Upper Eyelid Blepharoplasty 

Updated: Apr 26, 2019
Author: Eric M Hink, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Blepharoplasty is currently defined as excision of excessive eyelid skin, with or without orbital fat, for either functional or cosmetic indications.[1] Upper lid blepharoplasty may be performed in a traditional fashion, using stainless steel instruments, or may be modified with radiosurgery incisional techniques or laser incisional techniques.[2] In addition to standard suture techniques, tissue adhesives have also been used for skin closure.

The eyes and periorbital area are commonly the focal point during human conversation and communication. Changes in the eyelid appearance that are caused by aging may convey an inappropriate message of tiredness, sadness, and absence of vigor, which may diminish the aesthetic appearance of the face. In some cases, the dermatochalasis (excess eyelid skin) or steatoblepharon (pseudoherniation of orbital fat) is significant enough to cause a pseudoptosis. These patients have symptoms related to the obscuration of superior visual fields.

Sex, race, and age influence the relationships of the landmarks of periorbital anatomy. The structures around the eyes differ significantly among people of different sexes and races. These unique anatomic relationships are an important framework when surgical alterations of the periorbita are designed.

The cephalometric dimensions of the periorbital region are different in men and in women. In the female, the brow and lid crease are higher and more arched, and the lid fold is less prominent. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. In white women, the crease is usually 8-11 mm above the lid margin; in white men, it is usually 6-9 mm above the eyelid margin.

In contrast to white anatomy, the Asian eyelid has more fullness of the upper eyelid, narrower palpebral fissures, medial epicanthal folds, and a lid crease closer to the eyelid margin. The lid crease in the Asian population can be absent, nasally tapered, or flat but typically lies lower and is flatter than the typical white patient. This is because the orbital septum attaches to the levator aponeurosis at or slightly above the superior tarsal border or over the anterior surface of the tarsus.

Cosmetic surgeons must evaluate the periorbital aesthetic relationships before performing blepharoplasty surgery. Additionally, a basic ophthalmology examination, including testing visual acuity and testing for dry eyes, should be performed.

Blepharoplasty may be performed as an isolated procedure or in combination with ptosis repair, or rejuvenation of the upper and lower face. In particular, the aging process affects the position of the forehead, brows, and cheek complex. These all contribute to the position and appearance of the eyelids.

Actinic and degenerative changes of the facial skeletal and soft tissues lead to loss of elasticity of the skin, fat atrophy or redistribution, downward descent of the facial units, and rhytides. These features are all evaluated in the assessment of the upper eyelid and in the planning for surgical procedures to alter the periorbital tissue.

History of the Procedure

Cosmetic eyelid surgery has been described for over a century. Aulus Cornelius Celsus discussed skin excision in the upper eyelid in his De re Medica, published in 1478. In 1818, von Graefe used the term blepharoplasty (from the Greek blepharon, meaning eyelid, and plastos, meaning formed) to describe a case of eyelid reconstruction. In 1817, Beers wrote and described the first illustration of eyelid deformity caused by fat herniation and a mechanical ptosis due to excess skin. Some authors called this finding ptosis adiposa. Fox introduced the term blepharochalasis to describe the apparent excess of eyelid skin associated with aging changes.

Problem

Aesthetically, the eyes are an important facial unit, as well as a sensitive projector of facial aging. Patients may experience tired eyes, sad eyes, or extra tissue around the eyes. Dermatochalasis, fat herniation or protrusion, brow ptosis, and eyelid ptosis secondary to disinsertion or dehiscence of the levator aponeurosis all contribute to a patient's perception for the need of an upper eyelid blepharoplasty.[3]

This article discusses aging changes in the upper eyelid secondary to dermatochalasis and describes surgical techniques to modify these changes. Traditional upper lid blepharoplasty techniques, indications for surgery, psychological considerations in candidates for cosmetic surgery, and complications are also discussed.

Epidemiology

Frequency

The number of blepharoplasties performed has continued to increase over the last 20 years. Blepharoplasty continues to be the most common invasive cosmetic surgical procedure of the face. Blepharoplasty is performed more often in women than in men. Women continue to request the procedure at a younger age than males. Cosmetic blepharoplasty is most commonly performed in the fifth decade of life.

