Subciliary Approach Blepharoplasty 

Updated: Oct 26, 2018
Author: Antonio Riera March, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Some say that the eyes are one of the most striking features of a person's face. They transmit emotions and feelings and form part of the personality and "soul" of a person. 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 physiological changes of aging became better understood, new blepharoplastic techniques were developed for their correction. Even though modern cosmetic blepharoplasty techniques have been around for 50 years, only in the last 2 decades has the number of blepharoplasty procedures increased worldwide.

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 or 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.

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 has 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]

History of the Procedure

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.

Problem

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.

Epidemiology

Frequency

The number of blepharoplasties has increased progressively over the last 10 years, and blepharoplasty has become one of the most common cosmetic facial procedures. The most popular cosmetic surgical procedures according to the 2012 AAFPRS Membership Study are rhinoplasty followed by blepharoplasty, facelift, ablative skin resurfacing, and septoplasty.[3]

The frequency of blepharoplasty has increased progressively in the last 20 years in both males and females. Blepharoplasty is performed more often in women than in men. The current trend is approximately 4 times more often in women than in men. Women who request blepharoplastic procedures are typically younger than men who request blepharoplastic procedures.

Blepharoplasty is more common in persons aged 40-50 years. The number of blepharoplasties is expected to continue to rise and involve both older and younger individuals.

Etiology

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).

Pathophysiology

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.

Presentation

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,[4] 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.

Indications

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.

Relevant Anatomy

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.

Contraindications

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.[4]

 

Workup

Laboratory Studies

See the list below:

  • Laboratory testing required to perform a blepharoplasty under local anesthesia varies slightly according to the patient's age and past and present medical history.

  • The usual requested laboratory studies for a healthy person may include the following:

    • CBC count with differential

    • Prothrombin time, activated partial thromboplastin time, if suggested by past medical history

    • Platelet count

    • Serum electrolyte evaluation

    • Glucose level (optional as directed by history)

    • BUN and creatinine level (optional as directed by history)

    • Urinalysis (optional as directed by history)

Imaging Studies

See the list below:

  • Obtain a chest radiograph if the history so indicates.

Other Tests

See the list below:

  • Perform an ECG if the patient is older than 40 years or the history so indicates.

  • If the patient has a personal physician, advise the physician about the plan for a blepharoplasty so he or she can have input in the preparation and recommendations prior to the surgical procedure. Request further laboratory studies and/or consultations with medical specialists as needed.

 

Treatment

Preoperative Details

General discussion

Discuss all aspects of the procedure with the patient. A member of the family or a significant other (eg, partner, spouse) can witness and participate in the interview. A booklet with the precise information is very useful for this purpose.

Discuss the surgical fee and other fees (eg, laboratory, anesthesiology, ambulatory facility) in advance. Cleary indicate the time of expected payment once the patient commits to the surgery. As with every cosmetic surgery, the best plan is to have all fees paid preoperatively.

Detailed discussion of surgical procedure

Explain the procedure in front of a mirror or have the preop digital images display on a monitor screen. Point out (1) any skin lesion localized in the lower eyelid; (2) scleral show, if present; (3) any abnormal brow position in the resting position or in the dynamic position; (4) the relationship of eyelid surgery to the position of the brow. 5) any facial asymmetry. In addition, advise the patient if brow surgery is indicated. Removal of eyelid skin prior to brow correction yields a definitively unpleasant result.

Explain the anatomical abnormalities that can be corrected with blepharoplasty. Explain the anatomical abnormalities that can be partially improved with blepharoplasty. Fine wrinkles, crêpelike skin, pigmentation changes, and skin lesions in the lower eyelid can be only slightly improved by lower eyelid blepharoplasty; the final result is totally unpredictable. Explain the anatomical abnormalities that cannot be improved with blepharoplasty. Finally, explain the surgical procedure itself.

Preadmission preparation

See the tests recommended in the Clinical and Workup sections. Have the patient avoid aspirin and vitamin E for 2 weeks prior to surgery. Consult a medical service for patients on anticoagulation therapy. The patient must discontinue all herbal or natural substances that may have an effect on coagulation or anesthesia. Have the patient stop smoking for 2 weeks before surgery and avoid the use of alcohol and caffeine for 1 week before and after surgery.

Fully discuss surgical planning, risks, and complications with patients. Obtain informed consent. Check laboratory test results and information from consultations with the medical specialist; follow recommendations. Ensure that all this information is available for review prior to the day of surgery. Advise patients to take their usual medications up until midnight prior to the surgical procedure.

Advise patients to not wear makeup to the surgical suite. Also, instruct patients to take nothing my mouth after midnight the night before surgery.

Day of surgery (holding area)

Complete physical examination, laboratory results, and clearance reports must be on record at the time of admission for an outpatient surgery. Note in the past medical history allergies to medications, hypertension, diabetes, cardiopulmonary disease, chronic illness, and previous surgeries.

Write in the record the indications, the summarized problem, and the treatment plan with the selected surgical approach. Items to check include (1) that photographs are available for review, (2) that informed consent is signed and on record, (3) that an evaluation and premedication has been performed by the anesthesia service, and (4) that the patient has voided upon call to the operating room.

Intraoperative Details

The different modalities to approach the subciliary blepharoplasty of the lower eyelid are via (1) a skin-muscle flap, (2) a skin flap, and (3) a repositioning of fat technique.

Skin-muscle flap

This procedure consists of elevating the skin and the orbicularis muscle as a unit in the plane medial to the muscle and anterior to the orbital septum. The advantage is that the flap is easier to develop, with less bleeding and with immediate access to the fat pocket. Its use is recommended when skin and orbicularis muscle must be removed.

Skin flap

The skin flap involves elevating the skin and the orbicularis muscle in 2 different planes prior to fat pad removal. It is used when the amount of eyelid skin is excessive compared to the orbicularis muscle. The skin flap is a more laborious flap, and bleeding is more common; therefore, it is infrequently used today.

