Subciliary Approach Blepharoplasty

Eyelid changes occur with aging and are influenced by genetic factors. Initially, blepharoplasties were performed to correct acquired (ie, secondary to trauma or carcinoma) or congenital deformities, not for cosmetic purposes. However, once the physiologic changes of aging became better understood, new blepharoplastic techniques were developed for their correction.

Looking sleepy or tired because of physiologic changes is considered a sign of old age rather than a sign of maturity. To look young is fashionable. Furthermore, a younger-looking face is extremely useful in this competitive world in which the transmission of a good image is more important than ever before in the public, professional, social, and private environment. See the image below.

A: The lower eyelid has been cross-sectioned in order to appreciate the anatomy at this level. B: A magnified view of the cross-section is shown. Note the anatomic details at the level mentioned. From lateral to medial, the eyelid skin, the ciliary line, the orbicularis muscle, the gray line, the tarsal plate, the meibomian gland orifices, and the conjunctiva are visualized. C: Note the 2 fat compartments of the upper eyelid, the middle and the nasal. Note also the position of the lacrimal gland in the lateral aspect of the orbital area. Note the 3 fat compartments of the lower eyelid, the temporal, the middle, and the nasal. The largest compartment is the middle. D: Note the sphincteric structure of the orbicularis muscle and its portions, the orbital, preseptal, and pretarsal portions.

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A good analysis of eyelid changes, proper patient selection, and precise surgical technique results in a high level of satisfaction for both patient and surgeon. Therefore, blepharoplasty plays a role in dramatically diminishing the appearance of aging in contemporary society.

Classic blepharoplasty involves removal of the pseudoherniated fat pad that protrudes through a weakened orbital septum. This can be accomplished through the transcutaneous or transconjunctival route. The transcutaneous approach is still the most common approach used for lower eyelid blepharoplasty. The advantage of this approach is that it corrects excess skin and muscle laxity, and the disadvantage of this approach is a higher possibility of lower eyelid retraction. The advantage of the transconjunctival lower eyelid blepharoplasty is a lower possibility of lower eyelid retraction, and the disadvantage of transconjunctival lower eyelid blepharoplasty is an inability to correct excess skin and muscle laxity. ^[1]

In the second half of the 1990s, the blepharoplastic literature disseminated a new concept: the fat preservation technique. This technique redrapes and repositions the fat pad over the orbital rim in order to correct the groove over the nasojugal fold and the vertical fall of the anterior cheek. ^[2]

See the list below:

• Aulus Cornelius Celsus mentioned, for the first time, the excision of eyelid skin in the De Re Medica in 25-35 CE.

• Arabic surgeons, in the beginning of the 10th century, noted that the excess of upper eyelid skin impaired vision and designed ways to excise it.

• Von Graefe used the word "blepharoplasty" for the first time in 1818. He described it as a procedure used for repairing defects after excision of eyelid carcinomas.

• In 1830, several authors described imaginative techniques for cosmetic and reconstructive eyelid surgery. Famous surgeons during this time, such as Mackenzie, Graft, Dupuytren, and Alibert, described effective methods to excise excess upper eyelid skin.

• In 1844, Sichel described in full detail the condition of herniated orbital fat.

• In 1896, Fuchs first used the term "blepharochalasis."

• In 1908, Miller described multiple incisions to correct different eyelid deformities.

• In 1911, Kolle wrote about eyelids with wrinkles.

• In 1924, Bourguet described the transconjunctival approach for lower eyelid blepharoplasty.

• In 1925, Spaeth, in Newer Methods of Ophthalmic Plastic Surgery, explained eyelid reconstruction techniques.

• In 1929, Bourguet was the first author to promote fat removal for eyelid surgery.

• In the 1940s, fat removal was already part of the description of blepharoplasty in medical literature. May's work on fat removal in blepharoplasty was published in 1947, Padgett and Stephenson's work was published in 1948, and Spaeth's work was published in 1949.

• In 1951, Castañares published a full description of the different fat compartments in the orbit, their relationships to the eyelids, and the role of the orbicularis muscle.