Etiology

Aging changes in the eyelid are caused by a combination of degenerative and pathological processes (sun damage) that alter the skin and periorbital structures. Dermatochalasis results from aging changes in the skin and adnexal structures in the eyelid and brow. With age, the orbital septum, which is a distensible anatomical layer of the eyelid, weakens. New evidence suggests the orbicularis retains its morphology and function with age and may not be a contributing factor to dermatochalasis.[4]

The action of gravity on the fat and contents of the orbit produces a downward and anterior displacement of the orbital fat due to a loss of the septal and muscle support of the fat pads. Dehiscence or weakness of the levator aponeurosis may also cause an involutional ptosis associated with dermatochalasis. In the skin, the elastic fibers, collagen fibers, and ground substance demonstrate changes secondary to sun damage and degenerative processes (see Pathophysiology). The resultant loss of elasticity in the skin creates broadened surface areas of epidermis necessary to cover the protruding fat. This contributes to the redundant tissues of the upper lid.

Pathophysiology

Dermatochalasis is a process that occurs secondary to changes in collagen fibers, elastic fibers, and ground substances in the dermis and epidermis. The eyelid skin is divided microscopically, from superficial to deep, into the epidermis, the dermis, and the subcutaneous tissue. Aging and sun exposure are the primary factors that produce dermatochalasis by reducing the number of collagen and elastic fibers in the dermis. In addition, the epidermis becomes atrophic, the collagen content is reduced, and biochemical changes occur in the elastic fibers.

Indications

Upper eyelid blepharoplasty is performed for various functional or cosmetic indications. The upper eyelids protect the globe, distribute tears on the surface of the eye, and facilitate the drainage of tears through the lacrimal apparatus. If any of these functions is impaired or significant ptosis of the upper eyelid blocks vision, the physician must determine if a surgical procedure is indicated.

A literature review by Hollander et al indicated that beneficial results from upper eyelid blepharoplasty include a greater visual field and an enhanced quality of life in association with improved vision and a reduction in the number of headaches. Conflicting results were found with regard to the surgery’s impact on eye dryness and eyebrow height.[5]

Cosmetic upper lid blepharoplasty is an elective procedure performed to improve the appearance of the eyes. This procedure requires alteration of the relationships of the eyebrows, the sub-brow fat, upper lid dermatochalasis, or upper lid steatoblepharon. Often, the patient describes tired-looking or droopy eyes.

One of the most important issues that all facial plastic surgeons should consider is the psychological status of the cosmetic patient. The two most important issues to evaluate before the surgeon agrees to perform a cosmetic blepharoplasty procedure include the patient's motivation and expectation of the outcome. The best way to produce a satisfied patient is to have clearly defined and well-understood goals for the surgery. Patients who anticipate secondary gains such as improvement in personal relationships or professional status are not good candidates for cosmetic surgery. Patients who expect this type of result judge the success of the surgery by their own personal satisfaction rather than by restoration of aging changes.

Relevant Anatomy

For any physician involved in the care and surgery of the periorbital structures, thorough knowledge of the anatomy is vital in order to achieve the optimal results and to avoid potential complications. Superior to the level of the tarsus, the upper eyelid consists of several individual layers from anterior to posterior: skin, orbicularis muscle, orbital septum, preaponeurotic or orbital fat, eyelid retractors (levator palpebrae superioris and Müller muscle), and conjunctiva. At the level of the superior tarsus, the layers from anterior to posterior include skin, orbicularis muscle, fibers from the levator palpebrae, tarsus, and conjunctiva. Superficially, the skin of the upper eyelid is the thinnest throughout the body. The orbicularis muscle is divided into the pretarsal, preseptal, and orbital orbicularis, depending on the structure immediately posterior to it.

The orbital septum attaches between the bony orbital rim at the arcus marginalis and the levator aponeurosis several millimeters above the tarsus. The fat in the upper eyelid consists of medial and middle fat pads. The medial fat pad is located just medial to the medial horn of the levator aponeurosis in the upper eyelid and is considered orbital fat. It is often whiter than the preaponeurotic fat. The middle fat pad is considered preaponeurotic fat and is immediately anterior to the levator aponeurosis.