Fat preservation/suspension technique

This technique can be executed in 2 ways, either by not removing the fat pads and reinforcing the retaining action of the orbital septum or by repositioning the fat pads over the orbital rim. The latter approach is the one most commonly used.

By preserving the fat and repositioning the fat pads with sutures to or over the orbital rim, a convex/youthful appearance is reestablished without adverse effects, such as a concave/sunken appearance. Using this technique, the vertical dropping of the orbicularis and the midface can also be addressed by suspending these structures in the vertical plane in order to counteract the negative effects of gravity.

Preparation, anesthesia, and design

The authors use local anesthesia with intravenous sedation for almost all blepharoplasties. Very rarely, general anesthesia with endotracheal intubation is necessary. This is required when blepharoplasty is performed concurrently with other facial plastic procedures.

Having the patient sedated but awake is advantageous for consistently good cosmetic results because the patient can cooperate with the surgeon by following basic commands.

In the authors' university facility, blepharoplasties are performed as outpatient procedures, with full attendance of an anesthetist under direct supervision of an attending anesthesiologist. They administer the intravenous sedation for the entire surgical procedure. Protocols and recommendations for anesthesia sedation vary slightly among different anesthesiologists in the authors' institution, and the reader is referred to references on this subject.

The authors recommend that the markings for the incision and the planning of the operation be made with the patient in the sitting position prior to lying on the operating table.

In every patient, the factors involved in the cosmetic problem are reviewed in the medical history and supported by photographs.

The authors do not usually use markings for the subciliary incision except for its lateral aspect; however, in an academic setting, delineating incisions, anatomical abnormalities, and asymmetries is useful. A sterile commercial skin marker or the tip of a broken cotton-tip applicator moistened with methylene blue is useful for this purpose.

The head of the patient is elevated slightly from the lying position, and the eyelids and orbital areas are fully cleaned with surgical soap and cotton-tip applicators. Re-marking of the incision is performed after cleansing. Sterile draping is used. Be careful that the draping does not cause any distortion of the lower eyelid. Plastic adhesive drapes are not recommended because they may lead to a miscalculation of the eyelid tissue to be resected.

In each eyelid, the authors use 1-2 mL of 1% lidocaine (Xylocaine) with 1:100,000 epinephrine injected subcutaneously with a 27- or 30-gauge, 1.5-inch needle. Other concentrations of lidocaine, such as 2% or even 0.5%, can also be used with 1:100,000 or 1:200,000 epinephrine. The needle moves from lateral to medial, going parallel to the edge of the lower eyelid. Avoid deep penetration with the needle, which could cause severe damage to the globe. A word of caution: in every incidence, the surgeon must personally verify the contents of the syringe before injection.

Timing of the injection varies depending on whether a 4- or 2-quadrant blepharoplasty is performed. Usually, 2 eyelids superiorly or 2 inferiorly are anesthetized at a time. Approximately 1 hour of painless time is achieved using the above technique. After that period, further anesthesia is added if needed. A waiting period of 10-15 minutes is generally needed to achieve both anesthesia and adequate vasoconstriction after the initial injection.

Skin-muscle flap technique

First, a stab incision with a No. 15 Bard-Parker blade is made below the ciliary line into the bony orbital rim approximately 10 mm from the external aspect of the lateral canthal area.

Note that the most external aspect of the incision is in a horizontal direction into the area of the crow's feet. If a 4-quadrant blepharoplasty is performed at one time, the external aspect of the lower blepharoplasty incision must be separated by at least 5 mm from the external aspect of the upper blepharoplasty incision.

A single or small double skin hook is used to elevate the tissue, while small curved iris scissors are used to create a skin-muscle flap just below the orbicularis muscle. The blades of the scissors are spread using blunt movements, creating a dissection plane from superior to inferior to medial.

The exact plane of the dissection is precisely in the submuscular plane, just above the orbital septum. With the assistance of the single or small double skin hook to keep the dissected plane elevated, one scissors blade is passed above the eyelid skin and the other in the previously created plane.

The cutting follows the stab wound incision and then the initial marking line or an imaginary subciliary line parallel to the lower eyelid edge just 2-3 mm below the line of the lashes.

The incision stops medially prior to reaching the lower eyelid puncta. Advancing the incision past the lower lid puncta produces postoperative scarring and fibrosis, which can lead to epiphora.

Bleeding is reduced to a minimum if the plane of dissection is correct. However, once the flap is developed, small bipolar electrocautery, ophthalmic disposable battery cautery, or a Colorado needle (Colorado Biomedical; Evergreen, Colo) can be used for coagulation.

A wet sponge is placed over the closed upper eyelid. Further exposure is achieved by clamping a small hemostat to a 4-0 or 5-0 silk suture, which is passed through the open superior edge of the lower eyelid and is used as traction. A small double skin hook is used for gentle retraction of the open inferior edge of the lower eyelid.

A clear vision of the orbital septum is achieved at this point. The amount of orbital fat to be removed has already been estimated. Removal of too much fatty tissue produces an unfavorable result, giving a sunken, debilitated look that is difficult to correct.

The orbital septum must be opened over the fat pads, either with the assistance of forceps and scissors or with the forceps and cautery. A horizontal strip of orbital septum must be resected, exposing the 3 fat compartments. The same can be accomplished by making a buttonhole incision just above each of the fat compartments using the described instruments.

The small layer of connective orbital septum just over the lateral fat pad is grasped and gently cauterized with the disposable ophthalmic cautery unit. The fat pad localized below is under direct view.

Gentle pressure to the globe over the superior eyelid makes identification of the fat compartments easier.

Grasp the fatty tissue with an ophthalmic forceps and isolate it with the assistance of a cotton-tip applicator.