• In the 1950s and 1960s, many authors (Castañares in 1964 and 1967, Converse in 1964, Gonzalez Ulloa in 1961, Rees in 1969, Lewis in 1969, Silver in 1969) created various blepharoplasty techniques that were differentiated only by small details.

• In the 1970s, blepharoplasty techniques were advanced to include resection of the hypertrophied orbicularis muscle (described by Loeb in 1977) and fixation and suspension of the lower lid (described by Furnas in 1978).

• In the 1980s, the transconjunctival approach for lower eyelid blepharoplasty became popular. This approach was practiced by a great number of blepharoplastic surgeons trying to avoid the lower eyelid retraction associated with the subciliary approach.

• In the 1990s, the new concept of fat sparing rather than fat removal was developed. This concept involved repositioning the fat pads. By using this technique, the vertical descent of the orbicularis muscle and the midface area could be suspended and elevated at the same time.

The eyelids are usually the first areas in the face to develop permanent, progressive changes due to aging and genetic inheritance. These changes are related to a decrease in the elasticity of skin and other orbital structures, such as the tarsus, orbicularis muscle, and orbital septum. These progressive anatomic changes create a baggy eyelid appearance. Refer to the Pathophysiology section for a full description of these changes. Blepharoplasty is designed to reverse the consequences of the aging and genetic inheritance process on the eyelid. Finally, taking into consideration that the eyes are only one aspect of the entire face, the aging process in the orbital areas that often accompanies other facial changes can influence eyelid appearance. These other areas may include the brow; the forehead; and cervifacial, periorbital, and submental areas.

Frequency

According to the 2020 Plastic Surgery Statistics Report from the American Society of Plastic Surgeons, an estimated 325,112 blepharoplasty procedures were performed in 2020, making it the second most common cosmetic surgical procedure that year (after rhinoplasty). The total included 279,306 operations on females and 45,806 surgeries on men. ^[3]

A 2021 member survey of the American Academy of Facial Plastic and Reconstructive Surgery, Inc. (AAFPRS) reported that blepharoplasty was one of the top three procedures performed on males, at 42% (following rhinoplasty and neurotoxin administration, at 79% and 58%, respectively). Moreover, a downward trend existed in the percentage of surgeons stating that more women than men undergo neurotoxin procedures and blepharoplasty. ^[4]

The terminology used in blepharoplastic literature to describe the changes in the eyelids due to the aging process is not very clear and can be confusing. Two examples are the words blepharochalasis and dermachalasis. Historically, the term blepharochalasis described young women with redundant eyelid skin folds involving recurrent episodes of swelling and edema. The term dermachalasis usually referred to a relaxation and redundancy of the eyelid skin and was associated with prolapsed orbital fat. On the other hand, the term baggy eyelid, used to describe the general appearance of the aging eyelid, is more general but less confusing. Therefore, understanding the particular changes that take place over time and which of these changes can be successfully corrected by blepharoplasty is more important than understanding the nuances of the terminology used.

Eyelid changes that can be corrected by lower eyelid blepharoplasty include (1) excess eyelid skin, (2) pseudoherniation of fat, and (3) hypertrophied orbicularis muscle.

Laxity or "senile" changes of the lower eyelid, if present, can be corrected by applying the appropriate technique (suspension or horizontal shortening) during the blepharoplasty procedure.

Inferior periorbital changes that can be improved with an adjunctive surgical vertical/midface lift (suborbicularis oculi fat lift) and/or a repositioning of orbital fat performed with the lower eyelid blepharoplasty include (1) infraorbital rim skeletonization and (2) a deep nasojugal depression/groove.

Eyelid changes that cannot be corrected by lower eyelid blepharoplasty are (1) eyelid edema, (2) hypothyroid changes, (3) prominent inferior orbital rims, (4) exophthalmos, and (5) cheek and malar bags.

Eyelid conditions in which correction by lower eyelid blepharoplasty is unpredictable include (1) fine wrinkles of the lower lids, (2) crow's feet (small wrinkles lateral to the lateral canthus), (3) changes in coloration of the eyelid, and (4) skin lesions (eg, telangiectasias, keratosis seborrheica, xanthelasmas, others).

