented by sedatives.

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