The superior levator muscle originates at the apex of the orbit and divides into an anterior aponeurotic layer innervated by cranial nerve III and the posterior superior tarsal muscle (Müller muscle) innervated by the cervical sympathetic system. The anterior aponeurosis attaches to the anterior tarsal surface with fibrotic bands that attach to the pretarsal muscle and skin, and the Müller muscle inserts on the superior tarsal border. Posteriorly, the tarsus is a plate of dense connective tissue that occupies the inferior aspect of the upper eyelid with several meibomian glands on the inferior border. The conjunctiva is attached to the tarsus and superior tarsal muscle.

In the eyelids of whites, the orbital septum inserts on the anterior surface of the levator aponeurosis 2-5 mm above the superior tarsal border. The preaponeurotic fat is located beneath the septum and is shaped by the position of the orbital septum. The eyelid crease is determined by the insertion of extensions of the levator aponeurosis to the skin. The contours of the eyelid fold are influenced by the position of the orbital septum. The eyelid crease and fold are important aesthetic landmarks and are a vital feature of the upper eyelid appearance.

In white women, the crease is usually 8-11 mm above the lid margin; in white men, it is usually 6-9 mm above the eyelid margin. In contrast, the Asian eyelid has more fullness of the upper eyelid, a lower lid crease, and narrower palpebral fissures. A medial epicanthal fold may also be present. The lower lid crease is due to the orbital septum inserting into the levator at or over the anterior surface of the tarsus. With this anatomic configuration, the lid fold overlaps and obscures the position of the eyelid crease.

Prior to surgery, the surgeon should discuss lid crease position with the patient to determine the patient's desires regarding the postoperative lid crease position. The location of the incision and the technique of closure are modified according to the desired confirmation of the eyelid crease. Some asymmetry in preoperative margin crease distance may result from disinsertion of the levator aponeurosis. This should be considered by the surgeon prior to surgical intervention. Blepharoplasty alone does not modify this asymmetry.

The globe position (hypoglobus, hyperglobus, enophthalmos) and globe protrusion should be evaluated prior to surgery. Asymmetry of globe position may alter the appearance of the superior sulcus, and blepharoplasty alone does not necessarily correct the full asymmetry.

Surgery of the Asian eyelid is unique and is not detailed in this article. However, it is important to take into account the varied shape of the upper eyelid tarsus in Asians before performing blepharoplasty.[6]

Contraindications

Patients who anticipate secondary gains, such as improvement in personal relationships or professional status, are not good candidates for cosmetic surgery. Patients who expect this type of result judge the success of the surgery by their own personal satisfaction rather than by restoration of aging changes.

 

Workup

Diagnostic Procedures

Patients must undergo a complete medical evaluation prior to upper eyelid blepharoplasty.

  • All current medical conditions must be discussed.

  • Whether cosmetic or functional, upper lid blepharoplasty is an elective procedure, and underlying medical conditions must be evaluated and treated prior to elective surgery.

  • Patients with thyroid eye disease should exhibit 12 months of stability in their orbitopathy before elective cosmetic surgery.

  • A history of keloid scar formation or dry eyes is concerning but not a contraindication for upper lid blepharoplasty.

  • Abnormal coagulation and actively inflamed blepharitis should be addressed prior to surgery.

  • Specific questions should be asked about Graves disease, other thyroid abnormalities, autoimmune and inflammatory diseases, dry eye syndrome, chronic blepharitis, previous refractive surgery such as laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK), and other conditions that may alter the natural recovery process after blepharoplasty.

  • A history of allergic reactions is obtained in order to avoid complications from medications used before or after the procedure.

Current medications, including vitamins, herbs, nonsteroidal anti-inflammatory medications, and aspirin, need to be documented. To avoid a postoperative hemorrhage, preoperative clearance must be obtained to stop all medications that cause platelet dysfunction and tendencies for increased bleeding.

The evaluation should include a thorough ophthalmologic evaluation that includes visual acuity, ocular motility, visual field testing, and basic tear secretion testing such as the Schirmer test. The Schirmer test is performed by placing a strip of test paper over the temporal palpebral conjunctiva and measuring the wetting on the strip after 5 minutes. If the measurement is less then 10 mm (reference range is >10 mm), the patient may have difficulty producing tears, which may be a contraindication to blepharoplasty. The value of the Schirmer test in predicting postoperative dry-eye problems is controversial.

