Sensory Innervation

Sensation of the brow and anterior scalp region is provided by the ophthalmic division of the trigeminal nerve. The ophthalmic division divides into the lacrimal nerve, which provides sensation to the skin and conjunctiva of the upper eyelid, and the frontal nerve, which further divides into the supraorbital and supratrochlear nerves. The supratrochlear innervates the conjunctiva, upper eyelids, and inferomedial aspect of the forehead, whereas the supraorbital nerve innervates the upper lid skin, forehead, and anterior scalp. The supratrochlear nerve lies 1.5 to 1.7 cm from the midline, and the supraorbital nerve lies 1 cm lateral to the supratrochlear nerve (Fig. 30-3).⁵

Figure 30-3. Sensory nerves of forehead.

Motor Innervation

The temporal, or frontal, division of the facial nerve supplies the muscles of the forehead and the orbicularis oculi muscle. This division of the facial nerve courses from the parotid gland, anterior to the superficial temporal artery, toward its final destination, where it pierces the undersurface of the frontalis muscle 1.5 cm above the lateral canthus. The frontal branch of the facial nerve lies deep to the superficial musculoaponeurotic system fascia (SMAS) and its continuation in the temporal region, the temporoparietal fascia (Fig. 30-4). The course of the nerve may be approximated by a line drawn from a point 0.5 cm anterior to the tragus to a point 1.5 cm lateral to the lateral brow. The danger zone for the temporal branch of the facial nerve has been further described and is shown in Fig. 30-5. The nerve enters the orbicularis oculi muscle and frontalis muscle along the deep surface of the muscles. As the nerve crosses over the zygomatic arch, it lies between the periosteum of the zygoma and the SMAS. Dissection in the region of the zygomatic arch requires caution to avoid injury to the nerve and should be carried out either subcutaneously or subperiosteally.^4,5

Figure 30-4. Temporal branch of facial nerve deep to the superficial musculoaponeurotic system fascia and temporoparietal fascia.

(From Weinberger MS, Becker DG, Toriumi DM. Rhytidectomy. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:650.)

Figure 30-5. The danger zone for the temporal branch of the facial nerve, defined as the region overlying the zygomatic arch between 1.8 cm anterior to the helical root and 2 cm posterior to the anterior end of the arch.

(From Weinberger MS, Becker DG, Toriumi DM. Rhytidectomy. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:650.)

Fascial Layers of the Forehead and Temporal Region

The scalp consists of five layers: the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and periosteum. The galea is a tendinous, inelastic sheet of tissue that connects the frontalis muscle of the forehead with the occipitalis muscle. The frontalis muscle originates from the galea and inserts into the forehead skin. At the superior orbital rim, the galea becomes tightly adherent to the periosteum. Laterally, the galea continues as the temporoparietal fascia, which lies in the immediate subcutaneous plane in the temporal region. The temporoparietal fascia is continuous with the SMAS layer of the face and the platysmal layer of the neck (Fig. 30-6). Deep to the temporoparietal fascia lies the deep temporal fascia, which envelops the temporalis muscle. The temporal fascia is contiguous with the calvarial periosteum at the temporal line of the skull, the conjoint tendon. The temporal fat pad, just superior to the zygomatic arch, is ensheathed by the temporal fascia inferior to the level of the supraorbital ridge. At that point, the temporal fascia splits to become the intermediate temporal fascia and the deep temporal fascia, with the fat pad between them. The intermediate fascia layer attaches to the superior aspect of the zygoma laterally, whereas the deep layer attaches medially.^4,5

Figure 30-6. The superficial musculoaponeurotic system and the temporoparietal fascia is one continuous layer.

(From Weinberger MS, Becker DG, Toriumi DM. Rhytidectomy. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:649.)