Traction of the fatty tissue causes deep pain to the patient. Therefore, inject the base of the fat pad with 1% lidocaine (0.2 mL) with a 30-gauge needle before clamping the base with a small curved hemostat. Alternately, the base of the fat pad can be cauterized with a bipolar cautery.

Some surgeons believe that excising and cauterizing the fat pad without clamping its base with a hemostat is safer. The reason for this thinking is that the clamped hemostat places extra traction on the fat pad, thereby increasing the possibility of retroorbital hemorrhage. The authors feel that clamping is acceptable as long as gentleness is used in handling the fat pad at all times.

All fatty tissue above the hemostat is excised with scalpel or scissors. The cuff remaining below is cauterized before retracting intraorbitally. Hemostasis must be complete prior to return of the stalk to its previous position. Extra caution is needed to avoid damage to the inferior oblique muscle that divides the middle and the nasal compartment. No sutures of any type are needed to close the orbital septum.

After the fat pads are removed, some surgeons believe that the gentle touch of the ophthalmic cautery unit over the remaining septum reinforces the strength of its diaphragmatic action and keeps the fat in its compartment, avoiding protrusion or herniation.

The traction suture placed in the superior edge of the eyelid is removed. The skin-muscle flap is grasped with the forceps and tractioned superiorly for redraping over the subciliary incision with the assistance of a cotton-tip applicator. Care must be taken to ensure that the skin-muscle flap drapes over the underlying structures and is not tented, which would result in excess skin removal.

The authors ask the patient to open the mouth and look upward. This creates the maximum possible separation of skin edges and helps to maintain a conservative focus for the final excision.

Observing experienced surgeons performing this excision is highly recommended before performing the first case. In general, do not exceed 4 mm of vertical skin excision in the lower lid margin. Again, the authors emphasize a conservative approach for the vertical dimension of the resection.

The redundant skin-muscle flap is excised in a triangular form, ie, wider laterally and decreasing the amount of the excision from lateral to medial. This avoids shortening in the vertical dimension and prevents, as much as possible, postoperative ectropion and/or lid retraction. The excision is accomplished using a straight iris scissors with the blades beveled downward in order to cut the orbicularis muscle at a lower level of the flap border. This makes both sides of the incision even and avoids a step-off deformity at the skin margins. The amount of muscle to be removed is slightly more if a hypertrophied orbicularis muscle is present.

Meticulous hemostasis is achieved using bipolar cautery, ophthalmic portable cautery, and/or a Colorado needle. The skin is then sutured.

Lower lid closure can be accomplished in several ways, including (1) interrupted 6-0 polypropylene (Prolene), 6-0 nylon, or 6-0 silk sutures going from lateral to medial; (2) a running suture with untied long ends from lateral to medial using the same materials plus Steri-Strips; or (3) interrupted 6-0 fast-absorbing gut sutures going from lateral to medial. The eyes are irrigated with a normal saline solution, and antibiotic ophthalmic ointment is applied over the suture line.

Skin flap technique

The skin flap is developed in a similar fashion to the skin-muscle flap. The skin is dissected from the orbital muscle. More bleeding than with the skin-muscle flap is not uncommon. Therefore, complete hemostasis is required.

The subciliary incision is made after marking the incision line just 2-3 mm inferior to the lower lid edge with a No. 15 scalpel blade going only through the skin. Remember several points mentioned previously. First, keep away from the lower lacrimal punctum. Second, at the lateral aspect, extend approximately 1 cm into the crow's feet area. Finally, separation from the incision of the upper blepharoplasty, if performed, is at least 5 mm in its lateral aspect.

Using slightly curved scissors and the assistance of inferior traction placed on the lower lid skin and superior traction placed on the external skin area, the skin flap is undermined and developed. Once fully developed to the orbital rim, use scissors to complete the subciliary incision that was previously initiated with the scalpel.

The orbicularis muscle can be managed using 1 of 3 methods, including (1) division and separation sufficient enough to reach the orbital septum to access the fat pad, (2) small resection of the hypertrophied orbicularis muscle fibers across the septum to access the fat pad, or (3) elevation of the orbicularis muscle as a flap to access the fat pad below. The third approach is used most commonly by surgeons to access the fat pad, resect excessive sagging and/or laxity of the orbicularis muscle, and suspend the muscle to the orbital periosteum.

Then, removal of the fat pads is performed in a manner described for the skin-muscle technique. No sutures are needed to close the orbital septum.

Skin resection is slightly more than occurs with the skin-muscle flap because this particular technique is applied to patients with more redundancy of skin. Still, remember to remain conservative with skin removal.

Recommendations for closure, suture materials, and dressings are the same as described for the skin-muscle flap.

Fat preservation/repositioning technique

The information below is a synopsis of this particular technique. The reader is referred to recent publications on the subject for details of the surgical procedure.

The fat preservation technique can be accomplished by either the subciliary or the transconjunctival approach. In general, the subciliary approach is selected for younger patients and patients with adequate lower eyelid tone. The transconjunctival approach is preferred for older patients and patients with poor lower eyelid tone.

If the subciliary approach is used, the skin-muscle flap technique is developed as described previously in the preseptal plane.

The orbicularis muscle (relating to the lower eyelid) is elevated from periosteal attachments. The inferior midface route of dissection varies among surgeons. The 2 different routes are the subperiosteal route and the supraperiosteal route. The subperiosteal route creates a pocket to bury the transposed fat pedicles over the orbital rim.

The supraperiosteal plane or suborbicularis plane changes to a different plane in the lateral or medial aspect of the dissection. In the lateral aspect, the dissection proceeds below the zygomatic major and minor muscles. In the medial aspect, the dissection proceeds above the levator muscle of the lip and nasal ala. By doing this, the fat pads are suspended and the midface is elevated.