Examination of the patient should include an evaluation of specific landmarks, including palpebral fissure distance; margin reflex distance-1 (MRD1), which is the distance between the center of the pupil in primary position and the central margin of the upper eyelid; margin reflex distance-2 (MRD2), which is the distance between the center of the pupil in primary position and the central margin of the lower eyelid; margin fold distance; and eyelid crease position, as depicted in the image below. Ptosis of the upper eyelid should be suspected when the palpebral distance is less than 10 mm (reference range is 10 mm) and MRD1 is less than 4 mm (reference range is 4-4.5 mm).

Clinical photograph of the complete face used to e Clinical photograph of the complete face used to evaluate specific landmarks such as brow position, palpebral fissure, margin reflex distance-1 (MRD1), margin reflex distance-2 (MRD2), margin fold distance, and eyelid crease position.

The individual components of the periorbital region are thoroughly assessed prior to surgery.

  • The surgeon assesses the relationship of the brow position to the upper lid and makes an early decision as to whether isolated upper lid blepharoplasty is sufficient or whether brow position adjustment is necessary to achieve the desired results. The patient should be reminded that the tail of the brow may be further pulled downward following isolated upper eyelid blepharoplasty.

  • Manual elevation of the brow to the desired position allows the patient and surgeon to assess the role the brows play in the appearance of the upper eyelid. In males, the brow is positioned along the supraorbital rim. In females, the brow is elevated to a position at or up to 1 cm above the supraorbital rim. This is done with the patient in an upright position and with the patient looking in a mirror to help judge how brow position affects the upper eyelid.

  • Repositioning of the brow, the brow fat pad, and the skin between the lid crease plays a profound role in the appearance of the upper eyelid. Do not let the patient underestimate its relevance to the upper eyelid appearance.

Once brow position has been determined, the surgeon assesses the components of excess skin, skin laxity, and fat herniation in the upper lid. Upper eyelid aging changes are typically a combination of excess skin or skin laxity, causing redundancy of the tissues. Excess or herniated fat causes a protrusion or convex contour of the upper eyelid. The medial or nasal fat pad, the middle fat pad, and the lacrimal gland in the temporal upper eyelid influence the overhang of the upper lid fold. The sub-brow fat may also descend into the superior sulcus, altering the indentation between the lid fold and the brow. The position and protrusion of these tissues are amenable to surgical modification.

Photographs are taken to document the clinical findings in each patient, as depicted in the image below. Traditional views include full face and a close up of the eyes in primary, upward, and downward gaze. Additional views may include right and left oblique views and a lateral view to document the globe position relative to the inferior orbital rim.

Clinical photograph showing a male patient with ag Clinical photograph showing a male patient with aging changes that include brow ptosis, dermatochalasis, and steatoblepharon in the upper and lower lids.
 

Treatment

Medical Therapy

No common medical treatments are suggested to correct the excess skin and fat of the upper eyelid. In patients with severe functional deficits in visual fields or contraindications to elective surgery, spectacles with a ptosis crutch or taping up of the dermatochalasis may provide some temporary and inconvenient improvement.

Surgical Therapy

Traditional blepharoplasty is performed with an external incision in the upper eyelid crease. In conjunction with upper lid blepharoplasty, the brow position is corrected through direct and indirect elevation techniques. Numerous techniques may be used to address brow ptosis, including a direct incision, brow pexy, endoscopic forehead brow lift, pretrichial brow lift, and coronal incision. A full description of these surgical techniques is beyond the scope of this article. Additionally, internal or external ptosis repair, canthoplasty, and lower eyelid blepharoplasty may be performed concurrently. Laser resurfacing is frequently used to correct aging changes of the skin in the periorbital region. The effect of laser resurfacing on the epidermis and dermis is to smooth the skin by resurfacing the epidermis and stimulating the rearrangement of collagen in the dermis.

Preoperative Details

Preoperatively, surgical landmarks and planned skin excisions are marked on the patient. Many techniques are used for marking the upper eyelid incisions, but some basic principles should be followed to minimize complications and to achieve reproducible results. With the patient in an upright position, the surgeon uses a fine marking pen to draw the incision lines on the surface of the eyelid skin. The lid crease incision is marked first, generally following the eyelid crease in the upper lid. If alteration in the natural position of the crease is desired, the incision may be placed at the desired location of the postoperative crease rather than the natural eyelid crease.