Musculature

There are four muscles in the eyebrow: frontalis, procerus, corrugator supercilii, and orbicularis oculi (Fig. 30-7). The frontalis is a paired subcutaneous muscle that inserts into the skin of the eyebrow. It is the continuation of the galea aponeurotica from the coronal suture downward, and inserts in the dermis at the level of the supraorbital ridge. Laterally, the frontalis terminates at the conjoined tendon. The frontalis muscle has no bony insertions, and its only action is brow elevation. Horizontal forehead rhytids correspond to the long-term effects of frontalis activation. Inferonasally, the frontalis muscle extends to form the procerus muscle. The procerus originates on the caudal aspect of the nasal bones and cephalic margins of the upper lateral cartilages, and inserts onto the medial belly of the frontalis muscle and the dermis between the eyebrows. The action of the procerus muscle produces inferior brow displacement and is responsible for horizontal glabellar wrinkles (Fig. 30-8).

Figure 30-7. Eyebrow muscles include the frontalis procerus, corrugator supercilii, and orbicularis oculi.

(From Graney DO, Baker SR. Anatomy. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:404.)

Figure 30-8. Corrugator supercilii contraction causes vertical glabellar rhytids and procerus contraction causes horizontal glabellar rhytids.

(From Graney DO, Baker SR. Anatomy. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:404.)

The corrugator muscle originates from the nasal process of the frontal bone, near the superomedial orbital rim, and inserts into the dermis at the middle third of the eyebrow after blending with the frontalis and orbicularis muscles. Its action produces inferior and medial forehead and brow movement, and results in vertical glabellar wrinkle.^4,5

Blood Supply

The internal and external carotid artery systems supply the blood to the forehead. The internal carotid artery, via the ophthalmic artery, branches to form the frontal, supraorbital, and supratrochlear arteries. The external carotid artery system supplies the largest area of the scalp via the superficial temporal artery. Thus there is a rich anastomotic complex of vessels providing adequate nutrients to the forehead, allowing for safety in aesthetic surgery of the forehead and scalp.

Surface Anatomy of the Eyelids

The normal horizontal palpebral fissure is 28 to 30 mm and the normal vertical palpebral fissure is 9 to 10 mm. The intercanthal distance, the distance between the medial canthi of the two eyes, is approximately 25 to 30 mm. The upper eyelid margin normally rests at a point midway between the superior corneal limbus and the pupil, whereas the lower eyelid margin typically abuts the inferior corneal limbus. The apex of the upper eyelid is located midway between the medial pupillary margin and the medial corneal limbus. The nadir of the lower eyelid is at the lateral corneal limbus.⁶

The upper lid crease is the line formed by the insertion of the levator aponeurosis and orbital septum into the orbicularis oculi muscle and skin. In women, the lid crease is 10 to 12 mm above the lid margin, whereas in men it is 7 to 8 mm above the lid margin. The lateral canthal angle is more acute and 2 mm higher than the rounded and lower medial canthal angle (Fig. 30-10).^4,6

Figure 30-10. The lid crease is 10 to 12 mm above the lid margin in women and 7 to 8 mm above the lid margin in men.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:678.)

A number of anatomic differences exist between the Asian and Occidental eyelids. In the Asian eyelid, the orbital septum and levator aponeurosis attach to the skin further inferiorly, anterior to the tarsus. As a result, orbital fat prolapses anteriorly, thereby preventing the formation of a prominent upper eyelid crease and creating a fullness of the upper eyelid.^4,5

The Anterior Lamella

The skin of the eyelids is the thinnest skin of the body with almost no reticular dermis, and it is highly vascular. These factors allow the eyelid skin to heal rapidly and with minimal scar. As it approaches the orbital rim and the hair-bearing areas of the periorbital region, the skin of the eyelids thickens rapidly. The changes in skin thickness are important to consider when planning incisions in periorbital surgery (see Fig. 30-9).^4–6

The orbicularis oculi muscle is a subcutaneous muscle that serves as the sphincter of the eyelid. It is innervated by the temporal and zygomatic branches of the facial nerve. In addition to its function in eye closure, the orbicularis oculi muscle is essential for the proper functioning of the lacrimal pump apparatus, which propels tears into the puncta, canaliculi, and lacrimal sac. Failure of the pump mechanism, as may result with facial nerve paralysis, may result in epiphora.^4–6

The orbicularis oculi muscle is divided into three segments: the pretarsal, preseptal, and orbital segments (Fig. 30-11). Even though they all act to close the eye, each segment plays a unique role. Blinking is an involuntary action that depends on contraction of the pretarsal orbicularis. Winking is a voluntary action dependent upon the orbital orbicularis. The preseptal fibers contribute to both the involuntary and voluntary functions of the eyelids.^4–6

Figure 30-11. The sphincter mechanism of the eyelids depends on the three divisions of the orbicularis oculi muscle.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:679.)

