Upper Eyelid Blepharoplasty Treatment & Management
- Author: Eric M Hink, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
No common medical treatments are suggested to correct the excess skin and fat of the upper eyelid. In patients with severe functional deficits in visual fields or contraindications to elective surgery, spectacles with a ptosis crutch or taping up of the dermatochalasis may provide some temporary and inconvenient improvement.
Traditional blepharoplasty is performed with an external incision in the upper eyelid crease. In conjunction with upper lid blepharoplasty, the brow position is corrected through direct and indirect elevation techniques. Numerous techniques may be used to address brow ptosis, including a direct incision, brow pexy, endoscopic forehead brow lift, pretrichial brow lift, and coronal incision. A full description of these surgical techniques is beyond the scope of this article. Additionally, internal or external ptosis repair, canthoplasty, and lower eyelid blepharoplasty may be performed concurrently. Laser resurfacing is frequently used to correct aging changes of the skin in the periorbital region. The effect of laser resurfacing on the epidermis and dermis is to smooth the skin by resurfacing the epidermis and stimulating the rearrangement of collagen in the dermis.
Preoperatively, surgical landmarks and planned skin excisions are marked on the patient. Many techniques are used for marking the upper eyelid incisions, but some basic principles should be followed to minimize complications and to achieve reproducible results. With the patient in an upright position, the surgeon uses a fine marking pen to draw the incision lines on the surface of the eyelid skin. The lid crease incision is marked first, generally following the eyelid crease in the upper lid. If alteration in the natural position of the crease is desired, the incision may be placed at the desired location of the postoperative crease rather than the natural eyelid crease.
The natural crease is typically located 8-11 mm above the eyelid margin in females and 6-9 mm in males. The eyelid crease is curvilinear in white patients. The arc of the incision peaks just nasal to the central point of the eyelid. Nasally, the incision should be limited by a line drawn upward from the medial commissure, avoiding the deep concavity of the medial canthal region. The temporal aspect of the lid crease incision is curved gently upward, extending toward but generally not beyond the orbital rim.
To assess the amount of skin to be removed, the surgeon may use the pinch technique. The patient is asked to gently close the eyelids. A smooth forceps is used to grasp the excess skin above the eyelid crease incision just until the eyelashes begin to rotate upward. This is marked as the maximum amount of skin that may be safely removed.
For a clear margin of safety, the superior border of the incision should pass no closer than 1 cm from the inferior border of the brow hairs. This prevents excess skin removal that may cause lagophthalmos and also prevents the blepharoplasty excision from causing downward traction on the brow position. The appearance of the incision may also be less than optimal if the upper incision is made too close to the brow hair. This would be the case when a patient with brow ptosis undergoes an upper eyelid blepharoplasty without lifting the brow. The thickness of the skin increases as it nears the brow and forehead. Creating a junction between the thin eyelid skin and the thicker brow skin results in uneven closure. Carrying the incision too far medially may result in cicatricial band formation or a medial web. Lateral extension of the incision beyond the orbital rim also results in a more prominent and visible scar.
Once the skin has been marked with the patient in an upright position, the surgeon gently presses on the globe to observe protrusion of the fat pockets. Protrusion or prolapse of the lacrimal glands is noted, and when present, resuspension of the lacrimal glands is considered. The location and amount of sub-brow fat is assessed and considered for surgical contouring. This is especially relevant in the absence of a brow lift procedure.
Both topical and local anesthesia is used during upper lid blepharoplasty surgery. A topical anesthetic such as tetracaine may be used for conjunctival anesthesia if a protective shield is used.
Local infiltration provides sufficient blockage of pain sensation for isolated upper lid blepharoplasty. Lidocaine (Xylocaine 0.5-2%) is the most frequently used agent for infiltrative anesthesia because it diffuses well through tissue and produces little irritation. When it is used without epinephrine, the effects last about 30 minutes.
When the anesthetic agent is mixed with epinephrine, this causes vasoconstriction and prolongs the duration of analgesia to 60-90 minutes and decreases the rate of absorption. The epinephrine is also beneficial for intraoperative hemostasis. In order to decrease the discomfort associated with infiltration, sodium bicarbonate may be used as an additive agent to modify the pH of the solution. This results in less chemical irritation and pain with the local anesthetic injection but significantly decreases the effective duration.
