Upper blepharoplasty

Because blepharoplasty surgery is concerned with anatomy, understanding the surface anatomy of the eyelid complex and its deep underpinnings leads to an accurate assessment of the individual patient, as well as to a sound surgical plan. The best way to learn what blepharoplasty accomplishes is by examining preoperative and postoperative photographs of blepharoplasty patients. This discipline of photograph review should extend to the individual surgeon’s own patients, so that one can learn from one’s own experience.

Aging changes are important. Although some young patients come in for blepharoplasty because of congenital characteristics that displease them, most patients seek blepharoplasty surgery because of age-related changes in the eyelid complex, which are characterized by skin texture changes (with loss of elasticity and formation of wrinkles), enophthalmos (with loss of fat), and inferior displacement of fat (with lower eyelid fat prolapse). It is important to avoid excessive fat removal from the upper eyelid, and attention to eyebrow position is critical for successful rejuvenation of the aging eyelid complex.

Upper eyelid fullness is generally a congenital condition (Fig. 51.6A). It can be addressed by removal of fat from the upper eyelid, exposing the underlying levator aponeurosis and tarsus (Fig. 51.6B, presurgery and C, postsurgery). The surgeon must recognize when the fullness in the eyelid complex is caused by eyebrow descent. The eyebrows are held at a certain position by the tone of the frontalis muscle, which maintains comfortable vision. If heavy tissues are removed from below the brow, it will descend to its resting position (Figs 51.7 and 51.8).

Fig. 51.6 (A) Upper eyelid fullness is generally a congenital condition as demonstrated in photographs of this patient at a young age. (B) In middle life. (C) The same patient with good structure and good eyebrow position demonstrating effective conservative removal of redundant tissue to display the underlying structure of the septal fat pannus in the upper eyelid to reveal the underlying platform of tightly apposed skin, levator, and tarsal plate.

Fig. 51.7 Eyebrows maintained in comfortable position for vision by frontalis tone.

Fig. 51.8 Eyebrow descent cause by release of frontalis tone following blepharoplasty.

If too much of the septal fat pannus and ROOF (retro-orbicularis oculi fat or eyebrow fat pad) is removed, the underlying structures will be exposed to an undesirable degree (Fig. 51.9A and B). As already mentioned, excessive hollowness of the superior sulcus gives an aged appearance to the eyelid complex. Blepharoplasty in the thin aged upper eyelid must be conservative, with minimal removal of fat. Because there will not be much of a septal fat pannus or eyelid fold to cover the incision, the crease is often made high in the eyelid where it will fall into the shadow of the superior sulcus and be relatively hidden.

Fig. 51.9 (A) Removal of too much of the orbital fat and associated soft tissue reveals the deep structures of the levator and orbital rim (B) (including the inverted ‘V’ of the superior orbital notch and valley of the superior oblique tendon).

If the globe is relatively prominent, the tarsal platform show will be more readily exposed by removing orbital fat (Fig. 51.10). The orbital fat and full eyelid tissues actually benefit the patient by masking underlying proptosis. In this situation the admonition ‘big eye, big trouble’ should be heeded, and fat removal should be conservative or even avoided altogether, perhaps in favor of orbital decompression for proptosis reduction.

Fig. 51.10 The orbital fat and full eyelid tissues actually benefit the patient by masking underling proptosis. Prominent globe is revealed by orbital fat removal. In the circumstance of a prominent globe, fat removal should be conservative or avoided altogether.

Among Caucasian patients, the most obvious structural variations are those between men and women. Women should have a high, arched brow with a relatively deep superior sulcus, and a well-defined upper eyelid crease. Men typically have a straight brow, perpendicular to the nose, with a minimal sulcus and a low, subtle upper eyelid crease. Clearly, with different goals in mind, different approaches must be employed for men and women. There are, however, a few consistencies. Of note, the lateral canthus generally lies 2 mm superior to the medial canthus; the upper eyelid generally crosses the cornea 1–2 mm below the superior limbus, and the lower eyelid generally crosses the cornea tangential to the inferior limbus.