Then, the fat pads are localized and separated from the surrounding tissue with the assistance of a cotton-tip applicator. They are prepared in a T-shaped fashion and sutured to the periosteum of the infraorbital rim or adjacent tissue or buried into the subperiosteal pocket as described above. For all of these, 5-0 or 6-0 Vicryl is used.

The orbicularis muscle and the vertical dimension of the created flap are sutured to the orbital rim periosteum with buried 4-0 Vicryl. A conservative approach is mandatory when resecting skin and muscle if a subciliary approach is used with the fat preservation/repositioning technique.

Surgeries associated with lower lid blepharoplasty

See the list below:

  • Suspension technique for lower eyelid laxity: If the degree of laxity is not significant or prevention of eyelid retraction is intended, a suspension technique is used along with the cosmetic blepharoplasty. This technique is based on a single 5-0 noncolored nylon suture to perform the plication of the orbicularis muscle to the periosteum of the lateral orbital rim. Another way to produce the same effect, although less common, is placement of the same type of suture through the lower eyelid tarsal plate, just inferior to the lateral canthal tendon, and localization of the periosteum above the same tendon.

  • Horizontal shortening for lower eyelid laxity

    • When patients present with a weak or atonic lower eyelid, a horizontal shortening procedure is performed with the cosmetic blepharoplasty. Lateral canthal tendon shortening and eyelid horizontal shortening are both used.

    • For lateral canthal tendon shortening, the lateral canthal tendon is identified, isolated, and grasped in order to evaluate the amount of resection required to decrease the laxity of the lower lid. The tendon is transected and resected the amount necessary to tighten the lower lid. A 6-0 noncolored nylon U-type suture is used to reapproximate both ends of the cut tendon.

    • In the eyelid horizontal-shortening procedure, shortening requires excision of a full-thickness lateral segment of the lower eyelid. The shape is usually triangular or pentagonal, with the apex directed inferiorly. After the initial cut is made, both ends are pulled facing each other to determine the amount of full-thickness including the tarsal plate to be removed for adequate tightening. The amount varies according to the degree of laxity. An average of approximately 4-5 mm is usually necessary.

    • Closure is performed first in the marginal area starting at the gray line with a 6-0 silk suture. Ensure that both ends are long enough to be attached to the lower eyelid skin with a Steri-Strip, providing easy access for final removal. The remaining sutures are through the tarsal plate and soft tissue using an absorbable 6-0 Vicryl suture. The skin is reapproximated with 6-0 nylon. The conjunctiva remains open. The marginal silk sutures remain in place for approximately 7 days.

  • Chemical peeling/laser resurfacing

    • The eyelid skin is very thin, the thinnest in the body. Therefore precise control of depth is crucial in ablative periorbital techniques such as: chemical peels, carbon dioxide (CO2) and Erbium: yttrium, aluminum, garnet (Er:YAG) laser technologies.

    • Chemical peeling and laser resurfacing can be used for management of periorbital and eyelid rhytides. Medium-depth chemical peeling, 35% trichloroacetic acid and Jessner’s solution, are commonly used for this purpose. The advantage of a chemical peel is that it is less expensive than laser resurfacing. However, the new laser technology is replacing the chemical peeling in periorbital rejuvenation due to the controlled depth the tissue ablation, less thermal damage, rapid healing, efficacy and safety.

    • Chemical peeling and CO2 and Er:YAG laser resurfacing at reduced power output, performed along with the muscle-skin flap technique, are safe according to recent medical literature. However, no chemical peeling or laser resurfacing is safe enough to be used in conjunction with the skin flap technique because of the high risk of lower eyelid skin necrosis.

    • Some surgeons prefer to perform an independent chemical peeling or laser resurfacing at a later time, usually 2 months or longer postoperatively.

  • Botulinum toxin

    • The botulinum toxin may be useful to enhance the benefits of blepharoplasty once the healing process is over. It may improve wrinkles that would not be modified by any other treatment modality.[5]

    • The botulinum toxin type A is a neurotoxin that results in a transient paralysis of the related muscle when injected intramuscularly or subcutaneously. This is temporary, lasting an average of 5-6 months.

    • Facial wrinkling is produced by continuous contraction of the related muscles and the loss of elasticity. Therefore, by paralyzing the involved muscle, wrinkling diminishes. This technique can be useful in the treatment of forehead, glabellar, lower eyelid, and lip regions and for crow's feet wrinkles. The dosage, timing, and injection techniques are not in the scope of this article.

    • Blepharoplasty can also be performed in combination with a facelift, cervifacial liposuction, and/or submentoplasty. The authors strongly encourage the reader to review the medical literature regarding all the topics that can be performed in combination with blepharoplasty.

Other procedures are designed to improve the orbital area by restoration the infraorbital volume with injectable fillers and fat grafting.

  • Injectable fillers: The most common fillers used in this area are based with hyaluronic acid and calcium hydroxyl apatite.[6] The hyaluronic acid used in the infraorbital area for temporary treatment of the "tear through" deformity has an specific formulation of nonanimal source. In this region, using topical and/or local anesthesia, the filler material is injected in small incremental aliquots into the supraperiosteal/suborbicularis plane. Following several injections a gentle massage is performed to smooth out possible irregularities. Calcium hydroxyl apatite fillers has the characteristic of a longer lasting time compared to fillers based on hyaluronic acid.[7]

  • Fat Grafting: The beneficial effect is based on volume restoration in the infraorbital area. The fat injection can be perform in conjunction with blepharoplasty or as an independent procedure without blepharoplasty. Fat grafting alone can be adequate to improve deformities to aging which do not involve the eyelids. Autologous fat is harvested from the lower abdomen and thighs using a low pressure liposuction technique.[8]

  • Secondary blepharoplasty: Minor "touch-up" surgery may be necessary after blepharoplasty and is usually related to insufficient removal of fat pads. After lower subciliary blepharoplasty, use extreme caution with any further removal of skin in the lower lid because of the high possibility of cicatricial ectropion. Rigorous analysis and a conservative approach are mandatory.

