Upper Lid Blepharoplasty 

Updated: Sep 19, 2018
Author: Bhupendra C K Patel, MD, FRCS; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

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.[1, 2] See the image below.

Preoperative view of patient who underwent previou Preoperative view of patient who underwent previous brow lift and laser resurfacing of the entire face. The patient did not like the upper eyelid overhang and desired well-defined folds without exaggeration.

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,[3, 4] but Fernandez created the dynamic upper eyelid fold procedure largely used today.[5] Extension of this procedure into the invagination or anchor blepharoplasty was largely the work of Flowers.[6]

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.[7]

Problem

Upper eyelid blepharoplasty is the surgical approach to addressing dermachalasis (also known as dermatochalasis) of the upper eyelid. Dermachalasis represents redundant, loose skin of the upper eyelid that occurs with aging.

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 Medscape Reference text on brow lift (Periorbital Rejuvenation Brow Lift) 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.

Epidemiology

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

The etiology of upper eyelid deformity is related intimately to the anatomy of the area (for more information, see Eyelid Anatomy ). Weakening of connective tissues, loss of skin elasticity, and the effects of gravity over time all contribute to the development of dermachalasis. Loss or lowering of the palpebral crease is caused by failure of the skin-adhering bands of the levator aponeurosis to cause folding of the skin. The conjoined tendon from the orbital septum and levator inserts bands into the skin, which results in the upper eyelid fold. This is a dynamic fold that is not present in the closed eye. In the Asian patient born without a fold, these attachments are not present or are weak, allowing preaponeurotic fat to fall beneath the skin, leading to the observed fullness. This also occurs in individuals with septal fat ptosis. The correction of both of these conditions involves creating a direct, dynamic connection between the conjoined tendon and the upper eyelid skin—the anchor blepharoplasty.

Steatoblepharon is also frequently seen in association with dermachalasis, representing herniated orbital fat visible beneath the eyelid skin secondary to weakening of the orbital septum. 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.

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.

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.[8] 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.

 

Presentation

History

Patients may report a decrease in peripheral vision, most commonly associated with temporal hooding from redundant skin in the superotemporal visual field. Weight from excessive upper eyelid skin may mechanically depress the eyelashes, resulting in lash ptosis, which may interfere with visual acuity. Patients may also report frontal headaches or brow ache secondary to chronic attempts to elevate the brow to combat the redundant upper eyelid skin from interfering with the visual field.

Physical Examination

A thorough eyelid examination is essential in the patient presenting with upper eyelid dermachalasis, with the patient evaluated for the following:

  • Quantity and quality and symmetry of the upper eyelid skin
  • Lid crease position
  • Eyelid margin height (to look for concomitant blepharoptosis)
  • Amount of orbital fat prolapse
  • Lagophthalmos and amount of skin from lid margin to inferior border of brow hairs
  • Bell phenomenon (both forceful and gentle lid closure)
  • Lacrimal gland prolapse (may be addressed at time of surgery)
  • Brow height and effect of mechanical brow lifting on amount of dermachalasis
  • Strength of orbicularis

A preoperative ophthalmic examination with assessment of visual acuity, pupillary response, and assessment of the ocular surface for preexisting dry eye conditions is recommended.

Patients typically present with a heaviness of the upper eyelids and may report drooping of the eyelids. In many cases, once this skin is manually elevated, the true height of the eyelid margin can be seen and reveals a normal position. If the lid height is indeed low, then blepharoptosis may also need to be addressed at the time of surgery. The aging upper eyelid, with crepe paper skin, ptotic fat, or both, is well known. The diagnosis of each component problem and the proper correction are sought from the competent cosmetic surgeon.

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.[9]

Once the diagnosis has been narrowed to an upper eyelid problem, an anatomic evaluation, as follows, 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 is 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.

 

DDx

Differential Diagnoses

 

Workup

Laboratory Studies

No preoperative laboratory tests are required in the typical patient. A template bleeding time may be useful in patients with suggested anticoagulant use (eg, prescriptive, over-the-counter, herbal).

Imaging Studies

No imaging studies are necessary unless bony orbital irregularities are suggested.

Other Tests

See the list below:

  • Vision screening

  • Visual fields

  • Schirmer test

 

Treatment

Surgical Therapy

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. Recent advances in the understanding of anatomy, histopathology, and the process of aging have led to changes in surgical techniques.