Racial variations are also significant in planning and executing upper blepharoplasty. For example, compared with the Occidental configuration, the Oriental eyelid is characterized by a full, sometimes bulging superior sulcus and a low crease with narrow or absent tarsal platform. The crease narrows medially to form an epicanthal fold. The fullness is based anatomically on abundant and somewhat fibrotic fat in the subcutaneous, suborbicularis, and postaponeurotic spaces. This abundant fat can be carefully sculpted because it is fibrotic, but it is unforgiving, so it is easy to create a contour abnormality, a visible dent, or an undesired second crease if the fat is not evenly, or conservatively, sculpted. The goal of Asian blepharoplasty is usually to retain the full characteristic of the eyelid while better defining the thin tarsal platform show. To accomplish this, conservative debulking of the inferior edge of the septal fat pannus (with sparing and avoidance of the remainder) is performed. Fixation of the orbicularis or skin edge to the exposed tarsus can also be performed to create a firm, low, and meticulously symmetric crease (Fig. 51.11A and B).

Fig. 51.11 Blepharoplasty in the Asian eyelid must respect the fullness of the orbital, preseptal, and eyebrow fat pads: to preserve the racial characteristic, a low tarsal platform is maintained by designing a low crease incision that follows the medial epicanthal fold and by excising fat conservatively at the inferior edge of the septal fat pannus allowing the crease to form onto the tarsal plate. In this Asian patient with full septal fat pannus and preorbicularis fat (A) conservative tissue removal preserves the full Asian eyelid and low eyelid crease (B).

Removal of more skin and associated orbicularis muscle than is necessary is not only the mark of the inexperienced or unsophisticated blepharoplasty surgeon, it is also the cause of most of the functional problems associated with the surgery. The significant effect of minimal skin removal can be appreciated in ‘touch-up,’ or reconstructive, upper eyelid surgeries.

Lower blepharoplasty

Lower blepharoplasty addresses the contours of the lower eyelid and cheek. When evaluating patients for possible lower eyelid surgery, the contours of the orbital fat should be observed. Often the medial, central, and lateral fat pads can be identified and individually graded (Fig. 51.12). This type of analysis helps with surgical planning. Inferior to the fat pads, the orbital rim can be seen as a groove marking the arcus marginalis, or orbital septal insertion. There exists an orbitomalar ligament that folds the skin. Medially, the groove can be quite prominent and is often referred to as the ‘tear trough deformity’. Inferior to the groove of the orbital rim, the cheek fat forms various contours over the face of the maxilla and malar prominence. Descent of the SOOF fat pad gives rise to a hollow region below the orbital rim that is bordered inferiorly by a visible trailing edge of the descended SOOF fat pad. Young patients may have a congenitally prominent tear trough deformity.

Fig. 51.12 Preoperative older patient with fat atrophy and hollow superior sulcus.

The lower eyelid skin should be evaluated for wrinkles and folds of skin and orbicularis muscle. Discrete folds of skin and orbicularis can be removed by a skin pinch technique. Fine wrinkles are best removed with chemical peel or CO₂ laser resurfacing, which can be performed at the time of blepharoplasty. In general, we advise patients that lower lid wrinkles cannot be improved with surgery. Additional preoperative evaluation includes assessment of the lower eyelid position and tension. In patients with extreme lower eyelid laxity, retraction, ectropion, or entropion, consideration may be given to performing a lateral canthal tightening procedure, or even a transconjunctival entropion surgery, at the time of transconjunctival fat excision.

Anesthesia

Blepharoplasty surgery is most often performed under local anesthesia. In our experience, 2% lidocaine is necessary, to achieve adequate anesthesia of the eyelid and deep periorbital structures. Epinephrine is important for hemostasis; we use a concentration of 1 : 100 000. Addition of Wydase (hyaluronidase) to the anesthetic mixture allows more rapid, and more even, spreading of the anesthesia through the tissues. One vial (75 units) is added to a 25 cc bottle of 2% lidocaine with epinephrine (this bottle is then used for all of the morning cases). We inject 3–5 cc of anesthetic into each of the four eyelids. In the upper eyelid, the injection is performed just subcutaneously by making a single puncture and ‘milking’ the fluid across the eyelid. It is often possible to anesthetize the entire lid through one puncture, thus reducing the risk of hematoma formation with the needlestick. If the injection is then given slowly, through a 30-gauge needle, successful eyelid anesthesia can be achieved comfortably with little, or no sedation. Removal of orbital fat is usually the most uncomfortable part of the surgery for the patient, especially when unipolar electrocautery is used. Therefore, in both the upper and lower eyelids, we make a point of injecting behind the orbital septum so that a deep orbital block is achieved.

