Conventional upper and lower blepharoplasty

Published on 22/05/2015 by admin

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Last modified 22/05/2015

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CHAPTER 29 Conventional upper and lower blepharoplasty

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.

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.