A dramatic change has occurred over the past few years in the performance of upper eyelid blepharoplasties. Unlike the major skin and fat resections that many plastic surgeons were taught, conservative skin resection with adequate but not skeletonizing fat resection and the production of a well-defined and deep upper eyelid fold are the ideal results of surgery. Anatomic knowledge has largely fueled this change, as have unsatisfactory results from simple skin and fat resection over the years. The anchor or fold blepharoplasty yields a much more predictable and cleaner palpebral fold than standard previous techniques.[10]

For the Asian double-eyelid procedure, basically 3 operations are possible. The first involves simple suture techniques that pass through the conjunctiva and cause stitch adherence between the deep dermis and the fascial network. The disadvantages of this procedure are the ease with which the stitches detach, its nonpermanent nature, and the resulting static fold. Its advantage is that it is nonincisional.[11, 8]

The tarsus fixation method, although more permanent and predictable, also has the disadvantage of producing a static fold, which is present in the closed eyelid.

The levator aponeurosis method, which has changed into the invagination or anchor method of fixation, produces a dynamic fold with natural and predictable adherence between the levator aponeurosis and the deep dermis. This is the preferred method of upper eyelid blepharoplasty and is described in detail. Simple upper eyelid blepharoplasty also is discussed.

A study by Jeon et al indicated that sunken upper eyelids can be corrected during upper eyelid blepharoplasty by anchoring the central fat pad to the medial fat pad. The investigators reported that 51 of 54 patients in the study had effective correction of sunken upper eyelids, with the surgery having little effect on three patients owing to the fact that they had undergone preaponeurotic fat pad removal during previous upper lid blepharoplasty.[12]

A randomized, doubled-blind study by Pool et al indicated that prior to upper eyelid blepharoplasty, injection of the upper eyelids with lidocaine with epinephrine is significantly less painful than injection with prilocaine with felypressin. The study, which included 40 patients, also found that compared with prilocaine, lidocaine was associated with less postoperative edema, erythema, and hematoma.[13]

Preoperative Details

Stemming from the preoperative assessment, discussed in Presentation, is the preoperative plan (as follows), which should include what the surgical procedure addresses and in what amount:

  • Preoperative photographs should be taken for comparison purposes and to help illustrate asymmetry that exists in every patient; this aids in managing patient expectations
  • Plan the exact height of the upper eyelid fold, the amount of skin to be resected, and the amount of fat from each compartment

  • Assess the lacrimal gland position along with the need for resuspension

  • Assess the need for ptosis correction and plan for levator aponeurosis shortening, if necessary

  • Tarsal height can be assessed readily by inverting the upper lid completely and measuring the height; the tarsus is 1-2 mm shorter than this because of the thickness of the conjunctiva and lash presence when this is performed

  • The author prefers to make a written diagrammatic plan prior to the procedure and have the plan and preoperative photographs available during surgery

  • Prepping and draping are standard

  • Pinpoint electrocautery should be available; a vascular plexus at the superior edge of the tarsus often needs cautery at that depth

Intraoperative Details

The procedure described is used with minor alterations for invagination (anchor) blepharoplasty and for the formation of palpebral folds in patients with low or nonexistent folds.

  • Begin the procedure with demarcation on the skin of the desired conservative skin resection with the patient in both upright and supine postures. More skin is necessary in the upper lid for invagination than in classic blepharoplasty, since the skin is not draped straight over the lid upon opening but folds as the skin normally folds back into the lid upon opening. Patients with asymmetry of the upper lid crease may benefit from manipulation of the eyelid incision and crease formation.

  • Place the fold at the midpoint of the skin resection, which is curvilinear with slight flaring laterally or, in some patients, a simple overturned "U." If a fold already exists and its position is optimal but skin is still in excess, resecting from above the position of the fold is best to avoid disrupting the normal skin attachments and still have the fold fall within the depth of the palpebral fissure.

  • Infiltrate local anesthetic evenly throughout the upper eyelid.

  • Excise the skin and achieve hemostasis with pinpoint electrocautery. This procedure and subsequent deep tissue manipulations and resections can be performed by laser, although, in the author's experience, the skin heals slightly faster if at least that resection is performed by scalpel.