The factors responsible for the eyelid, orbital, and periorbital changes are (1) a decrease in the elastic properties of the cutaneous eyelid tissue, tarsus, orbital muscle, and orbital septum; (2) a decrease in the collagen of the eyelid and orbital tissues; (3) gravitational force on the orbital tissue; (4) sun damage; (5) acquired eyelid skin lesions; and (6) pseudoherniation of the orbital fat pockets.

Except for the last item listed, all the factors are a result of the physiological and acquired process of aging. Pseudoherniation of the orbital fat pockets is frequently genetically determined and not necessarily related to age.

The decrease in elasticity and collagen of the orbital structures and the increase of actinic changes and gravitational forces lead to excess skin, fine wrinkles, creases, and folds. This excess of eyelid skin leads to redundancy, dropping, and sagging.

The periorbital tissues undergo the same changes. Therefore, crow's feet wrinkles appear at the lateral aspect of the orbit. Inferiorly, a dropping effect of the anterior midface produces the appearance of a deep nasojugal groove. The entire eyelid can develop the same changes, causing effects ranging from mild lower eyelid malposition to frank lower eyelid ectropion.

The fat volume in the pocket remains basically the same; however, the diaphragmatic retaining action of the orbital septum decreases over the years, and this causes a lateral protrusion of the orbital fat pockets over the weakened orbital septum. The orbicularis muscle loses its unit round-sphincteric action over the years. In younger individuals, one can see a horizontal bridge of hypertrophic orbital muscle. In older patients, due to gravitational forces, one can see a dropping effect, giving the eyelid fold a hammocklike or festoonlike appearance.

The aging process can also produce acquired lesions in the eyelids, such as hyperpigmentation, telangiectasias, keratosis, syringomas, xanthelasmas, and benign and malignant tumors. These types of lesions should be taken into consideration, if present, prior to blepharoplasty.

See table 1 below depicting the pleasant features of the youthful eyelid, orbital and periorbital areas in which the pathophysiologic changes described above have not yet occurred.

Pleasant features of youth

The pleasant features of the youthful eyelid, orbital, and periorbital areas in which the pathophysiologic changes described above have not yet occurred are as follows:

• Eyes and face

  • Symmetry is common in the young individual.

  • Symmetry is perceived as attractive and beautiful.

  • Asymmetry is perceived as unattractive

• Forehead: This area is smooth and free of deep transverse rhytides and expression lines.

• Eyebrows

  • The medial brow, the medial canthus and the nasal ala should fall on the same vertical plane.

  • The medial and lateral aspects of the brow should lie on the same horizontal plane.

  • The lateral eyebrow should terminate on a diagonal line drawn between the lateral canthus of the eye and the lateral ala of the nose.

  • The medial aspect of the brow should have a club-head shape, and the lateral aspect should decrease progressively to a point-form appearance.

• Female brow position

  • The female brow is located at the level of the supraorbital rim and is more arched than the male brow.

  • Brow symmetry is perceived attractive.

• Male brow position

  • The male brow is located at the level of the orbital rim and is more flat than the female brow.

  • Brow symmetry is perceived attractive.

  • Glabellar area: This area is smooth, without horizontal or vertical expression lines.

• Palpebral aperture/shape: In general it has an “almond” shape and is slightly oblique; however, shape and position can vary depending on race, gender, and heredity.

• Palpebral aperture/dimensions

  • It is 10-12 mm vertically.

  • It is 28-30 mm horizontally.

• Intercanthal distance: The width of one eye should be equal to one fifth of the facial width at eye level or the distance between both inner canthal points. Both distances are equal to each other.

• Lateral canthal tilt

  • With the eyes open, the lateral canthus is positioned above the inner canthus. This is called lateral canthal tilt.

  • A positive value or upward tilt of the lateral canthus is attractive and pleasant.

• Lateral canthal angle: The lateral canthal angle is sharp and acute.

• Eye lashes: Lashes in both eyelids are long, gently curved and directed away from the globe.

• Upper eyelid characteristics

  • The upper eyelid fold is located at the superior edge of the tarsal plate.