The natural crease is typically located 8-11 mm above the eyelid margin in females and 6-9 mm in males. The eyelid crease is curvilinear in white patients. The arc of the incision peaks just nasal to the central point of the eyelid. Nasally, the incision should be limited by a line drawn upward from the medial commissure, avoiding the deep concavity of the medial canthal region. The temporal aspect of the lid crease incision is curved gently upward, extending toward but generally not beyond the orbital rim.

To assess the amount of skin to be removed, the surgeon may use the pinch technique. The patient is asked to gently close the eyelids. A smooth forceps is used to grasp the excess skin above the eyelid crease incision just until the eyelashes begin to rotate upward. This is marked as the maximum amount of skin that may be safely removed.

For a clear margin of safety, the superior border of the incision should pass no closer than 1 cm from the inferior border of the brow hairs. This prevents excess skin removal that may cause lagophthalmos and also prevents the blepharoplasty excision from causing downward traction on the brow position. The appearance of the incision may also be less than optimal if the upper incision is made too close to the brow hair. This would be the case when a patient with brow ptosis undergoes an upper eyelid blepharoplasty without lifting the brow. The thickness of the skin increases as it nears the brow and forehead. Creating a junction between the thin eyelid skin and the thicker brow skin results in uneven closure. Carrying the incision too far medially may result in cicatricial band formation or a medial web. Lateral extension of the incision beyond the orbital rim also results in a more prominent and visible scar.

Once the skin has been marked with the patient in an upright position, the surgeon gently presses on the globe to observe protrusion of the fat pockets. Protrusion or prolapse of the lacrimal glands is noted, and when present, resuspension of the lacrimal glands is considered. The location and amount of sub-brow fat is assessed and considered for surgical contouring. This is especially relevant in the absence of a brow lift procedure.

Intraoperative Details

Both topical and local anesthesia is used during upper lid blepharoplasty surgery. A topical anesthetic such as tetracaine may be used for conjunctival anesthesia if a protective shield is used.

Local infiltration provides sufficient blockage of pain sensation for isolated upper lid blepharoplasty. Lidocaine (Xylocaine 0.5-2%) is the most frequently used agent for infiltrative anesthesia because it diffuses well through tissue and produces little irritation. When it is used without epinephrine, the effects last about 30 minutes.

When the anesthetic agent is mixed with epinephrine, this causes vasoconstriction and prolongs the duration of analgesia to 60-90 minutes and decreases the rate of absorption. The epinephrine is also beneficial for intraoperative hemostasis. In order to decrease the discomfort associated with infiltration, sodium bicarbonate may be used as an additive agent to modify the pH of the solution. This results in less chemical irritation and pain with the local anesthetic injection but significantly decreases the effective duration.

For local infiltration in upper lid blepharoplasty, 1-2 mL of anesthetic is placed subcutaneously at the surgical site. The surgeon should use enough agent for anesthesia and hemostasis but no more than necessary because the volume of the local anesthetic disrupts the surgeon's ability to assess the contours of the tissues. When the eyelid or sub-brow fat pads are to be contoured during the procedure, additional local anesthetic is injected into the fat pads when these planes are surgically exposed. The initial subcutaneous injections do not adequately diffuse through the orbital septum to anesthetize the fat.

Anesthesia for upper lid blepharoplasty may be augmented with the adjunctive use of regional anesthesia (peripheral nerve block) and systemic sedation. Injection of local anesthetic near a peripheral nerve produces anesthesia over the distribution of the nerve. A peripheral nerve block is used for facial surgery to block the trigeminal nerve branches. In the case of upper lid blepharoplasty, a frontal or supraorbital nerve block may be used. Additional anesthetic may be necessary to locally block the lateral portion of the lid that may be partially innervated by the zygomaticotemporal branch of the maxillary nerve. Regional nerve block is rarely necessary for cosmetic blepharoplasty.

Systemic sedation may also be administered to augment the effect of the local anesthetic. Oral premedication may be used to reduce the patient's anxiety. Diazepam (Valium), at a dose of 5-10 mg orally, is the most common premedication used. Intravenous sedation may also be administered for induction and maintenance of anesthesia during the surgery. The most frequently used agents include midazolam, meperidine, fentanyl, and propofol. Standard protocol for monitoring of sedation anesthesia should be strictly used. The objectives of the intravenous sedative agents are to diminish the discomfort produced from local anesthetic injection, decrease patient anxiety, and augment intraoperative and postoperative analgesia. Amnesia may be considered an additional advantage of these agents.