We almost always use intravenous sedation. The surgery can be performed under straight local anesthesia in appropriately selected patients with careful slow injections, but deep fat removal usually necessitates intravenous sedation. Intravenous sedation also affords the availability of the anesthesiologist, or nurse anesthetist, who can provide additional psychological support to the patient with continuous communication, reassurance, hand-holding, and other physical contact.

The incisions are typically marked prior to anesthesia administration. They are made best with the patient in the sitting position, with patient cooperation, and with the tissues in their normal gravitational relationships (significant change in eyebrow, cheek, and orbital fat position occurs when patients relax into a supine position). Injection anesthesia is then performed. Even in the rare case performed under general anesthesia, we use regional injections of lidocaine and epinephrine to provide hemostasis and decrease the requirement for general anesthesia.

For eyelid work alone, it is unlikely that the toxic dose of lidocaine (7 mg/kg) will be reached. In the average-sized adult, a full 25 cc bottle of 2% lidocaine with epinephrine would be required to reach the toxic level. The same is true of epinephrine (toxic level 7 mcg/kg). In patients who are sensitive to epinephrine, more dilute solutions such as 1 : 200 000 or even 1 : 400 000 can be used to achieve similar degrees of hemostasis.

One of the most important aspects of local anesthesia surgery is ‘staying ahead of the curve’ with regard to the anesthetic wearing off. Even with epinephrine, the effect of lidocaine begins to wear off 45 minutes after the injection. Many cases take longer than this, so it is important to pay attention to the clock and to re-inject before the anesthetic wears off. Otherwise, negative consequences may ensue, including a rise in blood pressure in response to pain and increased bleeding in the field, requiring the surgeon to use more cautery – and more time – all of this creating a cycle that can double the case time. It is far better to stay ahead of the curve by reinjecting the lidocaine/epinephrine mixture every 30–45 minutes.

Designing and marking the eyelid crease

There can be no standard formula for measuring and marking the upper blepharoplasty incisions. The primary decisions involve the location of the inferior crease incision, and how much skin to remove vertically. Secondary decisions involve deciding how much tissue to excise medially and laterally.

The inferior incision, to a certain extent, determines the height of the ‘platform’ of the tarsal plate. However, it is incorrect to assume that the incision will form the eyelid crease and determine its height. If we remember the sagittal anatomy of the eyelid, it is clear that the redundant eyelid and eyebrow complexes will cover the surgical crease in most cases unless aggressive brow and lid surgery is performed.

In a very thin eyelid, for example in a very aged Caucasian patient, there will be little fat and skin to drape over the crease incision, and the incision itself may be visible. In this situation, it may be advantageous to make a high incision that will fall into the shadow of the superior sulcus. In such thin lids, minimal fat will be taken, with the goal of surgery being to remove some redundant skin in the superior sulcus, while smoothing out the long tarsal platform. In this setting a more inferiorly placed eyelid crease incision might not only be visible but also predispose to a second crease forming higher up on the levator aponeurosis.

In a more typical patient, a certain amount of the septal fat pannus will hang over the surgical incision, and therefore the inferior incision is drawn slightly higher than the height of the desired tarsal platform. In a woman, this will typically result in a lower incision, approximately 7–10 mm above the eyelash line centrally (Fig. 51.13). And in a man, an incision typically 5–8 mm above the lash line is indicated. In an Asian patient, the range might be 3–6 mm above the eyelash line centrally. Laterally, the incision dips down to pick up some of the temporal hooding. It is best to address this temporal hooding through eyebrow elevation, but if eyebrow surgery cannot be performed, or if redundant tissue persists after eyebrow elevation, temporal hooding can be excised directly at the expense of a scar in the thicker skin of the temple and at the expense of decreasing the distance between the tail of the brow and the lateral eyelid. Medially, it is also best to elevate redundant tissue out of the multicontoured area (the medial one fifth of the upper eyelid) through appropriate eyebrow elevation. However, if the surgeon elects to compromise and remove redundant skin in this area directly, a ‘lazy S’ incision helps to decrease webbing in this susceptible region by converting the vector of skin tension (upon closure) to a more horizontal direction. This incision is accomplished by dipping down the most medial component of the incision to pick up the medial redundancy. The proliferation of creative flaps such as W-plasties and T-shaped incisions is indicative of the difficulty encountered by surgeons working in the medial canthal region. It is not uncommon to see early web formation, even preoperatively, and any surgery that removes tissue in the medial canthal region is prone to web formation. Web formation is caused primarily by the tendency for the scar to contract, and to ‘clothesline’ the tissues from the nasal bridge across the hollowed concave region of the medial canthal multicontoured surface (see Fig. 51.4). The more the surgeon can lift these tissues out of the multicontoured area through eyebrow surgery, and avoid the temptation to draw the medial canthal incision line far into the multicontoured area, the less chance there is of web formation and other contour problems in this region.