For local infiltration in upper lid blepharoplasty, 1-2 mL of anesthetic is placed subcutaneously at the surgical site. The surgeon should use enough agent for anesthesia and hemostasis but no more than necessary because the volume of the local anesthetic disrupts the surgeon's ability to assess the contours of the tissues. When the eyelid or sub-brow fat pads are to be contoured during the procedure, additional local anesthetic is injected into the fat pads when these planes are surgically exposed. The initial subcutaneous injections do not adequately diffuse through the orbital septum to anesthetize the fat.
Anesthesia for upper lid blepharoplasty may be augmented with the adjunctive use of regional anesthesia (peripheral nerve block) and systemic sedation. Injection of local anesthetic near a peripheral nerve produces anesthesia over the distribution of the nerve. A peripheral nerve block is used for facial surgery to block the trigeminal nerve branches. In the case of upper lid blepharoplasty, a frontal or supraorbital nerve block may be used. Additional anesthetic may be necessary to locally block the lateral portion of the lid that may be partially innervated by the zygomaticotemporal branch of the maxillary nerve. Regional nerve block is rarely necessary for cosmetic blepharoplasty.
Systemic sedation may also be administered to augment the effect of the local anesthetic. Oral premedication may be used to reduce the patient's anxiety. Diazepam (Valium), at a dose of 5-10 mg orally, is the most common premedication used. Intravenous sedation may also be administered for induction and maintenance of anesthesia during the surgery. The most frequently used agents include midazolam, meperidine, fentanyl, and propofol. Standard protocol for monitoring of sedation anesthesia should be strictly used. The objectives of the intravenous sedative agents are to diminish the discomfort produced from local anesthetic injection, decrease patient anxiety, and augment intraoperative and postoperative analgesia. Amnesia may be considered an additional advantage of these agents.
After injection of the anesthetic agent, adequate time (7-10 min) is allowed for the epinephrine to cause vasoconstriction. If the surgeon desires, a protective scleral shell may be placed over the surface of the eye after placement of topical anesthetic. Most commonly, a No. 15 or other suitable blade is used for initial incision of the skin. The procedures described in these paragraphs involve traditional plastic surgical instruments, but other devices such as laser or radio frequency surgical instruments may be used in place of surgical steel. The excess skin is removed, either alone or with part or all of the underlying orbicularis muscle.
If only skin has been removed, the fibers of the orbicularis oculi muscle are clearly visible. If removal of the orbicularis is desired, Westcott scissors or monopolar cautery can be used to resect a strip of muscle. From the preoperative evaluation, if the surgeon has determined that the patient needs removal of eyelid skin, sub-brow fat, reconstruction of the eyelid crease, eyelid ptosis correction, brow ptosis correction, modification of the glabellar wrinkles, or resuspension of the lacrimal gland, any one or all of these procedures may be performed through this lid crease incision.
After incision of the orbicularis muscle, the surgeon identifies the orbital septum. The safest approach to the orbital septum is just below its attachment to the arcus marginalis, where the underlying levator muscle with its aponeurosis is not as likely to be injured if the septal resection is aggressive. When fat is to be removed, the orbital septum is opened to expose the preaponeurotic fat. In the upper eyelid, 2 fat pockets are present; one is central and the other is nasal (medial). When gentle pressure is placed on the globe, the fat tends to protrude through the open septum. The medial fat pad has a creamy yellow, almost white, color that is recognizable and distinct from the deeper yellow color of the central fat pad. The medial fat pad can be located just medial to the medial border of the levator expansion.
Additional local anesthetic is placed beneath the capsules of the orbital fat. The capsules are opened and the pads are trimmed to create the desired contour of the eyelid. Excess fat resection can result in a superior sulcus or "A-frame" deformity and should be avoided.
Hemostasis is a vital step in fat removal. This can be accomplished with clamping or careful cautery as the structures are cut or removed. In one technique, a small hemostat may be used to grip the excess fat that will be removed. The fat anterior to the clamp is removed using a No. 15 blade, and bipolar cautery is used for hemostasis prior to release of the clamp. Once the hemostat has been removed, the base of the fat pedicle tends to retract. The surgeon may grasp the fat pedicle with a forceps to fix the tissue while checking for hemostasis. Alternately, the base of the fat pad can be bipolar coagulated without clamping the fat if careful attention is given to complete cautery of the stump. The surgeon watches carefully for signs of bleeding that could lead to orbital hemorrhage. These are controlled prior to release of the pedicle.