  • Resect a sliver of orbicularis oculi muscle to reveal the preaponeurotic fat. Resect this according to the preoperative plan with careful hemostasis of the base. A laser is useful in this process.[14]

  • Additionally, after the amount of fat to be resected has been delineated and freed, a small amount of local anesthetic injected into its base allows for pain-free removal.

  • At this point, simple standard blepharoplasty deviates from the anchor procedure. In the simple procedure, the preaponeurotic fat is resected as desired, followed by entry into the orbital septum either in defined pinpoint fashion or by opening it along its length. The desired amount of orbital fat is resected, followed by reapproximation of the septal fascia. The skin then is reapproximated, and the procedure is complete. No dissection occurs down to the conjoined fascia; therefore, little danger exists of damage to the levator mechanism.

  • In the anchor procedure, the dissection is continued down to the conjoined fascia or orbital septum (depending on height above the tarsus).

  • Enter the septum either partially or along its length depending on the exposure required for the necessary levator work.

  • Describing ptosis correction is outside the scope of this article. For purposes of this discussion, make partial openings into the orbital septum and resect the predetermined amount of fat.

  • Place 6-0 Vicryl sutures through the levator aponeurosis/conjoined tendon and into the deep dermis of the upper (cephalic) eyelid skin flap.

  • Ask the patient to open and close the eyes. Ascertain folding and symmetry after the procedure has been performed on the opposite side.

  • A vascular arcade is present at the base of the tarsus; attain careful hemostasis if this plane is entered.

  • The eye may not open completely because of swelling and, occasionally, irritation by blood from the Müller muscle. Once this has resolved, complete eye opening is apparent.

  • Complete the procedure by suturing the inferior skin flap to the superior flap with 6-0 fast-absorbing or nylon sutures.

  • Apply triple antibiotic ointment and cool packs in the recovery area for approximately 1 hour. Ophthalmic formulations of medications are preferred.

  • The medial epicanthoplasty or lateral canthopexy and/or canthoplasty procedure is generally performed prior to the upper eyelid procedure in operative sequence. If the upper eyelid requires textural skin rejuvenation, laser resurfacing or laser nonresurfacing rejuvenation can be performed at this or a later time.

Postoperative Details

See the list below:

  • The amount of swelling varies among individuals. Little or no bruising should occur.

  • For the first 24 hours, apply intermittent cold packs, followed by nothing for 24 hours and warm packs for the following 24 hours.

  • Ophthalmic antibiotic ointment is applied to the incision sites three times daily for approximately 1 week.

  • Approximately 90% of the swelling resolves in 4-5 days.

  • Perform visual checks postoperatively. If the patient reports a "scratchy" feeling in the eye or true pain, seek a corneal abrasion using fluorescein. Seek ophthalmologic consultation as appropriate.

  • Remove sutures (or they should dissolve) in 3-5 days.

Follow-up

Arrange follow-up visits for the day following the procedure, 2-3 days later for suture removal, 1 week after suture removal, and again after 1 month. Correct release or unevenness of the upper eyelid fold no sooner than 3 months postsurgery, since scar contracture can cause changes in the upper lid during that time. The upper eyelid structures are incredibly fine and unique in composition and interaction. Multiple upper eyelid procedures are discouraged.

Complications

The most severe complication of periorbital surgery is blindness. This generally occurs after retrobulbar bleeding and subsequent compression of the optic nerve with loss of vascular supply. If excessive bleeding is encountered, locate and stop it prior to closure. If increased pressure and bleeding are found in the postoperative period, perform sequential and rapid decompression with release of all sutures (especially deep sutures in this procedure) and vigorously apply measures to control blood pressure and swelling.

If corneal abrasions are frequent, a scleral shield may be used during the procedure as desired by the practitioner. Should this occur, soothing ointment and occlusion for a few days is the best remedy.

The most common complications involve uneven folds, inappropriately high or low folds, or multiple folds. These are basically correctable by reoperation. Most irregularities can be corrected within reason and with consideration of the number of previous procedures and their extent as an indication of intralid scarring. If a portion of the upper eyelid fold releases and a fold is no longer apparent, taking down the entire lid and repeating the procedure is not necessary. The section can be reopened and dissection carried down to the levator followed by dermis-to-aponeurosis sutures and closure. When simple blepharoplasty is performed, little danger of damage to these deeper structures exists.