Fig. 51.13 Skin markings in upper blepharoplasty: skin excision should be conservative, and the position of the lower incision is designed to be hidden in the eventual eyelid fold.

In upper blepharoplasty, the vertical excision of skin should always be conservative. Flowers has suggested that at least 1 inch (25 mm) of skin between the eyebrow and eyelashes is necessary for proper eyelid closure. Certainly, older techniques, such as the ‘skin pinch,’ in which the surgeon tries to maximize skin removal while narrowly avoiding lagophthalmos, are philosophically and technically inappropriate. Rather, the goal should be just the opposite: How little skin can we remove from the lid and still accomplish our surgical goal of creating an eyelid platform while sculpting the eyelid tissues to reveal more of the underlying deep structures? In our experience, we leave at least 20 mm of total skin between the eyelid margin and inferior brow skin. Keep in mind, female patients may pluck their brow hairs and this may not be the true inferior extent of the brow; rather keep in mind the transition from the thick brow skin to the thin eyelid skin as the inferior extent of the brow skin. We have had good results with this and of course it can be customized to the individual patient’s needs. In the presence of uncorrected eyebrow ptosis, the surgeon has to be especially careful to avoid the temptation to address heavy eyebrow tissues by excising them from below, in the eyelid space. This can create a situation in which the ‘eyebrows are sutured to the eyelids’, so that the patient is functionally and esthetically crippled with persistence of heavy eyebrow tissues in the eyelid space and an inability to elevate the eyebrows without creating lagophthalmos (see Figs 51.7 and 51.8). Very rarely is it necessary to excise more than 10 mm of skin in the vertical direction. Typically, a 5–7 mm excision is appropriate, and an excision of 3–5 mm of skin is not uncommon, especially in younger patients.

Surgical technique

After the surgeon marks the incision, either the steel blade, scissors, electrocautery, or the CO₂ laser can be used to accomplish the actual cutting. More surgical precision, easier tissue dissection, and a relatively bloodless field are generally seen with the laser unit. At the same time, the need for an instrument that costs between $40 000 and $140 000, demands tighter safety principles, and necessitates additional training is debated by some eyelid surgeons.

In most instances the cutaneous flap is removed in one piece, leaving much or most of the orbicularis intact (Fig. 51.14). In some patients with full eyelids, a small strip of orbicularis can be debulked; care must be taken not to remove too much orbicularis.

Fig. 51.14 The skin and some of the underlying orbicularis muscle is removed in one piece, revealing the underlying orbital septum.

Below the orbicularis, the orbital septum can be visualized. In some patients a pronounced preseptal fat pannus can be noticed. This should not be confused with the preaponeurotic fat pads of the upper eyelid. This preseptal fat may represent a gravitational descent of the ROOF, which is the sub-brow fat that has descended to encroach on the upper eyelid esthetic unit, giving a full appearance. This fat can be sculpted or repositioned to its anatomic area with sutures.