After injection of the anesthetic agent, adequate time (7-10 min) is allowed for the epinephrine to cause vasoconstriction. If the surgeon desires, a protective scleral shell may be placed over the surface of the eye after placement of topical anesthetic. Most commonly, a No. 15 or other suitable blade is used for initial incision of the skin. The procedures described in these paragraphs involve traditional plastic surgical instruments, but other devices such as laser or radio frequency surgical instruments may be used in place of surgical steel. The excess skin is removed, either alone or with part or all of the underlying orbicularis muscle.

If only skin has been removed, the fibers of the orbicularis oculi muscle are clearly visible. If removal of the orbicularis is desired, Westcott scissors or monopolar cautery can be used to resect a strip of muscle. From the preoperative evaluation, if the surgeon has determined that the patient needs removal of eyelid skin, sub-brow fat, reconstruction of the eyelid crease, eyelid ptosis correction, brow ptosis correction, modification of the glabellar wrinkles, or resuspension of the lacrimal gland, any one or all of these procedures may be performed through this lid crease incision.

After incision of the orbicularis muscle, the surgeon identifies the orbital septum. The safest approach to the orbital septum is just below its attachment to the arcus marginalis, where the underlying levator muscle with its aponeurosis is not as likely to be injured if the septal resection is aggressive. When fat is to be removed, the orbital septum is opened to expose the preaponeurotic fat. In the upper eyelid, 2 fat pockets are present; one is central and the other is nasal (medial). When gentle pressure is placed on the globe, the fat tends to protrude through the open septum. The medial fat pad has a creamy yellow, almost white, color that is recognizable and distinct from the deeper yellow color of the central fat pad. The medial fat pad can be located just medial to the medial border of the levator expansion.

Additional local anesthetic is placed beneath the capsules of the orbital fat. The capsules are opened and the pads are trimmed to create the desired contour of the eyelid. Excess fat resection can result in a superior sulcus or "A-frame" deformity and should be avoided.

Hemostasis is a vital step in fat removal. This can be accomplished with clamping or careful cautery as the structures are cut or removed. In one technique, a small hemostat may be used to grip the excess fat that will be removed. The fat anterior to the clamp is removed using a No. 15 blade, and bipolar cautery is used for hemostasis prior to release of the clamp. Once the hemostat has been removed, the base of the fat pedicle tends to retract. The surgeon may grasp the fat pedicle with a forceps to fix the tissue while checking for hemostasis. Alternately, the base of the fat pad can be bipolar coagulated without clamping the fat if careful attention is given to complete cautery of the stump. The surgeon watches carefully for signs of bleeding that could lead to orbital hemorrhage. These are controlled prior to release of the pedicle.

The fat is kept and labeled according to eyelid and location so the surgeon can compare the amount of tissue removed from the 2 eyelids. Sometimes, fat is repositioned rather than removed to smooth the contour of the lid fold. This should be considered in thin elderly patients with fat atrophy and a deep superior sulcus but a protruding nasal fat pad.

If the lacrimal gland is found to be protruding from its usual lateral position under the orbital rim, simply suturing it back in position inside the orbital rim prevents postoperative fullness in the lateral aspect of the upper eyelid. This can be accomplished with an absorbable 5-0 suture such as polyglactin.

When the surgeon wishes to alter or emphasize the eyelid crease, a supratarsal fixation suturing technique is used to create adherence between the skin and underlying tissue. This may be accomplished by attaching the subcutaneous tissue at the lower aspect of the eyelid crease incision to the levator aponeurosis just above the tarsus. A longer-acting absorbable suture such as 6-0 polyglactin would be appropriate. Another technique that may be used is a full-thickness mattress suture through skin, orbicularis oculi, levator aponeurosis, and conjunctiva and then back out through conjunctiva, levator aponeurosis, orbicularis oculi, and the skin on the opposite side of the incision.

A more rapidly absorbable suture such as 6-0 chromic gut should be used, and the corneal surface must be monitored when full-thickness eyelid crease reformation techniques are used. The crease reformation may also be incorporated into the skin closure by constantly or intermittently imbricating the levator aponeurosis between the passes that approximate the upper and lower skin edges. Permanent or absorbable sutures may be used for this type of lid crease reformation.