Postoperative lagophthalmos may occur if during blepharoplasty the surgeon has removed an excessive amount of skin, resulting in an anterior lamellar shortage. This may especially occur if less than 20 mm of anterior lamella remain between the lid margin and the inferior border of the brow hairs. Small amounts of lagophthalmos may be tolerable to patients and may be managed with gentle lid massage, ocular surface lubricants, and possibly punctal plugs. Significant lagophthalmos may result in exposure keratopathy, corneal ulceration, and potentially corneal perforation, which is an ocular emergency; these complications must be recognized early and managed by an ophthalmologist.

Closely monitor postoperative ptosis. If it does not resolve within 3 months, perform correction. Alteration of levator function with the procedure is rare, and reanastomosis of the aponeurosis should yield a good result. Similarly, lagophthalmos is rare, since skin resection is minimal. In performing this procedure without the noted complications, take advantage of the ability of the patient and surgeon to assess function on the operating table.

Other complications such as infection, stitch abscess, Vicryl extrusion, and excessive bleeding are rare; address these complications in the normal manner.

A retrospective study by Saalabian et al found that in patients undergoing upper lid blepharoplasty, the presence of two medical preconditions and/or risk factors was associated with a significantly increased complication rate. Preconditions and risk factors considered included diabetes mellitus, arterial hypertension, oral anticoagulation and platelet aggregation inhibition treatment, nicotine use, chemotherapy, immune suppression, anti-estrogen therapy, and coagulation disorders. The investigators also reported that neither patient satisfaction with the procedure nor the complication rate was related to the amount of tissue resection, ie, whether the resection involved skin, skin/muscle, skin/muscle/fat, or skin/fat.[15]

Outcome and Prognosis

The predictable outcome and lack of loss of precious upper eyelid skin by using this and modified procedures have resulted in replacement of standard upper eyelid blepharoplasty over the last few years. Attributes of the procedure include the predictable nature of the fold and its longevity. To perform the procedure, an intimate knowledge of the anatomy of the upper eyelid is necessary.

Reaccumulation of upper eyelid skin over the years following the procedure should be thought of as normal aging. Consider brow ptosis, since that is the most frequent cause, and consider brow fixation or elevation if it has not been performed. See the images below.

Preoperative view of patient who underwent previou Preoperative view of patient who underwent previous brow lift and laser resurfacing of the entire face. The patient did not like the upper eyelid overhang and desired well-defined folds without exaggeration.
Postoperative view after anchor blepharoplasty of Postoperative view after anchor blepharoplasty of the same eye. Note the remaining fullness of the lateral upper lid area, considered by many to be a sign of youth.
Preoperative view of the opposite eye in a patient Preoperative view of the opposite eye in a patient who underwent previous brow lift and laser resurfacing of the entire face. The patient did not like the upper eyelid overhang and desired well-defined folds without exaggeration.
Postoperative view in a patient who underwent prev Postoperative view in a patient who underwent previous brow lift and laser resurfacing of the entire face. The patient did not like the upper eyelid overhang and desired well-defined folds without exaggeration.

Future and Controversies

Little controversy surrounds this procedure, since it commonly is performed with good result. The creation of the upper eyelid fold by the same mechanism by which it forms is becoming the preferred way of creating a well-defined upper eyelid fold. Lasers may hasten the healing process after initial skin opening. The future may hold the ability to use a tool, laser or otherwise, that simultaneously cuts and cauterizes.

The main controversy at present is the ubiquitous need for canthopexy and/or the need for correction of epicanthal folds. At present, conservatism and good patient communication are the best courses of action.

The CO2 laser has been used with excellent results in a lid with an excellent lid fold and limited or no excess fat in which skin tightening only is needed. The long healing time from this procedure has prompted investigation into using fraxelated resurfacing techniques, though multiple treatments are required and limited tightening is observed.

Even more recently, radiofrequency tightening of the skin using monopolar (eg, Thermage [Thermage Inc, Hayward, Calif]) or bipolar (eg, Aluma [Lumenis Inc, Santa Clara, Calif], Lux IR [Palomar, Burlington, Mass]) heating of the skin of the upper eyelid has been shown to have good effect. To date, no peer-reviewed articles have been published on these techniques of skin tightening particularly relating to safety, efficacy, complication types, and complication rates.