The orbital septum is incised horizontally (Fig. 51.15), usually across the full extent of the upper eyelid to provide an ‘open-sky’ approach to the underlying structures. The septum is not a single layer as is usually described, but rather, a multilaminar structure with varying thickness in different areas of the upper eyelid. As Flowers has suggested (see Further reading), the orbital septum should be opened just above its insertion into the aponeurosis, with particular attention to avoiding accidental sectioning of the underlying aponeurosis. The preaponeurotic fat pads will be viewed next. Most of the fullness of the upper eyelid is the result of herniation of the larger central fat pad, but occasionally the smaller nasal fat pad can contribute to significant and localized bulging. The fat that was preoperatively planned for reduction is removed (Fig. 51.16). This can be accomplished in a piecemeal fashion when using electrocautery by alternating the cautery and coagulation. Alternatively, fat vaporization can be accomplished with the CO₂ laser. Excessive pulling on the fat pads should be avoided to prevent avulsion of the orbital vessels that usually run within these fat compartments. In some individuals there is excessive fullness at the lateral aspect of the upper lid as a result of involutional stretching and descent of the lacrimal gland into the preaponeurotic tissue plane. Obviously, it is important to identify the more orange-looking friable lacrimal gland tissue, and to avoid its amputation. The lacrimal gland can be repositioned inside the lacrimal gland fossa and sutured to the overlying periosteum.

Fig. 51.15 The orbital septum is opened just superior to its attachment onto the levator aponeurosis. This leaves the septal fat pannus intact above the incision and allows graded sculpting of the septal fat pannus; it also sets the stage for sculpture of the pretarsal septal remnant and orbicularis.

Fig. 51.16 The orbital fat (septal fat pannus) is excised in graded fashion, with care taken to minimize excess excision over the superior orbital notch/valley of the superior oblique.

To reiterate, it is important to avoid excessive reduction of the preaponeurotic fat pads. Its ease of removal with the ‘open-sky’ approach should never lead to excessive removal. Enough fat should be left to serve as a physiologic sliding tissue for upper eyelid excursion. Sometimes, fat repositioning is all that it is required. The ‘valley’ of the superior oblique tendon separates the central fat pads from the nasal fat pads, and it is usually a hollow area (Fig. 51.17). Fat repositioning into this area can reduce the inverted ‘V’ deformity that characterizes the aged eyelid.

Fig. 51.17 The medial fat pad is white in color. It lies medial to the valley of the superior oblique muscle.

After the judicious removal of preaponeurotic fat, the septal edge can be trimmed to provide a flatter, smoother, and tighter upper eyelid platform (Fig. 51.18). This step can be supplemented with excision of a strip of pretarsal orbicularis oculi muscle along the inferior edge of the incision for further debulking of the pretarsal area. The CO₂ laser is an excellent instrument that can vaporize and tighten these preaponeurotic tissues to create a tight platform and a well-defined eyelid crease.

Fig. 51.18 The CO₂ laser is an excellent instrument to vaporize and tighten these preaponeurotic tissues to create a tight platform and well-defined eyelid crease.

The last step of the procedure, wound closure, includes the consideration of supratarsal fixation. The preoperative planning will determine whether a well-defined ‘hard’ crease or a more conspicuous ‘soft’ crease is desirable. Generally, a ‘hard’ crease is optimal for women to provide a well-demarcated upper eyelid platform for the application of eye shadow, whereas most men do not benefit from such an abrupt definition of the upper eyelid crease. When supratarsal fixation is performed, the skin and orbicularis oculi muscle of the pretarsal flap along the inferior edge of the incision are anchored together to the ‘leathery’ preaponeurotic fascia at the level of the superior portion of the tarsus. The exact anchoring level varies with each patient and is another manifestation of the individualization that is required in blepharoplasty surgery. Several interrupted sutures can be placed for supratarsal fixation, or a running suture that is used for skin closure can include a purchase of the preaponeurotic fascia (Fig. 51.19). A 6-0 or 7-0 running absorbable or non-absorbable suture on a cutting needle can be used to close the cutaneous incision; some surgeons insist on a subcuticular running closure, but we have not noticed any difference in wound healing or postoperative appearance.

Fig. 51.19 For supratarsal fixation, a bite of levator is included in each of the running suture bites.