  • This fold in whites is approximately 10 mm above the lash line in the female and 8 mm in the male.

  • The upper eyelid is free of drooping or folding and so does not overly the pretarsal skin and eyelashes.

  • The lateral and medial aspect of the eyelid is also free of hooding, bulging or creases.

• Lower eyelid characteristics

  • The lower eyelid is smooth, free of rhytides, redundancy, dropping or sagging.

  • The lower eyelid meets the cheek at approximately the level of the inferior orbital rim.

• Upper eyelid and iris relationship: The upper eyelid covers 2-3 mm of the iris on neutral gaze.

• Lower eyelid and iris relationship: The lower eyelid is either tangential to the iris or covers it by 1 mm on neutral gaze.

• Scleral show: No scleral show or minimal scleral show is seen beneath the inferior limbus.

• Periorbital skin: The periorbital skin is smooth and free of wrinkles or folds.

• Transition area between lower eyelid and upper cheek

  • The transition area is smooth without concavities or convexities.

  • Upper cheek symmetry is perceived as pleasant.

The typical clinical presentation is a patient, male or female, who comes to the office requesting a surgical eye rejuvenation procedure to improve eyelid changes that have occurred because of the aging process or heredity. Age at presentation and the motive for such requests vary widely. Usually, patients are middle-aged, working, productive, and stable individuals searching to secure a position in a competitive professional world with a better-looking and younger facial appearance. Importantly however, patients should relate to the surgeon the exact reason for their requests. Open questions are ideal in the first encounter with potential candidates. Do not assume anything.

The following open questions are appropriate to initiate the conversation: What can I do for you? How can I help you? Tell me why you made an appointment with my office? These types of open questions help put the patient at ease and open up discussion, which facilitates better initial contact. They usually help reveal the patient's true motivations and expectations.

In general, patients complain of a tired and fatigued look and request a younger-looking facial appearance. They believe they have redundancy and/or sagging of the eyelid tissues. Others may note increased wrinkles, sulcus, and creases in the lids or eye region.

Medical history

A complete medical history is mandatory. Inquire about the patient's general health history. A history of diabetes, hypertension, coagulopathy, hypothyroidism, hyperthyroidism, renal disease, or cardiopulmonary disease can play a role in eye symptomatology and the postoperative recovery. A history of collagen vascular diseases, such as scleroderma, systemic lupus erythematous, periarteritis nodosa, Wegener granulomatosis, Stevens-Johnson syndrome, rosacea, rheumatoid arthritis, or secondary Sjögren syndrome, carry the potential for dry eye syndrome.

Other significant elements of the medical history include (1) a history of allergies to medications, (2) previous use of local anesthesia with or without epinephrine, (3) alcohol or tobacco use, (4) previous operations and cosmetic surgeries, and (5) a history of psychiatric illness.

Finally, elicit an ophthalmologic history. This includes previous eyelid surgery, including LASIK surgery, ^[5] eyelid trauma, eyelid infection, eyelid allergy, eyelid swelling, the use of glasses or contact lenses, or any ophthalmologic condition such as glaucoma, dry eye syndrome, or decreased visual fields and/or visual acuity.

Physical examination

Ideally, have the patient sit in front of a 3-way mirror while the examination is conducted, or, another option is to give patients a small mirror. This helps the patient understand the technical aspects of the proposed surgery and facilitates the interchange of thoughts and expectations between the patient and surgeon.

The physical examination first includes looking at the full face. Note and assess the facial appearance, any asymmetry, and any wrinkles. Examine the periorbital area for crow's feet; fine wrinkles (at rest and with smiling); and the appearance of the infraorbital rim, cheeks, and malar bags. With the eyelids, look for areas of eyelid decoloration, hypertrophied skin, and eyelid skin lesions. Also look for proptosis. Note any pseudoherniated orbital fat and hypertrophied orbicularis muscle. Excessive skin produces a crêpelike quality in the lower eyelid skin.

Pressure on the upper eyelid and globe causes pseudoherniated orbital fat in the lower eyelid to be more evident. Having the patient look upward helps to better delineate the lower eyelid fat pockets. The surgeon can locate the different pockets and the relative amount of fat component.