The origin of the pretarsal orbicularis arises from two heads, one of which inserts into the posterior lacrimal crest, and the other inserts into the anterior lacrimal crest and into the anterior limb of the medial canthal tendon. The preseptal orbicularis also has two heads at its origin: the deep portion attaches to the lacrimal sac, and the superficial segment attaches to the anterior limb of the medial canthal tendon. The orbital orbicularis originates at the anterior limb of the medial canthal ligament and interdigitates with the frontalis, corrugator, and procerus muscles. Laterally, the three orbicularis segments fuse to form the inferior and superior crura of the lateral canthal tendon, which insert into Whitnall’s tubercle. The lateral attachments of the lateral canthal tendon to Whitnall’s tubercle are responsible for eyelid and globe apposition.^4–6

The Orbital Septum

The orbital septum, which lies just deep to the orbicularis oculi muscle, forms the anterior border of the orbit and confines the orbital fat (see Fig. 30-9). It is a fibrous sheath formed at the orbital rims at the arcus marginalis and is an extension of the orbital periosteum. In white upper lids, the septum fuses with the levator aponeurosis approximately 3 mm above the superior tarsal border. In Asian upper lids, the septum fuses with the levator aponeurosis further inferiorly, below the superior tarsal border, thereby allowing orbital fat to lie anterior to the tarsal plate, preventing the attachment of the levator to the skin, and preventing the formation of an upper eyelid crease. In the lower lids, the septum fuses with the underlying orbital retractor (capsulopalpebral fascia), 5 mm below the inferior tarsal border. The orbital septum acts as a barrier to the spread of infection and neoplasms between the preseptal space and the orbital space.⁴

The Orbital Fat Pads

All of the eyelid fat pads lie deep to the orbital septum. The upper eyelid contains two fat pads medially and centrally, and the lacrimal gland laterally (Fig. 30-12). The lacrimal gland should be avoided during eyelid surgery to prevent postoperative dryness; it can be identified by its pink rather than yellow color and its firm rather than soft texture.^4,6

Figure 30-12. Fat pads of the upper and lower eyelids.

The lower eyelid contains three fat pads: medial, central, and lateral. The medial and central fat pads are separated by the inferior oblique muscle, which should be identified during lower eyelid surgery to help prevent its disruption. Disruption of this muscle may result in postoperative diplopia (see Fig. 30-12).^4,6

Upper Eyelid Retractors

Deep to the fat pads are the eyelid retractors. In the upper lid, the levator palpebrae superioris (the levator muscle) is the major retractor, and it originates from the lesser wing of the sphenoid bone at the orbital apex (see Fig. 30-9). The levator is innervated by the oculomotor nerve (cranial nerve III). The horizontal posterior segment of the levator consists of muscle fibers, which extend anteriorly along the orbital roof for 36 mm until it reaches Whitnall’s ligament. At Whitnall’s ligament, the levator changes its course by approximately 90 degrees and becomes an aponeurosis that travels vertically for a length of 14 to 20 mm until its insertion into the upper third of the tarsal plate. Some fibers of the levator aponeurosis fuse with the orbital septum approximately 2 to 5 mm above the superior tarsal border, and then together insert into the skin to create the upper eyelid crease. In addition to its inferior attachments to the septum, tarsal plate, and skin, the levator aponeurosis attaches medially to the medial canthal tendon, and laterally to the lateral canthal tendon.⁴

Müller’s muscle, or the superior tarsal muscle, arises from the undersurface of the levator aponeurosis just below Whitnall’s ligament, and courses inferiorly 10 to 12 mm to attach to the superior tarsal plate (see Fig. 30-9). Müller’s muscle is innervated by sympathetic nerve fibers, and its action produces 2 to 3 mm of eyelid retraction. Müller’s muscle is adherent to the levator aponeurosis anteriorly and is loosely adherent to the conjunctiva on its posterior surface.⁴