Different techniques of skin closure exist, and different materials may be used to create adherence of the incised skin edges. Commonly used materials include nonabsorbable sutures, such as 6-0 nylon or 6-0 polypropylene, in a running subcuticular fashion, interrupted fashion, or in an external running fashion. Another material frequently used is 6-0 fast-absorbing gut suture. The absorbable suture eliminates the discomfort of suture removal. Suture materials such as 6-0 polyglactin or 6-0 black silk have also been used for continuous closure of the skin incisions. All sutures are removed in 5–7 days. Tissue adhesives (glue) have been described as a closure technique for upper eyelid blepharoplasty incisions.

A randomized, controlled trial by Pool et al indicated that in patients undergoing upper eyelid blepharoplasty, starting the medial intradermal suture internally (within the blepharoplasty wound) rather than externally (in intact skin next to the wound) reduces the risk of medial suture abscess and wound inflammation. The investigators found that at 1-week follow-up, the incidence of medial upper eyelid abscesses was 13.3% for the internally sutured eyelids, compared with 40% for the externally sutured eyelids, with erythema and edema also being significantly less frequent in the internally sutured lids.[7]

Postoperative Details

Immediately after the surgery, an antibiotic ophthalmic ointment is placed over the skin incision. Ice compresses are used for 48 hours, 20 minutes per hour while awake, following the procedure. The skin is cleaned daily, and antibiotic ointment is applied to the incision before bed for 5 days. Some edema and ecchymosis are normal after this procedure, and the cold compresses help to minimize this and diminish patient discomfort. Acetaminophen is routinely prescribed, and, in some cases, a narcotic pain medication prescription may be given. The patients are asked to avoid heavy lifting, sudden bending, and strenuous sporting activities for 2 weeks following the procedure. Showering is permitted the day following the procedure. Normal activities may resume after 2-3 weeks.

Follow-up

Patients are seen the following day after upper eyelid blepharoplasty to evaluate the swelling and ascertain that the eye is soft without any evidence of bleeding. The incisions are examined, and the patient is shown how to care for the wounds. Patients are instructed to keep the incisions clean and dry by gently going over the incision line with a cotton tip applicator soaked with a dilute hydrogen peroxide solution. At that time, any additional questions or concerns are addressed. Patients are then seen 5-7 days after the operation to remove the sutures.

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

Complications

Patients may have the misconception that cosmetic blepharoplasty is a quick, simple, and complication-free procedure. With proper planning, adequate physician skill, and good patient selection, this may be the case. However, unsatisfactory results and unexpected complications still occur.

Bleeding and infection are uncommon serious complications. To help avoid eyelid hematoma and visual loss secondary to retrobulbar hemorrhage, control hypertension and discontinue use of medications that predispose to bleeding. The use of careful and diligent hemostasis at the time of the surgery is of the utmost importance. Retro-orbital hemorrhage and visual loss are, fortunately, uncommon complications. The reported incidence of blindness after blepharoplasty is 1 per 40,000 patients. Retro-orbital hemorrhage is most common after lower eyelid blepharoplasty.

Bleeding in the retro-orbital space may cause an acute compartment syndrome that requires urgent action. Skin sutures are removed, the hematoma is evacuated, and, if active bleeding is present, the wound is re-explored to find the source of the hemorrhage. If these procedures do not resolve the compartment syndrome, a lateral canthotomy and cantholysis may be performed. Intravenous mannitol and steroids can be used to decrease the intraocular pressure secondary to exophthalmos and vascular congestion. In unusual circumstances, orbital decompression may be required to decrease the orbital pressure.

Eyelid infections following blepharoplasty are very rare because of the rich vascularity of the upper eyelids. However, when they do occur, prompt attention and treatment with appropriate antibiotics is undertaken. The wound is opened, drained, and cultured, and any necrotic tissue is débrided.

Severe pain is not expected after upper eyelid blepharoplasty. A mild analgesic without aspirin is usually adequate to control postoperative discomfort. If uncontrollable pain is present following blepharoplasty, an examination is urgently performed to evaluate for the source of the pain.