Postoperative Details

The patient is taken to the recovery room for monitoring over the next 3-4 hours. Patients are positioned on their back with their head slightly elevated.

Cool, wet gauze or an eye pad is applied over the eyes and changed or recooled every 30 minutes. No compressive dressing of any kind is recommended. Pain is uncommon, but discomfort is common. Therefore, oral analgesics that do not contain aspirin are given.

Personnel in the recovery room are familiar with this type of surgery. However, always write in the chart the specific orders and warning signs of possible complications (ie, persistent pain, visual disturbance, unusual swelling, proptosis). Also, clearly write in the chart cellular telephone numbers that can facilitate immediate communication between the recovery room staff and the surgeon.

When the patient is fully awake, hemodynamically stable, without complications, and cleared by the anesthesiologist, the patient may be discharged home. The assistance of a family member or friend is crucial in the transportation process and perhaps during the first night or two at home.

Instructions for the patient are as follows.

  • Day of surgery: Remain at rest at home during the rest of the day. When lying down, slightly elevate the head. Cold dressings can be used while awake, and change them or recool them every 30 minutes. Take mild analgesics that do not contain aspirin as needed, usually every 4-6 hours. Apply antibiotic ointment or bland ophthalmic ointment in small amounts to the incision line twice daily with a cotton-tip applicator for the first week. (Some surgeons recommend prophylactic oral antibiotics for 1 week after the operation.)

  • Next day: Ambulation at home is permitted, but otherwise continue with the instructions for the day of surgery. (Some surgeons request that the patient come to the office on this day for the first follow-up visit.)

  • Second day: Continue with the instructions of the first postoperative day. Be aware that an increase in eyelid swelling is expected. The use of eyeglasses is now permitted. Avoid using contact lenses in the early postoperative period.

  • Third day: Leaving the house is permitted, but use sunglasses.

  • Fourth day: Return to the office for removal of permanent sutures.

  • Seventh to the tenth day: The eyes can be washed normally with gentle soap and water. At this time, a return to work is permitted if this does not involve the risk of trauma to the surgical area.

  • One month: Full sport activity can be resumed.

In general, the use of mascara, eyeliner, makeup, and contact lenses can resume around the beginning of the third week, although this varies widely according to each patient's healing process.

Provide the patient with clearly written telephone numbers of the surgeon and staff, and instruct the patient to contact the physician (surgeon) and/or staff with any questions or concerns during the recovery period.

Discharge criteria are (1) hemodynamic stability; (2) an alert and oriented patient who has been cleared by the anesthesiologist; (3) no evidence of bleeding, hematoma, swelling, proptosis, or visual disturbance; and (4) no significant pain. Remember that pain is unusual. Persistent pain, deep pain, or severe pain represents a warning sign of possible complications. Written instructions must be provided for the patient, family, or assisting personnel prior to discharge. Make sure that the patient understands the instructions. Provide written cellular telephone numbers with the instructions.

Follow-up

A nurse, the resident, or the attending physician calls the patient the night of discharge.

The patient may be requested to return to the clinic the first postoperative day. For some surgeons, this is routine. This visit is good for the surgeon and patient alike. The surgeon can make sure everything is as expected, and the patient can take the opportunity to ask any questions. If the patient and the surgeon feel comfortable with a phone conversation, this visit can be omitted.

Have the patient return to the clinic on the fourth postoperative day if the patient has nonabsorbable sutures. Remove the sutures at this visit. Reinforce the instructions and address any patient questions or concerns. A Steri-Strip may be applied to the incision line. The patient returns 7-8 days after the initial operation for removal of the Steri-Strip and cleansing of crusts from the eyelids.

Have the patient return to the clinic on the seventh postoperative day if the patient has gut-absorbing sutures. Remove the remaining partially absorbed gut sutures and cleanse any crusts from the eyelids. Reinforce the instructions and address any questions or concerns.

When the patient returns to the clinic after 3-4 months, healing is usually complete and pictures are taken. The patient then returns to the clinic every 4 months for the first year for a follow-up evaluation. At each visit, more pictures are taken.

For excellent patient education resources, visit eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education article Black Eye.

Complications

Lower blepharoplasty is a very common rejuvenating surgical procedure. In a busy facial plastic surgery clinic, complications and unsatisfactory results occur. Preventative measures, accurate analysis, and good patient selection are extremely important to reduce complications to a minimum. Preoperatively, an open discussion to educate the patient about possible complications is mandatory. This particular section focuses on general complications that can occur in lower eyelid blepharoplasty and specific complications that can occur in the lower eyelid blepharoplasty subciliary approach.

General complications

See the list below:

  • Unsatisfied patient

    • The best way to avoid the patient being unsatisfied with the procedure, even after a satisfactory objective result, is in the preoperative evaluation. Carefully analyze the exact reason for the surgery and the patient's expectations prior to commencing with the surgical procedure. Prevention is the best defense.

    • Once the patient is unsatisfied, key management is always to keep the communication line open, no matter how difficult. Select a time for an interview that is convenient for both surgeon and patient, and provide ample time to listen to the patient's concerns. Be honest and keep control of this difficult situation with meaningful comments. Always be available for and supportive of the patient's questions and concerns.

  • Dry eye syndrome

    • Temporary dryness is a common occurrence in the immediate postoperative period. After the edema resolves progressively over 1-3 weeks, dry eye syndrome resolves.

    • The medical history is the most important information from which to detect patients prone to dry eye syndrome postoperatively. Patients with a history of dry eye, eye irritation, foreign body, burning sensations, or decrease in tearing should be further investigated. Patients with illnesses such as scleroderma, systemic lupus erythematosus, Wegener granulomatosis, ocular pemphigoid, Stevens-Johnson syndrome, ocular rosacea, paralysis of the seventh cranial nerve, rheumatoid arthritis, or secondary Sjögren syndrome should prompt the surgeon to check for a potential postoperative problem.