Lower Eyelid Retractors

The capsulopalpebral fascia and inferior tarsal muscle comprise the lower eyelid retractors. The capsulopalpebral fascia originates from the fascia of the inferior rectus muscle and inserts on the inferior tarsal border. This fascia does not move independently, but rather mimics the movement of the inferior rectus muscle from which it originates. The inferior tarsal muscle arises from the undersurface of the capsulopalpebral fascia and the two are tightly adherent to each other and to the lower lid conjunctiva. The inferior tarsal muscle is sympathetically innervated.^4,6

The Tarsus

The tarsal plates are dense fibrous connective tissue that form the skeleton of the eyelids (see Fig. 30-9). Each plate is 25 to 30 mm in horizontal dimension. The upper eyelid tarsal plate is 10 to 12 mm in vertical height while the lower eyelid tarsal plate is 3 to 5 mm in vertical height.⁴

The Conjunctiva

The conjunctiva is the innermost surface of the eyelid, which is in contact with the globe (see Fig. 30-9). It is composed of nonkeratinized stratified squamous epithelium with goblet cells that produce the mucous layer of the tear film. The bulbar conjunctiva is the portion of the conjunctiva that lines the globe, whereas the palpebral conjunctiva lines the eyelid. These two segments meet at the conjunctival fornix, at the base of the upper and lower eyelids. Dispersed throughout the conjunctiva are numerous additional glands that produce the aqueous layer of the tear film. The lacrimal gland secretes additional lacrimation in response to stimuli such as ocular irritant and emotional triggers.⁴

Upper Eyelid Ptosis

The ptotic eyelid is often masked by dermatochalasis, so preoperative attention should be given to identifying and classifying upper eyelid ptosis. Blepharoplasty alone of the ptotic lid may lead to an unfavorable cosmetic result and need for additional surgery. The most common cause for eyelid ptosis is secondary to acquired involutional changes, although the patient should also be assessed for myogenic, neurogenic, and mechanical causes, as well as pseudoptosis.

Evaluation

The degree of ptosis can be quantified by the margin-reflex-distance (MRD). This is the distance between the central corneal light reflex and the upper lid margin, usually around 3 to 4.5 mm. Asymmetry between lids is not uncommon and is usually reflected in the MRD. Normally, the upper lid margin should rest about 1 mm below the tangent of the superior limbus. The muscle light should be held between the examiner’s eyes (coaxial to the examiner’s observation axis), the examiner’s eyes should be level with those of the patient. The light should not be too bright or else the patient may squint and give an artificially low measurement. The highest point in the upper lid is just medial to midline (near medial limbus) and has a greater curvature than the lower lid margin, whose lowest point is near or at the midline. In addition to the MRD, the central interpalpebral distance, which is another measure of comparison between lids, should also be recorded. Normally 8 to 10 mm, the central interpalpebral distance is the distance from the upper lid margin at its highest and the lower lid margin at its highest. A patient with ptosis of the upper lid and retraction of the lower lid may also have “normal” palpebral fissure measure.

The levator function is helpful in distinguishing the potential etiologies of the ptosis as well as in surgical planning. It is assessed by measuring the excursion of the upper lid margin in extreme downgaze to extreme upgaze. The brow should be fixated by the examiner to prevent recruitment of the frontalis. Normal function is usually greater than 12 mm. Levator shortening procedures potentially have a good prognosis with normal function. If the levator excursion is less than 5 mm, as is often seen in congenital ptosis, another surgical approach (e.g., frontalis sling) may be required.

An important landmark to document preoperatively is the position of the upper eyelid crease. Its position depends on sex and race (as described earlier). A high lid crease may suggest disinsertion of the levator aponeurosis, the anatomic etiology for acquired ptosis. As the levator moves posteriorly, the preaponeurotic fat overlying it likewise moves further into the orbit. This may decrease the upper eyelid fold and result in the appearance of a deep superior sulcus.

Additionally, one should assess the orbicularis function and extraocular movements to help identify possible myopathic causes for the ptosis. Orbicularis strength can be assessed by asking the patient to maximally close the eyelids and resist opening by the examiner. If normal, a patient should be able to nearly resist the examiners efforts in opening the fissures. The presence of lagophthalmos may also indicate slightly weakened orbicularis function. This is important to document and discuss with the patient because it may be exacerbated following ptosis surgery. Decreased extraocular movements can be seen in cases of chronic external ophthalmoplegia and adult onset muscular dystrophy. A decreased Bell’s phenomenon can also be seen in patients with a myopathy and may make patients more susceptible to ocular exposure after ptosis correction.