Excess skin removal or inappropriately placed skin incisions may cause problems. Extension of the incision over the medial canthal angle may result in band formation or webbing. Extension of the incision past the lateral orbital rim may also result in a visible scar or folds. Excessive skin removal from the upper lid may result in lagophthalmos with exposure keratitis, ectropion of the upper lid, or downward traction of the brow position that exacerbates brow ptosis. This complication can be avoided with meticulous preoperative measurement of the amount of skin to be removed. Mild lagophthalmos may occur in the immediate postoperative period, which is treated with lubricant eye drops and ointment.

Severe lagophthalmos may result from excess skin resection, scarring of the orbital septum to the skin, excess levator advancement, or unusual scar contraction. A second operation may be required to release the adherence of the septum on scar tissue or to place a skin graft to repair the anterior lamellar shortening in the upper eyelid.

Blepharoptosis is an uncommon complication that may occur secondary to inadvertent levator injury during the procedure. Observation and repair of the levator aponeurosis is required if the ptosis persists longer than 6 months. Transitory mechanical ptosis is sometimes found secondary to eyelid edema or hematoma.

Extraocular muscle imbalance (diplopia) may result from inadvertent damage to the superior oblique muscle during the excision of medial fat pad. Cautery and tissue removal in the medial supraorbital quadrant may result in injury to the superior oblique tendon.

Hollowing of the soft tissue above the lid crease or a deep superior sulcus results from excessive fat removal in the upper eyelid. Residual excess skin or fat is another problem that may cause asymmetry or folds in the eyelids and, thus, an unhappy patient. Asymmetry of eyelid creases is occasionally the result of poor preoperative planning or a less-than-gratifying response to the surgeon's attempt to alter the crease position. In patients with a preexisting unilateral ptosis, the asymmetry may appear more prominent following removal of the overlying skin folds.

Outcome and Prognosis

Upper lid blepharoplasty results in improvement of the natural aging changes. The main indication for functional upper lid blepharoplasty is correction of the excess skin of the upper eyelid, thereby resulting in visual field improvement. The indication for cosmetic upper lid blepharoplasty is to improve appearance, as shown below.

Preoperative (left) and postoperative (right) clin Preoperative (left) and postoperative (right) clinical photographs for upper lid blepharoplasty. The upper eyelid position, dermatochalasis, and steatoblepharon are aging changes that may be addressed with this technique.

A cross-sectional study by Putthirangsiwong et al found that 15% of patients who underwent upper eyelid blepharoplasty experienced a postoperative reduction in the marginal reflex distance–1 of more than 1 mm. This distance change was particularly likely in patients in whom orbicularis resection was performed.[8]

No reports describe long-term follow-up of patients after upper lid blepharoplasty. The prognosis in this surgery depends on many factors: sex and age of the patient at the moment of the surgery, race, underlying medical conditions, brow structure, type of skin, and previous skin damage by the sun.

Dissatisfaction after upper lid blepharoplasty may be related to unrealistic surgical expectations by the patient. The patient's motivations and expectations are important points to discuss in depth during the preoperative consultation. Patients who expect positive alterations in their personal lives after surgery are poor candidates for cosmetic blepharoplasty. Aging changes such as redundant skin around the eyes and fat herniation may be improved with surgery; however, dynamic wrinkles around the eyes (particularly crow's feet) are not corrected with blepharoplasty. Patient goals should be established before the surgery is performed.

A prospective cohort study by Bahceci Simsek indicated that upper eyelid blepharoplasty can relieve tension-type headaches, as can ptosis repair. In the study, 38 out of 108 patients who underwent standard upper eyelid blepharoplasty and 28 out of 44 patients who underwent ptosis repair (levator resection, Müller muscle resection, or frontalis suspension) had tension-type headache symptoms. In both groups, the Headache Impact Test (HIT-6) scores improved significantly after surgery (mean 13.5-week follow-up), dropping from a mean preoperative figure of 55.9 to a postoperative score of 46.4 in the blepharoplasty patients, and from 60.0 to 42.3 in the ptosis repair group.[9]

Future and Controversies

New technology alters and refines the techniques but not the indications for upper eyelid blepharoplasty. Laser resurfacing of the eyelids, as well as incisional laser surgery, is becoming increasingly popular. Botulinum toxin type A may be used as an adjuvant to blepharoplasty to treat the lateral canthal wrinkles or to modify brow position. Prevention is less expensive than treatment, and increased consciousness of health issues may contribute to cessation of smoking and protection from ultraviolet light.