The squint test involves the contraction of the orbicularis muscle without completely closing the eye. This test should be performed with the patient in front of a mirror. The test helps confirm pseudoherniation and allows an evaluation of fine wrinkles, creases, and folds.

The pinch test, ie, grasping the skin, demonstrates the relationship of the contraction of the orbicularis muscle to the adjacent skin. Also, note the position of the lacrimal gland, in particular whether or not it has fallen from the lacrimal fossa. Finally, look for palpebral fissure asymmetries. Differences in palpebral fissures may not be evident to the patient prior to the surgical procedure. Therefore, preoperative discussion is mandatory.

• Lower eyelid tone

  • Evaluate the lower eyelid for the presence or absence of adequate tone. The snap test, or lid distraction test, is performed by pulling the lower eyelid skin with the thumb and index fingers away from the globe and noting after its release the presence or absence of eyelid laxity. If the eyelid returns immediately (normal) to its previous position, the eyelid has good elastic effect and resection of the skin will be well tolerated. If the eyelid returns slowly to the previous position, a conservative resection of skin is advisable. If the eyelid moves very slowly (seconds) into the previous position or after blinking, the patient will require a lid-shortening operation to avoid ectropion. Further, if the eyelid margin can be pulled 6-8 mm away from the globe, abnormal lid laxity is present.

  • The lid retraction test is performed by displacing the lower eyelid inferiorly toward the orbital rim with the index finger. After its release, note how fast the eyelid returns to the normal position. This demonstrates the character of the lower eyelid tone.

  • Finally, look for scleral show. In the normal situation, the lower eyelid margin lies tangential to the cornea or covers the cornea by 1 mm. If the lower eyelid margin is located inferior to the cornea, then the white sclera, or scleral show, is seen. Scleral show greater than 1 mm frequently indicates significant eyelid laxity. Scleral show present prior to surgery remains after surgery.

• Ophthalmologic examination

  • Evaluate visual acuity for near and distant vision in both eyes independently using standard tests for this purpose. If the patient wears glasses or contact lenses, visual acuity is measured with the corrective device.

  • Also, an eye fundus evaluation is advisable, as is a test for Bell phenomenon and lagophthalmos. Further, evaluate facial nerve function, corneal reflux, and extraocular motor function and perform visual-field defect testing.

  • Identify persons with deficiencies in tearing production or dry eye syndrome. Ask screening questions about burning eye sensations, tearing, and excessive blinking. If a patient has these conditions, a referral to an ophthalmologist is advisable. The usefulness of the Schirmer test for screening purposes is frequently in question. A normal result is a paper wetness of more than 15 mm. Wetness of 10-15 mm is inconclusive, while wetness of less than 10 mm is most likely a tearing deficiency.

  • If any gross ophthalmologic abnormality is found or the patient has a history of an eye illness, the patient is sent to an ophthalmologist for a complete preblepharoplasty evaluation. Some surgeons send all patients older than 40 years for a preblepharoplasty evaluation by an ophthalmologist.

Photographs

Prior to any blepharoplasty, patients must have a recent photographic record to document the different abnormalities to be corrected by blepharoplasty. This is for insurance, medicolegal, and academic purposes and to allow for an evaluation of the results later.

With practice, consistent high-quality photographs can be obtained. The photographs should be uniform for evaluation purposes. Using the same lens, lighting, background, film sensitivity, and position of the patient helps obtain the appropriate uniform results.

A single-lens reflex camera with a 100-macro lens and a ring flash using 64 or 100 American Standards Association (ASA) slide film is adequate. The exposed film is processed in the photography laboratory into 35-mm slides. The slides are stored and are available for consultations or presentations. The slides can be converted to either black and white or color prints. A slide scanner can convert 35-mm slides to digital images.

Digital technology is advancing rapidly and taking the lead over 35-mm photography in facial documentation. The digital image is immediately displayed through the liquid crystal display. If the picture is not satisfactory, it is retaken. Excellent digital cameras with close up and macro capabilities are available. These offer quality, convenience, and affordability. Image storing is easy with compressed JPEG files (good quality, less memory disk space) and uncompressed TIF files (excellent quality, more memory disk space).