The fat is kept and labeled according to eyelid and location so the surgeon can compare the amount of tissue removed from the 2 eyelids. Sometimes, fat is repositioned rather than removed to smooth the contour of the lid fold. This should be considered in thin elderly patients with fat atrophy and a deep superior sulcus but a protruding nasal fat pad.
If the lacrimal gland is found to be protruding from its usual lateral position under the orbital rim, simply suturing it back in position inside the orbital rim prevents postoperative fullness in the lateral aspect of the upper eyelid. This can be accomplished with an absorbable 5-0 suture such as polyglactin.
When the surgeon wishes to alter or emphasize the eyelid crease, a supratarsal fixation suturing technique is used to create adherence between the skin and underlying tissue. This may be accomplished by attaching the subcutaneous tissue at the lower aspect of the eyelid crease incision to the levator aponeurosis just above the tarsus. A longer-acting absorbable suture such as 6-0 polyglactin would be appropriate. Another technique that may be used is a full-thickness mattress suture through skin, orbicularis oculi, levator aponeurosis, and conjunctiva and then back out through conjunctiva, levator aponeurosis, orbicularis oculi, and the skin on the opposite side of the incision.
A more rapidly absorbable suture such as 6-0 chromic gut should be used, and the corneal surface must be monitored when full-thickness eyelid crease reformation techniques are used. The crease reformation may also be incorporated into the skin closure by constantly or intermittently imbricating the levator aponeurosis between the passes that approximate the upper and lower skin edges. Permanent or absorbable sutures may be used for this type of lid crease reformation.
Different techniques of skin closure exist, and different materials may be used to create adherence of the incised skin edges. Commonly used materials include nonabsorbable sutures, such as 6-0 nylon or 6-0 polypropylene, in a running subcuticular fashion, interrupted fashion, or in an external running fashion. Another material frequently used is 6-0 fast-absorbing gut suture. The absorbable suture eliminates the discomfort of suture removal. Suture materials such as 6-0 polyglactin or 6-0 black silk have also been used for continuous closure of the skin incisions. All sutures are removed in 5–7 days. Tissue adhesives (glue) have been described as a closure technique for upper eyelid blepharoplasty incisions.
A randomized, controlled trial by Pool et al indicated that in patients undergoing upper eyelid blepharoplasty, starting the medial intradermal suture internally (within the blepharoplasty wound) rather than externally (in intact skin next to the wound) reduces the risk of medial suture abscess and wound inflammation. The investigators found that at 1-week follow-up, the incidence of medial upper eyelid abscesses was 13.3% for the internally sutured eyelids, compared with 40% for the externally sutured eyelids, with erythema and edema also being significantly less frequent in the internally sutured lids.
Immediately after the surgery, an antibiotic ophthalmic ointment is placed over the skin incision. Ice compresses are used for 48 hours, 20 minutes per hour while awake, following the procedure. The skin is cleaned daily, and antibiotic ointment is applied to the incision before bed for 5 days. Some edema and ecchymosis are normal after this procedure, and the cold compresses help to minimize this and diminish patient discomfort. Acetaminophen is routinely prescribed, and, in some cases, a narcotic pain medication prescription may be given. The patients are asked to avoid heavy lifting, sudden bending, and strenuous sporting activities for 2 weeks following the procedure. Showering is permitted the day following the procedure. Normal activities may resume after 2-3 weeks.
Patients are seen the following day after upper eyelid blepharoplasty to evaluate the swelling and ascertain that the eye is soft without any evidence of bleeding. The incisions are examined, and the patient is shown how to care for the wounds. Patients are instructed to keep the incisions clean and dry by gently going over the incision line with a cotton tip applicator soaked with a dilute hydrogen peroxide solution. At that time, any additional questions or concerns are addressed. Patients are then seen 5-7 days after the operation to remove the sutures.
Patients may have the misconception that cosmetic blepharoplasty is a quick, simple, and complication-free procedure. With proper planning, adequate physician skill, and good patient selection, this may be the case. However, unsatisfactory results and unexpected complications still occur.
Bleeding and infection are uncommon serious complications. To help avoid eyelid hematoma and visual loss secondary to retrobulbar hemorrhage, control hypertension and discontinue use of medications that predispose to bleeding. The use of careful and diligent hemostasis at the time of the surgery is of the utmost importance. Retro-orbital hemorrhage and visual loss are, fortunately, uncommon complications. The reported incidence of blindness after blepharoplasty is 1 per 40,000 patients. Retro-orbital hemorrhage is most common after lower eyelid blepharoplasty.