Finally, patients should be questioned about dry eye symptoms and tear secretion should be evaluated, because dry eye may be exacerbated after ptosis surgery. Schirmer test paper is used to estimate tear secretion (Fig. 30-18). If the wet paper measures less than 5 mm after 5 minutes with the use of topical anesthetic, there is a possibility of further complications. A punctal plug inserted postoperatively allows for an increased reservoir of natural tears; however, the patient must be counseled that dry eye symptoms may worsen.

Figure 30-18. The Schirmer test paper is placed in the conjunctival fornices and evaluated after 5 minutes. Repeated measurements of less than 5 mm of wetting, with anesthesia, can be highly suggestive of aqueous tear deficiency.

Upper Eyelid

Success in blepharoplasty requires that the surgeon understand the aesthetic relationships between the eyelids, eyebrows, forehead, orbit, and midface. These aesthetic ideals are discussed earlier in the chapter and may be reviewed. Once the individual patient’s good medical health, psychological motivations, and expectations regarding the surgery are understood to be reasonable, the surgery may proceed. Typically, blepharoplasty is performed as outpatient surgery under either local or general anesthesia.¹²

If performed in conjunction with a browlift, the blepharoplasty incision markings are placed after the browlift is complete and all incisions have been closed. Marking the eyelids is the single most important step in blepharoplasty, and as such, great care must be taken to ensure precision (Fig. 30-19). If there is no eyelid ptosis, the initial lid marking is made at the natural skin crease or 1 mm above the natural crease. Making the incision 1 mm above the natural crease allows for wound contracture to bring the ultimate lid scar into the proper position at the natural crease. Generally, the lid crease is at the same level bilaterally, but if not, the incisions may be designed to create lid symmetry with the use of a caliper. The medial end of the incision descends approximately 1 to 2 mm from the central vertical height and is carried to the punctum of the medial canthus but not beyond the punctum. Incisions medial to the punctum and beyond the nasal orbital depression may cause irreversible webbing. The lateral extent of the incision curves upward slightly, within a natural crease in the sulcus between the orbital rim and the eyelid. The lateral extent is determined by the degree and location of lateral hooding, and may even extend beyond the lateral orbital rim. The patient must be told preoperatively that the skin incision lateral to the lateral orbital rim will take longer to heal because the skin thickens beyond the lateral orbital rim. To determine the amount of redundant skin to excise, the pinch test is performed (Fig. 30-20). One blade of a Graefe forceps grasps the skin at the previously marked lid crease, and the other blade grasps the skin at a point superiorly, which just smooths out the skin of the eyelid until slight eversion of the lid occurs. This technique helps prevent postoperative lagophthalmos. Leaving approximately 20 mm of eyelid skin may also help prevent postoperative lagophthalmos. The superior extent of the eyelid skin can be identified by palpating the abrupt transition from the thin upper eyelid skin to the thicker eyebrow skin. The inferior extent of the brow cilia should be avoided as an endpoint because the patient may have epilated and therefore altered the apparent end of the inferior brow.⁶ Both the medial and lateral ends of the upper lid fusiform excision should form a 30-degree angle.^12,14

Figure 30-19. Upper eyelid skin incision is marked. The inferior portion of the lid incision is made approximately 8 mm above the lid margin. A skin muscle flap has been excised.

(Redrawn with permission from Mayo Clinic.)

Figure 30-20. The pinch test helps determine the amount of lid skin to be excised.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:687.)

If the patient has eyelid ptosis, the lid crease is likely to be higher on the more affected side and therefore a new lid crease may need to be created. The new lid crease is placed according to sex and race as described previously.