Images can be stored on USB flash drives, compact discs, digital video discs, computer hard drives, and tapes for easy review and analysis. At present, 35-mm single lens reflex photography and digital photography are capable of achieving high-quality pictures that serve well for documentation in blepharoplasty. In addition, digital images can be used to demonstrate and discuss with each patient the preoperative findings, facial asymmetry, features of aging, and even anticipated and realistic surgical results.

In the academic setting, the authors find that digital photography is very useful for cosmetic facial surgery because the photographs are immediately available for discussion among residents and faculty members at daily rounds and meetings. Using a notebook computer and a liquid crystal display projector, the digital facial images can be projected to a screen. Prints are available through high-quality color photography printers.

Photographic views include (1) frontal view of the entire face; (2) frontal view close-up with eyes open; (3) frontal view close-up with eyes closed; (4) frontal view close-up with eyes looking upward; (5) oblique view close-up, left and right side; and (6) lateral view close-up, left and right side.

Using the Frankfort horizontal line, which is a line from the upper aspect of the tragus to the inferior orbital rim, as a reference helps maintain continuity of the results.

The following are general recommendations.

Proper patient

As in every plastic surgery procedure, patient selection is the first step in the operation. The ideal candidate is a psychologically stable individual, either male or female, with stable employment or a secure economic position and with the affective support of a significant other (eg, partner, spouse). The patient, after careful consideration, seeks realistic rejuvenation of the eyelids. Blepharoplasty should not be performed during a period of transition or crisis in the life of the patient, nor should it be the result of a sudden decision. Patients must fully comprehend the objectives and limitations and the possible complications of the surgery.

In the initial encounter with a candidate for blepharoplasty, open questions are important to clarify and understand the motivation and final expectations. Aptitude, general appearance, manner of dress, presence, expression, tone of voice, and behavior are extremely important. The surgeon should determine in this particular interview if the patient has reasonable wishes, realistic expectations, and psychological fitness. Then the surgeon must determine whether the patient's anatomic abnormalities can be corrected to meet the patient's expectations.

Finally, the surgeon ensures the patient has no contraindications for blepharoplasty. If a patient is determined to have the indications mentioned for a blepharoplasty after the initial interview and physical examination, then a detailed preoperative evaluation should be performed prior to making the final decision.

Proper eyelid condition

Patients should have eyelid changes either acquired by aging or by inheritance that will benefit from blepharoplasty. Not all acquired eyelid or orbital changes can be managed with blepharoplasty. Usually, only redundant eyelid skin and sagging eyelid tissue (eg, skin, orbital muscle, or fat, in any combination) can be treated by the procedure.

Proper eyelid surroundings

Other types of abnormalities or asymmetries in the orbital area, such as crow's feet, fine or deep wrinkles, sulcus or grooves, and discoloration, can diminish the result or cause an unsatisfactory result. Facial digital images are helpful in reviewing and discussing these aging unpleasant features and asymmetries with each patient, prior to blepharoplasty surgery. Also include a plan for adjunctive interventions capable of solving these abnormalities.

Proper preoperative evaluation

A complete preoperative evaluation helps determine whether the patient is a suitable candidate for blepharoplasty; any contraindications for the surgical procedure should be revealed. The surgeon, in selecting the proper person for blepharoplasty and applying the above indications, takes into consideration first instinct, technical and surgical knowledge, and previous personal experience.

In order to understand how to perform a blepharoplasty, knowledge of the relevant orbital anatomy is mandatory. Surface eye and orbital analysis and full knowledge of the anatomy of deeper structures and their surgical landmarks are crucial to understanding how to perform a successful blepharoplasty.

Eyelid anatomy

The lower eyelid has a tangential relationship to the limbus. Occasionally, the lower eyelid can cover 1 mm of the limbus.