    • A patient with the aforementioned conditions or with clear symptomatology of dry eye syndrome should have a consultation with an ophthalmologist prior to a blepharoplasty procedure. In any case, a conservative surgical approach is the rule for these patients. Involvement of an ophthalmologist in the treatment of patients is highly recommended to achieve the best results possible.

    • A routine Schirmer test is usually recommended in the medical literature in the preoperative evaluation of asymptomatic patients and is required for patients with an unclear history, older patients, or patients with minimal symptomatology.[9, 10] Keep in mind that the Schirmer test does not confirm the tearing deficiency in all patients.

    • If dry eye syndrome is present after 2-3 weeks postoperatively, consultation with an ophthalmologist is advised, along with artificial tears and eye protection.

  • Contour defects

    • Eyelid surface irregularities can occur if removal of skin, fat, or muscle is sufficiently asymmetrical to cause defects after redraping the skin. Furthermore, asymmetries are already present preoperatively. Therefore, even a well-planned blepharoplasty can result in asymmetrical eyelids. Small differences are not uncommon and can occur after the surgery heals. Importantly, show the patient the differences in symmetry preoperatively; asymmetries are present in almost every patient. This is the best prevention against postoperative disappointment. Fat removal should be planned prior to anesthesia injection. Use of preoperative photographs can help in this matter.

    • Trimming and redraping of the skin and the orbicular muscle should be performed carefully, paying attention to details in order to avoid differences between both sides.

  • Hematoma

    • Usually, hematoma is recognized in the immediate postoperative period by pronounced protrusion of the eyelid with ecchymosis of the flaps. Hematoma is usually due to orbicularis muscle bleeding. Most of the time, it is diagnosed several hours after the operation and the extension and the time of presentation determines the treatment.

    • If a hematoma is recognized immediately, it should be treated by opening the incisions, eliminating the hematoma, and achieving hemostasis. If the hematoma is small, localized, and nonexpanding, it is usually self-limiting. If the hematoma is of moderate size and not expanding, it can usually be eliminated by waiting 7-10 days until the accumulated blood liquefies. Then, it can be evacuated with a No. 11 blade or a large-bore needle. Hematomas that are large and expanding, presenting early after blepharoplasty or causing symptoms such as pain, proptosis, or decreased visual acuity, should be explored immediately.

    • If severe, consultation with an ophthalmologist and orbital decompression may be indicated.

  • Suture marks: All sutures can leave a mark on the skin. The most reactive sutures are plain gut, fast-absorbing gut, and chromic gut; the least reactive are polypropylene, nylon, and silk. Plain gut, fast-absorbing gut, and chromic gut are less than adequate compared to the other sutures. However, some surgeons favor the fast-absorbing gut for blepharoplasty because of its capability to dissolve in 3-4 days. The remaining sutures (ie, polypropylene, nylon, silk) should remain for no more than 4 days to avoid marking.

  • Milia: The epithelium grows rapidly around the skin sutures. If the sutures stay in too long, this induces a white, round nodule or inclusion cyst by obstructing the sebaceous glands at the suture opening. These can be resolved by unroofing the cyst with a surgical needle or a No. 11 surgical blade. Tunnels completely epithelized may require unroofing by opening with scissors along the created tunnel. Prevention involves removal of the sutures in 3-4 days.

  • Wound separation: Wound separation can occur, especially at the lateral aspect of the lower eyelid incision after early removal of sutures. Applying Steri-Strips to keep the edges approximated after suture removal can prevent this complication.

  • Ocular injury

    • Ocular injury, in particular corneal abrasion and ulceration, is not uncommon. Corneal damage is caused by iatrogenic trauma with gauze sponges, cotton-tip applicators, drapes, instruments, or sutures. Symptoms related to corneal trauma include eye pain, eye irritation, and blurring of vision. Corneal trauma is best demonstrated with fluorescein eyedrops and a slit-lamp examination. Treatment involves the application of an antibiotic ophthalmic solution and eye closure for 48 hours.

    • Preventing this type of injury is mandatory. Protection of the eye at all times is imperative. Protection is accomplished by maintaining eye closure as much as possible. Do not pass sutures, cotton applicators, and instruments over the open eye. Some surgeons believe that corneal protectors are useful during blepharoplasty. Protection can also be achieved by using ophthalmologic ointment (eg, Lacri-Lube) in the inferior cul-de-sac and keeping the eye closed with a traction suture placed at the edge of the lower eyelid. For optimal protection, repeat instillations of ophthalmologic ointment throughout the surgical procedure. More severe injuries are rare. Penetrating globe injuries with a sharp instrument are extremely rare. If they occur, immediate intraoperative consultation with an ophthalmologist is required.

  • Infection

    • Infection is a rare complication. It occurs more frequently in patients with diabetes or in patients with immunodeficiencies. The clinical picture is cellulitis in the orbital region with pain, eyelid edema, erythema, chemosis, and fever.

    • Cellulitis can progress to abscess formation, manifesting severe pain, proptosis, diplopia, and decreased visual acuity. In most instances, the organisms involved are staphylococci and streptococci.

    • Treatment consists of warm compresses, head elevation, culture, and broad-spectrum antibiotics. At the initial stage of the infection, an oral antibiotic may suffice. However, if no improvement is noted after 24-36 hours, intravenous antibiotics are mandatory. Intravenous antibiotics are used in patients with diabetes or in patients who are immunocompromised.

  • Loss of eyelid: One case of eyelid necrosis has been published. As reported by Putterman, this was due to the injection of formaldehyde instead of local anesthesia.[11] Remember, nothing should be injected unless first personally verified by the surgeon.