Once the markings are complete, local infiltrative anesthesia is injected in the immediate subcutaneous plane. If ptosis surgery is also being performed, care should be taken to ensure that the minimum amount of local anesthesia is used so as to not affect the underlying levator. Usually 1 to 2 mL of local anesthesia is all that is needed. After adequate time is given for the anesthetic to take effect, the skin incisions are made with a fresh blade of the surgeon’s choice, and the skin is taken as a single layer or as a two-layer skin-orbicularis unit (see Fig. 30-20). If skin only is excised, a determination is subsequently made regarding the amount of orbicularis oculi muscle to excise. Resection of a strip of orbicularis along the inferior length of the skin excision helps recreate a distinct upper eyelid skin crease. A variable amount of orbicularis oculi muscle should be resected, depending on the degree of muscle hypertrophy.

Resection of orbicularis exposes the orbital septum and allows visualization of the orbital fat through the septum. Two different techniques may be used to address the pseudoherniation of fat. Bovie cautery of the orbital septum contracts the septum and reduces the degree of fat pseudoherniation as has been described for lower lid blepharoplasty.¹⁵ Alternatively, opening the orbital septum and removing fat from the medial and central compartments may be achieved (Fig. 30-21). Clamping the fat that will be removed, followed by cauterization of the fat in the clamp, helps prevent postoperative hematomas. Anterior traction should not be placed on the clamp to prevent avulsion, bleeding, and excessive resection. Only fat that protrudes into the wound with gentle globe pressure should be clamped and excised to avoid overaggressive removal of orbital fat and a hollowed postoperative look. However, care should be used to help avoid the common error in upper eyelid blepharoplasty of failing to remove enough of the medial orbital fat. Laterally, the lacrimal gland may come into view and should be recognized to avoid its injury. The lacrimal gland is more pink, vascular, and firm than is the fat.

Figure 30-21. A and B, A silk traction suture has been placed through the gray line. The orbital septum has been opened and a portion of the levator aponeurosis has been released from its tarsal insertion. Müller’s muscle is partially visible deep to the levator. C and D, A Desmarres retractor has been placed and the preaponeurotic fat is visible. E and F, A double-armed mattress suture is placed through the tarsus and levator. One to three mattress sutures may be required to achieve a natural appearing contour. G and H, The lid crease can be reformed with interrupted sutures through the skin and orbicularis. The skin is then closed in a running fashion.

(Redrawn with permission from Mayo Clinic.)

If only blepharoplasty is performed, after excellent hemostasis is achieved, wound closure proceeds with a single layer closure of the skin with a 6-0 fast-absorbing gut suture.^12,14 However if ptosis surgery is also going to be performed, then the lower edge of the incision is grasped with a Castroviejo forceps (0.3 or 0.5) and the pretarsal orbicularis is dissected medially and laterally to expose the surface of the tarsal plate (see Fig. 30-21). Next, this strip of orbicularis can be removed to further debulk the lid fold and expose the underlying layers to help identify the levator aponeurosis. An important landmark for identifying the levator aponeurosis is the preaponeurotic fat pad. It lies posterior to the orbital septum and is anterior to the levator. A cotton tip applicator can be used for gentle dissection and may help prevent inadvertent damage to the underlying levator. Once identified, the orbital septum should be opened medially and laterally because leaving the orbital septum attached may result in postoperative lid lag or lagophthalmos. A Desmarres retractor can be used to retract the fat, exposing the underlying levator aponeurosis. To ensure that one has correctly identified the levator, the patient can be asked to look up while grasping the levator. If identified appropriately, a force is transmitted via the forceps. A double-armed 6-0 silk suture can be used as a cardinal suture by passing it in a horizontal mattress fashion through the tarsal plate approximately 5 mm from the lash line. This tarsal bite should be approximately half thickness, because a full-thickness bite may lead to postoperative keratopathy. The sutures are then passed through the cut edge of the aponeurosis and tied in a slip knot. The position of the lid may then be assessed and additional horizontal mattress sutures may be placed medially or laterally to adjust the lid contour. Initially, a slight overcorrection may be desired to allow for postoperative descent that may occur from the stimulation of Müller’s muscle by the local anesthesia. Once the desired height and contour are achieved, the sutures may be tied down and the skin closed as described previously.^6,13,20

