Conventional upper and lower blepharoplasty

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CHAPTER 29 Conventional upper and lower blepharoplasty

Pierre Saadeh

History

That versions of the aphorism “the eyes are the windows on the soul” date back at least to Roman times is testimony to the emotional significance that the eyes possess. More precisely, it is the periorbital tissues surrounding the relatively inert and unindividualistic globes that convey information spanning both the expressive and physiologic gamut.

As a person ages, a constellation of changes gradually, albeit variably, occur in the periorbital tissues ultimately culminating in a patient concerned about a “tired, unhappy look” which can belie an otherwise normal emotional state. The changes that occur include descent of the brow, glabellar prominence with vertical rhytids, development of asymmetrical and redundant upper eyelid skin and lateral upper lid skin “hooding”, elevation of the upper lid crease, hollowing of the upper orbit due to soft tissue atrophy, lower lid laxity, pseudoherniation of lower lid fat resulting from orbital septum attenuation, development of lower lid rhytids, accentuation of the tear trough, and the development of lateral “crows feet”.

Although these changes are commonly seen together, it should be emphasized that many of the underlying etiopathologies are distinct and often subtle and, therefore, require a very individualized approach. Furthermore, more often than not, these changes accompany age-related changes affecting the rest of the face ideally requiring expertise in the various facets of facial rejuvenation.

An ever-improving understanding of the dynamic nature of facial anatomy accompanied with a more holistic approach to facial aging has altered the surgical treatment of age-related periorbital changes. Conceptually, trends point towards decreasing tissue removal in favor of tissue rearrangement and repositioning. Standard blepharoplastic incisions now allow for effective treatment of all of the aforementioned age-related changes. Increasingly limited upper eyelid fat excision and minimal lower lid orbicularis occuli violation has helped avoid exacerbation of orbital hollowing and minimized ectropion, respectively. Moreover, precise soft tissue augmentation (autologous and non-autologous) of the upper lid can help recreate a more youthful appearance.1 Similarly, these techniques can be quite useful in blunting the tear trough deformity. Complementing these trends is the use of botulinum toxin (Botox, Allergan) to help decrease rhytids that characterize aging.

Note should be made of other periorbital conditions, the discussions of which are beyond the scope of this chapter, that require recognition as distinct from age-related changes, and therefore specific treatment. A short, non-comprehensive list includes blepharochalasis, blepahrophimosis, Graves’ disease, and myasthenia gravis.

Physical examination

Eye exam

A detailed medical and ophthalmologic history and a standard eye exam including visual acuity in each eye is required. Dry eyes, which can be exacerbated by blepharoplasty, are best identified through careful history taking and Schirmer’s testing (less than 10 millimeters of moisture on a piece of filter paper in the conjunctival sac after five minutes is considered abnormal).2 Evaluation includes the assessment of a Bell’s phenomenon which can be protective, particularly if an ectropion develops. Agents which promote bleeding and inhibit clotting must be eliminated and adequate time for reversal of their effects must elapse prior to surgery. Perioperative blood pressure control is vital and should be managed pharmacologically if indicated. A low threshold for ophthalmologic consultation in the event of positive findings on history and physical is advocated.

Excess skin

See Fig. 29.1. A common presenting complaint of patients, excess eyelid skin, or dermatochalasis, should be noted on physical evaluation and precisely assessed especially regarding extent and location. Occasionally, the upper eyelid skin redundancy is excessive enough to impact the visual axis and/or result in pseutoptosis. Asymmetry, the correction of which is a central goal of blepharoplasty, must be also identified. Excess skin resulting from blepharochalasis may, ultimately, be treated similarly to age-related skin excess but the risk of ptosis and other disease-specific conditions require recognition of this entity. Lower lid skin excess is less common than lower lid wrinkling which invites a more conservative surgical approach particularly in light of the possibility of ectropion. Pre-tarsal skin fullness is more often due to the underlying orbicularis occuli than to skin excess.

image

Fig. 29.1 Periorbital age-related changes. Upper lid: A, Skin excess and septal attenuation with fat herniation; B, Hooding with brow ptosis; C, Asymmetry; 1, compensatory brow elevation (not evident in this patient: hollowing, upper lid crease elevation). Lower lid: D, Tear trough; E, Fat herniation and septal attenuation; F, lower lid laxity; 2, descent of lateral canthus. (Not evident in this patient: vertical glabellar creases.)

Fat pseudoherniation

Frequently found in conjunction with skin excess, orbital fat pseudoherniation contributes significantly to the “tired look” of age-related periorbital changes (Fig. 29.2). The size and shape of the medial and middle fat pads of the upper lid and the three lower lid fat pads should be noted. Upward and downward gaze in an upright patient will accentuate the fat pads. The configuration of the lower lateral fat pads, should be documented, since they are easily underappreciated, particularly in the sedated, supine patient.

image

Fig. 29.2 Location of fat pads and upper and lower lid incisions (dotted lines).

Lateral brow position

Although the entire brow tends to descend with age, lateral brow descent is relatively more pronounced, augmenting “heaviness” to the upper lid and suggesting an aged appearance. This evolution is more relevant to women in whom the lateral brow is slightly elevated (by a few millimeters) in the youthful ideal whereas the male ideal is a straight brow. The cross-cultural relevance of the female eyebrow “arch” is reflected by the ubiquity of non-medical procedures to achieve this aesthetic ideal including eyebrow including plucking, painting, and tattooing.

Lower lid laxity

Careful attention must be placed on the recognition of lower lid laxity since this entity has both functional and aesthetic consequences which may be aggravated by surgery. Skin quality should be noted and the position of the lower lid assessed (normally at the lower limbus in neutral gaze). The following tests suggest lid laxity when positive. The “pinch test” is positive if the lateral can be medially displaced to the lateral limbus for more than two millimeters. The “snap back” test is positive if, after being pulled from the globe, the lower lid requires more than one second to return without blinking. The “distraction” test is positive when the lower lid can be pulled more than seven millimeters away from the globe.

Ptosis

An ophthalmologic condition unto itself, ptosis requires identification and evaluation prior to aesthetic rejuvenation of the upper lid. Ptosis is defined as an upper lid margin (unilateral or bilateral) lower than two millimeters below the upper limbus. In the presence of ptosis, the arc of lid excursion will aid in identifying potential reparative interventions. The causes of ptosis are varied, but in the typical, older population seeking aesthetic eyelid rejuvenation, levator palpebrae superioris attenuation or dehiscence will yield aponeurotic ptosis. An elevated upper lid crease and a history of extensive contact lens use are also consistent with this entity. The practitioner needs to be aware that ptosis can result from conditions ranging from Horner’s syndrome to myasthenia gravis.

Negative vector

The position of the cornea anterior to the infraorbital rim entails an increased potential for untoward sequelae after lower lid surgery including lid retraction and ectropion.3

Periorbital evaluation

Since the eyelids are but a component of the periorbita, a comprehensive assessment of the surrounding tissues will optimize preoperative planning. Specifically, the presence of glabellar rhytids, orbital hollowing, the tear trough, and the crow’s feet should be noted.

Technical steps

Intraoperative referral to standard medical photographs is very valuable in blepharoplasty since intense operative lighting, the recumbent position, and the edema from both local anesthetic and surgical trauma can easily obscure subtle anatomic derangements requiring correction.

The patient’s upper lid is marked with a fine-tip, water insoluble marker while sitting upright (Fig. 29.2

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