Anesthesia

Local anesthesia for transconjunctival blepharoplasty is somewhat different from that for other lower eyelid surgeries. The injection must be made through the conjunctiva because the sensory nerves of the conjunctiva and orbital fat originate in the orbit. First, a drop of proparacaine HCL 0.5% is placed on the conjunctiva. Two percent lidocaine with 1 : 100 000 epinephrine and Wydase (one vial of Wydase per 50 cc bottle of lidocaine) is then injected with a 27- or 30-gauge needle. The surgeon sits at the head of the table and tents up the eyelid so that the injection can be delivered through the conjunctival fornix under direct visualization. The needle is directed slightly posteriorly to the inferior orbital rim behind the orbital septum and then walked posteriorly until the needle literally touches the floor of the orbit. Injections of 1 cc are made in this fashion medially, centrally, and laterally to anesthetize each individual fat pocket. The Wydase in the injection allows for posterior spread, and it is not uncommon to see pupillary dilation and weakness of the extraocular muscles causing temporary diplopia after the injection. Gentle intermittent pressure is applied to the lids, and 15 minutes is allowed to elapse for the hemostatic properties of epinephrine to become effective.

Surgical technique

After sterile preparation with povidone iodine solution and open-face draping of awake patients, the surgery begins with the transconjunctival incision. An assistant retracts the medial third of the lower eyelid downward with a medium or small Desmarres retractor to expose the cul-de-sac. A non-conductive eyelid plate (a Pyrex plate is available from Weiss Scientific Glass Blowing, Portland, OR, which also makes Jones tubes) is placed over the globe into the inferior fornix and is used to balotte the globe posteriorly. This action with the lid plate prolapses the orbital fat over the orbital rim. If the lower eyelid is too tight to allow adequate exposure, a lateral canthotomy and inferior cantholysis can be performed. This is rarely necessary, however. A needle-tip monopolar cutting cautery unit on a low setting is then used to palpate the medial, inferior orbital rim. We prefer the Valley Labs cautery unit set on 1.5–2.0 watts, and an insulated Colorado MicroDissection needle tip (available from Colorado Biomedical, Inc., Evergreen, CO). If the insulated cutting cautery needle tip is not available, a 19-gauge intracath can be placed over any cautery needle tip to avoid inadvertent cauterization of adjacent structures. An alternative cutting instrument that is very effective in lower blepharoplasty is the CO₂ laser, which can be used in the continuous or ultrapulse mode at a power of 7–10 watts to incise the conjunctiva. This setting may also be used to incise and vaporize the orbital fat. In addition, Stevens tenotomy scissors can also be used to incise the conjunctiva.

The conjunctiva and lower lid retractors are incised directly over the fat with the needle tip directed 1–2 mm posterior to the inferior orbital rim. The incision may be made from medial to lateral beginning at the apex of the caruncle and extending to the lateral canthus, if necessary, to expose the lateral fat. The incision should be made at least 4 mm inferior to the inferior punctum to avoid damage to the canaliculus. An alternative technique is to make several small (5–7 mm) incisions over the individual fat pockets and connect them as necessary for full exposure. It is important to be at least 4 mm inferior to the inferior tarsal border when incising the conjunctiva and lower lid retractors. After incising the conjunctiva and lower lid retractors, yellow orbital fat can be seen bulging into the field (Fig. 51.20).

Fig. 51.20 The conjunctiva is exposed, using a plastic eyelid plate over the cornea and a Desmarres retractor on the lower eyelid, and incised using cutting cautery or laser.

Once the fat is noted, the connective tissue septae can be dissected away with the needle tip or toothed forceps until a tuft of fluffy yellow fat is exposed. In some cases, gentle blunt dissection with a Stevens tenotomy scissor is helpful to expose and delineate the three fat components. The assistant grasps the posterior edge of the wound (lower lid retractors) with a 0.5 mm toothed forceps and lifts it up and over the globe. This maneuver protects the globe and further prolapses the fat into the surgical field. The Desmarres retractor can now be repositioned so that the blade is itself in the wound, providing wider exposure. With the connective tissue septae on stretch, the cutting cautery or blunt dissection with the tenotomy scissors can then be used to open the fat compartments widely. The closer the fat compartment is opened to the orbital rim, the easier the exposure and the less chance of encountering bleeding or damage to the inferior oblique muscle.