  • Loss of the eyelashes: This can occur if the incision is too close to the eyelashes, by direct trauma, or by thermal injury. Fortunately, most of the time the lashes regrow. Chronic inflammation, such as chronic blepharitis or chalazia, can occasionally reach the point of misdirection or loss of the eyelashes. In these cases, adequate treatment of the involved condition is necessary.

  • Overcorrection of fat pockets

    • Excessive removal of fat tissue produces a deep, concave, unsatisfactory eyelid surface, resulting in a cadaveric appearance. This condition is difficult to correct. Therefore, it should be avoided by being cautious with the removal of fat, which should not be excessive and should be just below the orbital rim edge.

    • Free fat grafting taken from the submental region may be used to correct this unpleasant result. However, reabsorption is unpredictable. Other techniques to increase volume in the concave areas include orbicularis muscle flaps, midface lifting, and autogenous fat pad sliding.

  • Undercorrection of the fat pockets: This situation is not as dramatic as overcorrection. If after 6-8 months the patient has evidence of insufficient fat removal, a new intervention can be planned to remove the excessive fat.

  • Chemosis: Chemosis is not common with the subciliary approach. It is usually temporary and resolves rapidly with the application of eye lubricants and artificial tears. Severe chemosis occurs with a greater frequency with the transconjunctival approach. Severe edema of the conjunctiva may develop, causing dryness not only of the conjunctiva but also of the cornea. At this point, in addition to increased lubrication, consultation with an ophthalmologist is advisable.

  • Malar bags

    • Blepharoplasty does not adequately correct malar bags that are already present. Furthermore, if they are unrecognized preoperatively, they can be more prominent in the postoperative period. Thus, recognize malar bags initially and discuss their presence with the patient; this step is important to avoid postoperative dissatisfaction.

    • Correction requires direct resection, necessitating another visible scar. Treatment of malar bags can be postponed until after the effects and results of the blepharoplasty are known.

    • Always remember to rule out other causes of chronic swelling, such as heart, kidney, thyroid, or allergy problems.

  • Blindness

    • Blindness has been reported by DeMere, with an incidence rate of 0.04%. Usually, loss of vision occurs in the first 2 hours after surgery. The reason blindness occurs is not clear. Most of the cases have been related to retrobulbar hemorrhage after blepharoplasties with fat removal. Retrobulbar hemorrhage results in increased intraocular pressure, leading to central retinal artery occlusion and ischemia of the optic nerve.

    • Another cause is vasospasm secondary to the adrenaline effect on the central retinal artery, leading to ischemia of the optic nerve.

    • Avoid medications that can cause bleeding episodes, such as aspirin, steroids, and anticoagulants. These medications should be stopped prior to surgery. Aspirin should be discontinued 2 weeks before the surgical procedure. Warfarin should be managed as instructed by the medical consultant.

    • Hemostasis is imperative in blepharoplasty. Avoid excessive traction of the fatty tissue. This maneuver can cause rupture of vessels deep to the fat.

    • Injection of local anesthetic into the fat tissue should be performed with caution and direct visualization of the injection site. Cauterization should be performed carefully and meticulously to achieve hemostasis after the fat tissue retracts.

    • For 2 days, patients should avoid maneuvers that increase intracranial pressure, such as straining, the Valsalva maneuver, or blowing their nose.

    • Close monitoring and care, including blood pressure checks, head elevation, and cold noncompressive eye pads, are mandatory in the first 1-4 hours after surgery.

    • Other symptoms include the eye pain (common, but not always present); proptosis, chemosis, and increased intraocular pressure; and Marcus Gunn pupil, edema of the optic nerve, or obliteration of the retinal artery.

    • Treatment of retrobulbar hemorrhage should occur as soon as it is diagnosed. Consultation with an ophthalmologist is mandatory. The sutures should be opened immediately to relieve the pressure and to see if further hemostasis is needed. Continue with ice compresses and head elevation. Give (1) mannitol 20% solution at 2 g/kg of body weight for 24 hours intravenously, not to exceed 12.5 g intravenously over 5 minutes; (2) acetazolamide (Diamox) at 500 mg slow intravenous push and then 250 mg intravenously every 6 hours for 24 hours; and (3) dexamethasone (Decadron) at 10 mg intravenous push.

    • If no improvement is achieved by these measures, consider lateral canthotomy with inferior cantholysis. Then, consider orbital decompression in consultation with the ophthalmologist.

Lower eyelid complications

  • Diplopia

    • Transient diplopia is more common in blepharoplasty procedures in which the repositioning fat technique is used. Because of the swelling caused by injected local anesthetics and the edema of the tissues in close proximity to the surgical area, diplopia is not uncommon in the immediate postoperative period if the subciliary approach for blepharoplasty is used. This is a temporary diplopia and lasts only hours or several days.

    • Permanent diplopia is rare. It is caused by damaging the inferior oblique muscle during dissection. This muscle is located between the medial and the middle fat compartment in the lower lid. Direct identification is advised in order to avoid damage by clamping, cutting, or cauterization. The consequences of its damage are diplopia in the upward and lateral gaze.

    • Most diplopia resolves over time. If the damage has been severe enough and no improvement is recognized, secondary muscle repair is advised after 6 months of observation.

  • Malposition of the lower eyelid

    • Malposition of the lower eyelid occurs because of an increased laxity of the lower eyelid or excessive skin removal.

    • A classification has been established by McGraw and Adamson to understand the different degrees of progressive lower eyelid malposition. Grade 0 is normal lower eyelid position. Grade 1 is lateral rounding of the lower eyelid without scleral show. Grade 2 is lateral rounding with central retraction of the lower eyelid with scleral show. Grade 3 is lower eyelid margin eversion with clear pooling of tears in the lower eyelid pocket. Grade 4 is clear ectropion with visualization of the palpebral conjunctiva.