Bleeding in the retro-orbital space may cause an acute compartment syndrome that requires urgent action. Skin sutures are removed, the hematoma is evacuated, and, if active bleeding is present, the wound is re-explored to find the source of the hemorrhage. If these procedures do not resolve the compartment syndrome, a lateral canthotomy and cantholysis may be performed. Intravenous mannitol and steroids can be used to decrease the intraocular pressure secondary to exophthalmos and vascular congestion. In unusual circumstances, orbital decompression may be required to decrease the orbital pressure.
Eyelid infections following blepharoplasty are very rare because of the rich vascularity of the upper eyelids. However, when they do occur, prompt attention and treatment with appropriate antibiotics is undertaken. The wound is opened, drained, and cultured, and any necrotic tissue is débrided.
Severe pain is not expected after upper eyelid blepharoplasty. A mild analgesic without aspirin is usually adequate to control postoperative discomfort. If uncontrollable pain is present following blepharoplasty, an examination is urgently performed to evaluate for the source of the pain.
Excess skin removal or inappropriately placed skin incisions may cause problems. Extension of the incision over the medial canthal angle may result in band formation or webbing. Extension of the incision past the lateral orbital rim may also result in a visible scar or folds. Excessive skin removal from the upper lid may result in lagophthalmos with exposure keratitis, ectropion of the upper lid, or downward traction of the brow position that exacerbates brow ptosis. This complication can be avoided with meticulous preoperative measurement of the amount of skin to be removed. Mild lagophthalmos may occur in the immediate postoperative period, which is treated with lubricant eye drops and ointment.
Severe lagophthalmos may result from excess skin resection, scarring of the orbital septum to the skin, excess levator advancement, or unusual scar contraction. A second operation may be required to release the adherence of the septum on scar tissue or to place a skin graft to repair the anterior lamellar shortening in the upper eyelid.
Blepharoptosis is an uncommon complication that may occur secondary to inadvertent levator injury during the procedure. Observation and repair of the levator aponeurosis is required if the ptosis persists longer than 6 months. Transitory mechanical ptosis is sometimes found secondary to eyelid edema or hematoma.
Extraocular muscle imbalance (diplopia) may result from inadvertent damage to the superior oblique muscle during the excision of medial fat pad. Cautery and tissue removal in the medial supraorbital quadrant may result in injury to the superior oblique tendon.
Hollowing of the soft tissue above the lid crease or a deep superior sulcus results from excessive fat removal in the upper eyelid. Residual excess skin or fat is another problem that may cause asymmetry or folds in the eyelids and, thus, an unhappy patient. Asymmetry of eyelid creases is occasionally the result of poor preoperative planning or a less-than-gratifying response to the surgeon's attempt to alter the crease position. In patients with a preexisting unilateral ptosis, the asymmetry may appear more prominent following removal of the overlying skin folds.
Outcome and Prognosis
Upper lid blepharoplasty results in improvement of the natural aging changes. The main indication for functional upper lid blepharoplasty is correction of the excess skin of the upper eyelid, thereby resulting in visual field improvement. The indication for cosmetic upper lid blepharoplasty is to improve appearance, as shown below.
No reports describe long-term follow-up of patients after upper lid blepharoplasty. The prognosis in this surgery depends on many factors: sex and age of the patient at the moment of the surgery, race, underlying medical conditions, brow structure, type of skin, and previous skin damage by the sun.
Dissatisfaction after upper lid blepharoplasty may be related to unrealistic surgical expectations by the patient. The patient's motivations and expectations are important points to discuss in depth during the preoperative consultation. Patients who expect positive alterations in their personal lives after surgery are poor candidates for cosmetic blepharoplasty. Aging changes such as redundant skin around the eyes and fat herniation may be improved with surgery; however, dynamic wrinkles around the eyes (particularly crow's feet) are not corrected with blepharoplasty. Patient goals should be established before the surgery is performed.
Future and Controversies
New technology alters and refines the techniques but not the indications for upper eyelid blepharoplasty. Laser resurfacing of the eyelids, as well as incisional laser surgery, is becoming increasingly popular. Botulinum toxin type A may be used as an adjuvant to blepharoplasty to treat the lateral canthal wrinkles or to modify brow position. Prevention is less expensive than treatment, and increased consciousness of health issues may contribute to cessation of smoking and protection from ultraviolet light.
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