Laterally, the arcuate expansion of the inferior oblique muscle separates the central fat pocket from the lateral fat pocket (Fig. 51.21). Incision of this fascial band at its attachment to the orbital rim, with scissors or cutting cautery, makes the central fat pocket continuous with the lateral fat pocket. This permits identification and exposure of the lateral fat pocket. The lateral fat pad is covered with more septae than the central pad and may not spring forward as easily. Importantly, it is located superiorly in the orbit, often at the level of the lateral canthal tendon, so that exposing the inner lateral orbital wall with blunt dissection helps expose the lateral fat pad. With excision of the superficial portion of the lateral pad, the fat posterior to this point comes forward more freely.

Fig. 51.21 The arcuate expanse of the inferior oblique muscle separates the central and lateral fat pockets: here it is cut with scissors.

The medial fat compartment is the most difficult to locate, and partial resection of the central fat may be necessary to allow identification of the medial fat. Of note medially, the inferior oblique muscle separates the central and medial fat compartments. It is important to identify this ‘valley’, especially for the surgeon who is learning this technique. Early identification will ensure that both the medial and central fat compartments are excised, and will avoid injury to the inferior oblique muscle. After identification and exposure of the central fat, which lies most anteriorly of the three fat pads, the medial fat may be totally obscured, or may present as a slight bulge in the superior medial aspect of the wound. The glass lid plate can be replaced at this point and pressure placed on the globe to ballotte the fat forward. The needle tip can be used to sharply dissect the overlying septae and the tenotomy scissors used to gently blunt dissect the fat pad. The medial fat is different from the central and lateral fat in that it appears white and membranous (Fig. 51.22). Additionally, it may not be postseptal at all; rather, it may come from the muscle cone, bulging around the edge of the lower eyelid retractors. The only difference between the lower eyelid medial fat pad and the medial fat pad in the upper lid is that the palpebral vessels go directly through the medial fat pad, as opposed to the upper eyelid where the medial vessels lie on the surface of the fat pad. Once the central and medial fat pads are excised, the inferior oblique muscle will be in plain view.

Fig. 51.22 Medially, the valley of the inferior oblique muscle separates the central and medial fat compartments. Note the white appearance of the medial fat pad.

With advanced techniques, the medial fat pad can be sculpted into a pedicle that can then be transposed outside the orbit along the inferior orbital rim to fill in the tear trough deformity. The orbital septum is opened along the arcus marginalis, and the fat pedicle is arranged in a supraperiosteal, suborbicularis pocket (Fig. 51.23A–D).

Fig. 51.23 (A) Surgical photo of medial fat pedicle prepared for placement outside the orbit, through the orbital septum. (B) Diagram of suture placement to stabilize the fat pedicle in the subperiosteal pocket. (C) Preoperative photograph of young patient with prominent tear trough deformity. (D) Postoperative photograph demonstrating improvement in lower eyelid contour of the patient in (C)

With the standard techniques, once all the fat is exposed as described above, the fat is excised in a careful graded fashion with a cutting monopolar cautery or a scissors. Before any excision of fat, it is useful to expose the fat of both lower eyelids, especially for the beginning surgeon, to allow for more symmetric fat excision. The endpoint of fat excision is reached when the anterior border of the fat is seen to be flush with the orbital rim while light pressure is applied to the globe, simulating upright posture. This results in a slight concavity of the lower lid when the patient lies supine. Meticulous hemostasis is necessary during the procedure. The blood vessels associated with each fat compartment should be directly visualized via blunt dissection with applicator tips, followed by cauterization with the monopolar cautery unit (Valley Labs cautery unit on Coag set at 2.0–2.5 Ws). Even when the CO₂ laser is used, it is best to have electrocautery available for the occasional vessel that is refractory to coagulation with the laser. There are some large vessels in the orbital fat pockets medially and, to a lesser extent, laterally. These can often be identified and cauterized before they are violated.

After excising the fat, the lower lid margin is pulled superiorly to release any adhesions that might result in lid retraction, as well as to realign the tissue planes (Fig. 51.24). With the lid on stretch, gentle pressure on the globe reveals any residual fat bulges. If necessary, further fat can be excised at this point. In our experience, it is not necessary to close the conjunctiva and lower lid retractors; however, a single interrupted suture of 6-0 mild chromic gut is used to close the conjunctiva centrally if the tissues do not appear well opposed.

Fig. 51.24 After excising the fat, the lower lid margin is pulled superiorly to release any adhesions that might result in lid retraction, as well as to realign the tissue planes.