The internal and external angles of the palpebral aperture of each eye stay at least within the same horizontal plane, maintaining esthetic harmony with the lateral canthus and rising up to 2 mm higher than the medial canthus. This intercanthal axis difference or upward tilt of the lateral canthus is a pleasant feature of the young eye (see the Pathophysiology section)

The intrapalpebral distance is an average of 10-12 mm. This measurement can be divided into the mean reflex distance 1 (MRD1) and the mean reflex distance 2 (MRD2). The MRD1 is defined by the distance from the center of the pupil to the inferior edge of the upper eyelid. The MRD2 is defined by the distance from the center of the pupil to the superior edge of the lower eyelid. Therefore, using this concept, a lower eyelid ectropion causes an increase of the intrapalpebral distance and a resultant increase of the MRD2 measurement.

The skin of the eyelid is very thin medially, less than 1 mm, but is thicker lateral and superior to the bony orbital margins. With aging, a loss of elasticity and tonicity occurs, creating wrinkling and sagging of the eyelid. The thin and well-vascularized eyelid skin is excellent for blepharoplasty because after approximately 3-4 weeks, the scar is almost imperceptible. The first and second divisions of the trigeminal nerve conduct the sensory distribution of the upper and lower eyelids.

The structures of the infraorbital anatomy of the lower eyelid are the inferior orbital rim, inferior orbital septum, inferior tarsus, orbital periosteum, superficial musculoaponeurotic system, suborbicularis oculi fat, and cheek mimetic muscles. The relationships between these structures are important in order to understand the surgical anatomy of the region.

The inferior orbital septum extends from the inferior orbital rim to the inferior tarsus, attaching to it by a dense fibrous tissue. The inferior orbital septum is a prolongation of the orbital periosteum, the attachment of which is called the arcus marginalis.

The orbicularis oculi muscle is anterior to the orbital septum and is enveloped by the superficial musculoaponeurotic system of the face. Medial to the superficial musculoaponeurotic system lies the suborbicularis oculi fat, between the orbicularis muscle and the periosteum.

Eyelid edge

The landmarks of the eyelid edge, from lateral to medial, are the skin, ciliate line, gray line, meibomian gland orifice line, and conjunctiva. The ciliary line is formed by 2 or 3 irregular rows of lashes that project anteriorly and inferiorly. Sweat and sebaceous glands are located along the ciliary line.

The gray line separates the anterior and posterior parts of the eyelid. The gray line is histologically related to the most superficial portion of the orbicularis, muscle of Riolan, running in the eyelid margin between the lash follicles and the tarsus. The gray line is the most important anatomic line to keep in mind in eyelid reconstructive procedures and in repair of lacerations that involve the margin of the eyelid.

Orbital septum

The orbital septum attaches to the bony orbital margin at the arcus marginalis and to the inferior tarsus. It is continuous with the orbital periosteum and thus represents an effective retaining wall for the orbital contents. The orbital fat and the most delicate orbital structures are localized behind the orbital septum.

Orbital fat

The orbital fat lies posterior to the orbital septum. The orbital fat content remains unchanged in spite of changes in body weight, and, after blepharoplasty, the fatty tissue left behind remains unchanged. The fat separates the muscles, vessels, and nerves and provides a cushion between these structures and the sensitive structures of the eye.

The lower lid has 3 compartments, the temporal, the middle, and the nasal. The largest is the middle compartment. The inferior oblique muscle separates the middle and the nasal compartments.

Orbicularis muscle

The orbicularis muscle is formed by circles of striated muscles that surround the orbit just below the skin. It can be divided into 2 portions, the orbital and the palpebral. The palpebral portion can be subdivided further into preseptal and pretarsal portions. The orbital muscle covers the peripheral orbital rim. The preseptal muscles cover the orbital septum, and the pretarsal muscles cover the tarsal plates. The action of this muscle closes the eyes and milks the lacrimal sac. The orbicularis muscle is innervated by branches of the facial nerve.

Medially, the superficial heads of the pretarsal muscles, upper and lower, join together to form the medial canthal tendon. This tendon is firmly attached to the anterior lacrimal crest. At the same time, the superficial heads of the preseptal muscles attach to the medial canthal tendon. The deep heads of the preseptal and pretarsal muscles attach to the posterior lacrimal crest, just behind the lacrimal sac.

