Upper Lid Blepharoplasty Treatment & Management

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

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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

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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.

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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.

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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.

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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]

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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.
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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.

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