Upper blepharoplasty

Upon completion of the procedure, antibiotic ophthalmic ointment is applied to the suture line and to the cornea. This ointment can be applied daily for approximately 1 week postoperatively. Because of the rich vascularity of the eyelids, eyelid infections after blepharoplasty are exceedingly rare, and so we do not use systemic antibiotic prophylaxis.

Ice ‘burritos’ made with gauze or clean washcloths wrapped around crushed ice are applied continuously over the operated area for 24–48 hours to achieve local vasoconstriction and to minimize postoperative ecchymosis and edema. A mild, non-aspirin-containing analgesic is used to control postoperative discomfort.

Blepharoplasty surgery should not result in significant discomfort. It is imperative that the patient be examined immediately if any pain is noted that is not relieved by analgesics. In patients with excessive pain, acute postoperative hemorrhage is present until proven otherwise. Blindness after blepharoplasty is the most dreaded complication, with an incidence of approximately 1/40 000. Early recognition with prompt intervention is the only way to minimize progression to blindness. The patient should be examined immediately and have a visual acuity and pupillary examination. Should any evidence of optic nerve compromise be present, the wound should be opened without hesitation, and all blood should be evacuated. Medical decompression of the orbit with systemic osmotic agents and corticosteroids should also be initiated. If no response is noted, radical cantholysis and surgical decompression of the orbit should be considered.

It is good practice for the surgeon to contact the patient on the evening of the surgery. A simple telephone call can alleviate the patient’s anxiety and also identify potential warning signs that need immediate attention. The patient is usually examined 5 days after the surgery, as long as earlier problems do not arise. At that time, any non-absorbable sutures are removed. We have noticed that absorbable sutures are more reactive, especially in the younger patients.

The postoperative ecchymosis and edema are expected to gradually improve over the following 2–3 weeks. When all the edema has subsided, the surgeon should critically examine the eyelid contour and shape, identifying suboptimal results such as noticeable asymmetry, irregularity, or webbing. In these circumstances, additional touch up or ‘enhancement’ surgery may be required. The optimal timing for this surgery should be individualized, realizing that healing changes may continue for as long as 3 months, or even 6 months, after surgery. Therefore, there is often an advantage to waiting out subtle asymmetries or undercorrections.

Lower blepharoplasty

Antibiotic ophthalmic ointment or solution is applied to the conjunctiva and ice compresses are immediately applied to the lower lids and, as much as tolerated, for the first 48 hours postoperatively. After the first 48 hours, warm compresses are used four times per day for an additional 7–10 days. The conjunctival incision makes soft contact lens wear difficult for the first week or two, but generally soft contacts can be successfully resumed within 10 days. Hard contact lenses can be resumed after 3–4 days. Postoperative bruising lasts 10–14 days, in general, and patients should be warned that postoperative ecchymosis may increase, or may first appear on the third postoperative day (with the switchover to warm compresses).

The most common complication of transconjunctival blepharoplasty, as reported in five published series, is inadequate fat excision, ranging from 0% to 20% of cases. As previously stated, we do not consider this a complication at all, rather an expected sequela given our conservative philosophy of graded fat excision. Overexcision of fat can lead to a skeletonized, hollow appearance requiring late volume augmentation with fat grafting or synthetic fillers. Lower eyelid malpositions have not previously been reported, but, again, we have recently seen several cases of lower eyelid retraction and malposition. Increased skin wrinkling and redundant lower eyelid skin were reported as complications in 1.6–3.3% of patients, while one small series of seven patients reported redundant skin in two (28.6%) cases. This emphasizes the importance of careful preoperative evaluation and patient counseling, along with consideration for a skin-pinch excision or laser resurfacing at the time of transconjunctival fat excision.

Strabismus is a recognized risk of blepharoplasty, related to scarring and loss of supple function of the orbital motility system; excess removal of fat, excess cautery, and reoperative blepharoplasty are risk factors. We have reported one postoperative wound hemorrhage that resolved spontaneously without permanent ocular sequelae. Additionally, we have seen several cases of persistent conjunctival chemosis after transconjunctival blepharoplasty, all of which resolved over several months. Persistent chemosis can relate to incision placement too close to the globe, postoperative lymphedema, postoperative orbicularis weakness, and postoperative eyelid retraction.