Transconjunctival

The transconjunctival blepharoplasty has become increasingly popular over the past few years due to the hidden incision, the maintenance of the orbicularis support structure for the lower eyelid, and a reduced rate of postoperative ectropion. Proper patient selection is required for the successful use of this technique in blepharoplasty. Patients with pseudoherniation of fat and little need for skin excision are good candidates for this procedure. In addition, patients who heal with hypertrophic scars, and patients who will not accept an external incision are good candidates. The presence of a mild to moderate amount of excess skin in the lower eyelid does not preclude the transconjunctival approach, in that a pinch excision of skin and lid resurfacing techniques may be used to address the lower lid skin changes.¹³

After local anesthetic is injected and adequate time is allowed for the vasoconstriction to take effect, the lower eyelid conjunctival surface is exposed. Either a preseptal or postseptal approach may be used, depending on the surgeon’s preference (Fig. 30-22). A 4-0 silk suture is placed through the eyelid margin for traction. The traction suture, together with a Desmarres retractor, helps evert the lower eyelid. The preseptal approach involves a transconjunctival incision made at the inferior margin of the tarsal plate. A plane is developed just deep to the orbicularis muscle in the avascular plane between the orbicularis muscle and orbital septum, down to the level of the orbital rim, without exposing the orbital rim. A 4-0 silk suture is then passed through the conjunctival edge to provide traction and corneal protection. The orbital septum is then in clear view and may be entered with the Bovie cautery.

Figure 30-22. Preseptal (1) and postseptal (2) transconjunctival approaches to blepharoplasty.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:693.)

Alternatively, the postseptal approach may be used; this entails a single incision placed 4 mm below the inferior tarsal margin, directly through the conjunctiva and lower eyelid retractors, to expose orbital fat from the posterior aspect. The orbital septum is maintained completely intact in this technique. Traction sutures of 4-0 silk or nylon are placed on either side of the transconjunctival incision to allow for blunt and sharp dissection throughout the lower eyelid retractors to the orbital fat. Identification of the inferior oblique muscle, which separates the medial from the middle fat pads, should be performed in both the preseptal and postseptal methods to avoid injury to this structure. The fat is excised as described for the upper eyelid blepharoplasty, using a clamp and Bovie cautery. The lower eyelid fat pads communicate directly with the deeper orbital fat, so excessive traction on the fat should be avoided to help prevent orbital hemorrhage. The incisions may be left open to heal spontaneously, or loosely applied fast absorbing sutures may be used. If redundant skin is present, it may be excised with the scalpel, and the incision closed with 6-0 fast-absorbing gut sutures (Fig. 30-23).

Figure 30-23. Resection of skin is achieved, as needed, after fat removal.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:694.)

Subciliary Approach

The subciliary approach is most useful for those patients with large amounts of excess skin. A subciliary incision is made 2 mm below the lash line, extending from 1 mm lateral to the inferior punctum to 10-mm lateral to the lateral canthus. The incision extends through the skin and orbicularis muscle along the entire length of the incision (Fig. 30-24). A skin-muscle flap is elevated to the orbital rim, exposing the orbital septum in its entirety. The skin-muscle flap is extended over the rim so that the muscle is separated from the arcus marginalis to allow for proper skin redraping (Fig. 30-25). The orbital septum is then approached either with Bovie cauterization of the intact orbital septum or by excising the bulging orbital fat. After hemostasis is achieved in the fat compartment, a variable amount of skin and muscle is excised as needed (Fig. 30-26). Closure of the incisions is accomplished in two layers. Laterally, the orbicularis fibers are reattached with a 5-0 PDS suture to help prevent tension on the lateral-most aspect of the incisions. This allows the skin edges of the incision to approximate one another closely. Finally, the skin layer is closed with 6-0 fast-absorbing gut suture.^13,14

Figure 30-24. The lower eyelid incision may be made with a scissor or with a knife. Care is taken to avoid cutting the eyelashes.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:688.)

Figure 30-25. A, The skin and muscle flap is dissected bluntly and sharply. B, Access is gained to the septum and fat compartments for subsequent fat removal or cauterization of septum.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:689.)

Figure 30-26. The flap is repositioned and excess skin and muscle is excised. Care is taken to excise slightly more muscle than skin to ensure there is no bunching of tissue at the incision line.

(From Colton JJ, Beekhuis GJ. Blepharoplasty. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds. Otolaryngology Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998:689.)