  • Scleral show

    • Patients with scleral show should be told of their condition preoperatively, and, during the procedure, adjunctive surgical techniques should be used to avoid enhancement of this condition.

    • Some degree of scleral show in the immediate postoperative period is not uncommon because of postoperative edema and a deficit in the function of the orbicularis muscle. Once these factors are resolved, this type of scleral show resolves.

    • Mild degrees of scleral show can be treated conservatively with massage, Steri-Strips to hold and tighten the lateral aspect of the lower eyelid, and lubrication of the eye. At least 6 months of conservative management is necessary before advising surgery for this complication. An eyelid tightening procedure brings the lower eyelid to a higher position.

  • Ectropion

    • Ectropion is a downward retraction of the lower lid. This complication is due to an unrecognized laxity of the lower eyelid preoperatively and/or excessive removal of skin and muscle during the surgical procedure.[12]

    • Surgeons should make every effort to avoid ectropion. A preoperative evaluation of lower eyelid tone is imperative. If laxity of the eyelid is found, the surgeon should plan an adjunctive horizontal lower eyelid tightening procedure in addition to the blepharoplasty.

    • If the surgeon recognizes that excessive removal of skin has occurred during the surgical procedure, the skin should be replaced immediately. If ectropion is clearly recognized within 48 hours and the surgeon is sure that too much skin was removed, a skin graft should be placed during the 48-hour period after the initial surgery. If ectropion progresses in the postoperative period and fails to resolve with conservative measures, correction is indicated after 6 months. This usually requires a lower eyelid tightening procedure and/or possible skin grafting. The best donor sites for skin grafting are the upper lid (if not operated on previously), the postauricular skin, and the supraclavicular skin. Consultation with an oculoplastic surgeon is advisable.

  • Epiphora

    • Two types of epiphora occur, temporary and permanent. Uncontrolled tearing is not uncommon in the immediate postoperative period. This phenomenon is due, in part, to an insufficiency in the function of the lacrimal drainage system produced by an increased swelling in the operated tissues and displacement of the lacrimal puncta. Another factor is related to an increase in the tearing production due to abnormal irritation and stimulation in the immediate postoperative period. These factors resolve spontaneously. Therefore, this type of epiphora is a self-limiting phenomenon lasting approximately 4-5 days.

    • Permanent damage to the lacrimal drainage system (punctual and canaliculus) or eversion of the puncta by ectropion leads to constant, persistent epiphora. Extending the subciliary incision too close to the puncta leads to scarring and stenosis, causing damage to the lacrimal drainage system. Prevention is the best strategy. If noted during the operation, repair over Silastic stenting is advisable. If noted after surgery, permanent epiphora requires reopening, dilatation, and stenting of the lacrimal drainage system. Correction of epiphora is necessary for severe cases of eversion of the puncta. Consultation with an ophthalmologist is advisable any time the surgeon believes the epiphora is permanent.

Outcome and Prognosis

In the proper patient, any well-executed blepharoplastic approach, with precise attention to details, yields a satisfactory result for both the patient and the surgeon with minimal transient complications.

However, at present, no one particular approach achieves the best results in all patients. Selection must be on a case-by-case basis. According to recent blepharoplastic literature, selection of a specific approach is dictated by the particular characteristics of the patient, such as age, eyelid and orbital aging changes, and the presence or absence of adequate eyelid tone.

The subciliary approach has the advantage of an open flap with adequate exposure for resection of fat pads, orbicularis muscle, and skin and the possibility of correcting eyelid tone laxity if present. The main disadvantage is the increased possibility of eyelid retraction, malposition, and ectropion. Therefore, proper selection of candidates and a conservative approach in the resection of eyelid skin are advisable when applying this approach to avoid, in part, these problems.

The transconjunctival approach has the advantage of less trauma with the possibility of removing fat pads without causing eyelid retraction, malposition, or ectropion. The disadvantage is that eyelid skin and orbicularis muscle are not removed, giving less exposure and an inability to correct, if present, eyelid tone laxity. Therefore, proper selection of candidates for this approach is necessary in order to achieve the best possible result.

The repositioning/fat preservation blepharoplasty has been reported in recent publications to yield good results. It is a well-designed concept and approach that addresses the herniated fat problem. However, it is still in evolution, and the long-term results need to be evaluated further.

Standardization in the selection of the different approaches has not yet been fully achieved worldwide.

Future and Controversies

Information on cosmetic blepharoplasty will be made more available to the public due to the increase in information technology.

Cosmetic blepharoplastic web sites will become more interactive. Integration of voice, photography, and video capabilities will be available to patients and blepharoplastic surgeons alike.

The virtual cosmetic blepharoplastic office will become a reality. Dynamic interaction will increase among prospective patients, staff, and cosmetic surgeons. Postoperative blepharoplastic images will be available on the Internet for prospective candidates, even without having been seen in the surgeon's office.

For all the above reasons cosmetic blepharoplasties and blepharoplasty revisions will probably continue increasing in the future. Selection of the candidates will remain the most important step. Better standardization worldwide among surgeons using the different approaches is very possible.

The question of which blepharoplastic approach achieves the best results is tricky. No particular blepharoplastic approach yields the best results for all patients. One approach cannot be judged better than another. Furthermore, even among experienced surgeons, opinions about what is the best blepharoplasty approach varies. The artistic element in performing a blepharoplasty is difficult to measure, but unquestionably is present in each surgery.

Further, even excellent technique and great care cannot guarantee excellent or near perfect results. This is due to the individual characteristics of each patient, including their dynamic facial expressions.

The selection one approach over the other depends on the particular experience of the surgeon and the specific characteristics of the patient, such as age, eyelid and orbital aging changes, and the presence or absence of adequate eyelid tone.

Questions still remain about (1) whether the contemporary suspension/fat pad preservation technique will achieve popularity and satisfactory long-term results worldwide and (2) which patients and which eyelid changes will benefit the most from this particular technique.