Laterally, the pretarsal muscles, upper and lower, join together to form the lateral canthal tendon, which inserts just posterior to the orbital tubercle. The preseptal muscles, upper and lower, join together laterally to form the lateral palpebral raphe, which is attached to the skin.

Tarsal plates

The tarsal plates are the framework of the eyelid, giving it rigidity and support. The lower tarsal plate measures 3 X 0.5-cm. The tarsal plate contains fibrous connective tissue with multiple special sebaceous glands, ie, meibomian glands, that drain at the edge of the lid posterior to the gray line. The line of the meibomian gland orifices is also a reference line for fine eyelid reconstruction. The tarsal plates are in continuity with the orbital septum, completing a diaphragmatic barrier to the orbital content. The tarsal plates and the inner-layer conjunctiva form the medial layer of the eyelids.

Lacrimal system

The lacrimal gland is located in the superior temporal area of the orbital rim. The lacrimal gland is divided into 2 portions, or lobes. The lacrimal gland tissue is pinker and paler than the orbital fat.

The lacrimal ducts drain into the lateral superior conjunctival fornix. Blinking distributes the lacrimal fluid over the eye and also directs the fluid to the lacrimal papillae.

The superior and inferior canaliculi drain the lacrimal fluid medially to the lacrimal sac, then inferiorly to the nasal cavity just below the inferior turbinate.

Care must be taken during blepharoplasty to avoid any damage to the lacrimal puncta because this could result in scarring and fibrosis, leading to epiphora.

Nerves and vessels of the lower eyelid

The lower eyelid is innervated by the maxillary nerve. The branches of the maxillary nerve that innervate the lower eyelid are the infraorbital nerve and the zygomaticofacial and zygomaticotemporal nerves. The main innervation to the lower eyelid is supplied by the infraorbital nerve.

Arteries and veins

The terminal branch of the internal carotid artery, ie, the ophthalmic artery, anastomoses in the internal aspect of the eye with a terminal branch of facial artery, ie, the angular artery.

The terminal branches of the ophthalmic artery include (1) the supraorbital artery, which, after its exit through the supraorbital notch, supplies the upper eyelid; (2) the supratrochlear artery, which goes along with the supratrochlear nerve; (3) the dorsal nasal artery, which supplies the lacrimal sac and connects with the angular artery; and (4) the frontonasal artery, which forms the superior and inferior medial palpebral arteries—the main supply to both eyelids.

Along with these arteries are the corresponding angular and ophthalmic veins that anastomose at the same level. The angular artery lies medial to the vein at this level. In the superior-external aspect of the eye are arteries from the superficial temporal artery. In the inferior-external aspect of the eye are branches of the transverse facial artery.

Communicating arcades exist between branches of the ophthalmic artery, the facial artery, the transverse facial artery, and the superficial temporal arteries. However, the main source of blood to the eyelids is the terminal branches of the ophthalmic artery.

Be certain that the baggy eyelid condition is not related to any general medical conditions, such as chronic allergies or renal, cardiac, or endocrinological diseases, for which surgery is not necessary.

Do not perform a blepharoplasty for cosmetic purposes that involve removal of fat in the only seeing eye. A small chance of blindness is always present in any blepharoplastic procedure, especially if it involves fat tissue removal.

Dry eye syndrome is not an absolute contraindication for blepharoplasty; however, a consultation with ophthalmologist is advisable for preoperative examination and postoperative follow-up. Extreme caution is necessary in the evaluation of eyelid tone in these patients. In general, conservative skin excision is recommended. Also, explain to the patient prior to the surgery the need to use artificial tears and ophthalmic ointment in the postoperative period.

Both blepharoplasty and LASIK surgery can cause dry eye symptoms. When done together or within a short time periods of each other, the possible cumulative effect of dry eye symptoms is a legitimate concern. Both surgeries induce dry eye. However, dry eye symptoms after LASIK is usually temporary. Therefore, if the patient has had a previous LASIK surgery, wait at least 6 months after LASIK surgery. ^[5]