The consultation

As with all surgical approaches to rejuvenation, we must take into account what are the actual changes that occur in the upper periorbita and whether the existing methods consider these occurrences for a wide variety of individual presentations (Fig. 8-2). Do these techniques result in a rejuvenative appearance or simply achieve a ‘cause and effect’ outcome whereby an altered appearance replaces youth? (Fig. 8-3). And, ultimately, what surgical procedures are some patients willing to undergo and what do they expect from surgery?

Figure 8-2 This 40-year-old patient shows many of the typical changes that occur, especially in the upper eyelid with aging of the periorbita. What are the anatomic changes that cause this?

Figure 8-3 This patient presented to her surgeon for cosmetic rejuvenation of the eyelids. Surgery was performed and she was unhappy with the result. What techniques were performed that caused the changes noted and what could have been done to avoid the unwanted effects?

Often when a patient consults with one or a number of surgeons in consideration of rejuvenation of the upper periorbita, the possibility of brow lift is discussed. Some surgeons may suggest that a patient requires a brow lift while others may not. What is the basis of this inconsistency and what has been the justification and anatomic rationalization of either approach? Moreover, if the patient who presents for upper periorbital rejuvenation has a mild to moderate degree of perceived brow ptosis and refuses to undergo a brow lift of any sort, are there other methods that can significantly improve the appearance without the incorporation of browplasty/pexy?

We are all aware that at times particular procedures are offered for lack of knowledge or ability to achieve a desired effect in another, perhaps more accurate, manner. For instance, when consulting with a young female who presents for improvement of the appearance of the upper periorbita, what are the findings on examination that suggest a particular approach? How much has the eyebrow actually descended and why would one then offer a brow lift if there has been little change over the patient’s lifetime? (Fig. 8-4). What has been the justification and anatomic rationalization of any given approach?⁹ What effects have been ignored with this approach that could be improved upon? Is there ever an indication for a 35 to 40-year-old (or younger) to have a brow lift? (Fig. 8-5). Have we considered what this individual patient’s brow position was in youth? Why, in fact, are many patients resistant to brow lifts? What should we strive for to accomplish the most acceptable and aesthetic rejuvenative result? A review of some simple but common observations of the changes in the aging upper periorbita for a majority of our patients sheds more light on which surgical solutions are both physiologically and aesthetically feasible (Figs 8-2, 8-6):

Figure 8-4 This individual exhibits the youthful and aesthetic fullness to the ‘lid–brow junction’ and a well positioned lateral eyebrow.

With permission from Corbis. Copyright © Royalty-free/Corbis.

Figure 8-5 Would there ever be an indication to perform a brow lift on this configuration if the patient presented for periorbital rejuvenation?

Figure 8-6 This exemplifies the aging changes that can occur around the periorbita with the red arrows pointing to the aged left side of this patient. A true rejuvenative appearance should consider techniques that restore the youthful complement as in the direction of the green arrows pointing toward this patient’s right side.

Eyebrow position and volume

The term brow ptosis suggests a descent of the eyebrow position from its ‘normal’ state. Obviously some younger individuals with ‘low’ brows may request a ‘change’ or improvement of their brow position much as one would desire otoplasty or rhinoplasty (Fig. 8-5). Additionally, many patients will present wishing for surgical correction to accomplish more pretarsal ‘show’ for reasons that include creating more area to apply cosmetics, a mistaken memory of what their upper eyelid looked like in youth, or simply their desired outcome. A review of old photographs is most often revealing, yet the ultimate determination must rest on the choice of each individual patient. Careful analysis including the use of morphing techniques as shown by Lambros¹¹ and others,¹² repeatedly and consistently has shown that the deflationary effects from facial volume loss with age can yield the apparent and illusionary effects of facial soft tissue ptosis. These misperceptions include an illusion of brow ptosis in some individuals that is due to soft tissue volume depletion, particularly in the temporal and lateral infrabrow regions, which may have prompted a brow lift when replacement of soft tissue volume has been shown to enhance aesthetics (Fig. 8-7)¹³ (see Chapter 23). There are also some individuals who would have compromised aesthetic results by not undergoing the necessary brow lift. Which individuals then, benefit from which procedures?

Figure 8-7 A, This patient had undergone a four-lid blepharoplasty elsewhere and was unhappy with the appearance. Her concerns related to a lower appearance of the eyebrow, a sunken appearance to both the upper and lower eyelid and increased appearance of ‘wrinkles’. B, Restylane was administered in this patient to the lateral infrabrow region for brow lift effect with extended application to the lower eyelid and lateral canthus to improve volume.

The upper eyelid crease and fold

What has been less understood, are the actual changes that occur to the upper eyelid crease and fold. Often the position of the eyelid crease is obscured by the appearance of redundant upper eyelid skin and fold displacement. A careful analysis of the crease in most individuals shows varied change from youth. The changes may also be asymmetric in any one individual (Fig. 8-8). This includes an elevated crease that may manifest in one or both upper eyelids. The solution has been, in most cases, to raise the eyelid crease of the affected upper eyelid with the excision of ‘excess’ soft tissue with or without brow lift. This maneuver, however, is routinely and repeatedly performed without respect for the presenescent appearance or understanding of the actual age-related changes of the upper periorbita (Figs 8-2, 8-3, 8-6).

Figure 8-8 This patient presented with marked asymmetry of her upper eyelids that appeared to get much worse in recent years.

The routine applications of traditional concepts in incision placement and soft tissue excision have also plagued some other technical aspects in upper blepharoplasty. The usual design of the upper eyelid crease commonly involves the use of 10 mm or greater (height) eyelid crease incision with excision of skin, orbicularis oculi muscle, and preaponeurotic fat.^7,8 This is customary whether or not upper blepharoplasty is performed with or without a brow lift. In part, the basis of this approach has been an attempt to elevate the upper eyelid crease, in essence, to expose a greater amount of the pretarsal surface and to ‘debulk’ the upper eyelid fullness by en-bloc or separate resection of skin and muscle.⁸ This approach, however, facilitated additional steps in upper blepharoplasty that are also aesthetically detrimental, including better access to the preaponeurotic fat (resulting in further soft tissue reduction and volume depletion) and the levator aponeurosis for supratarsal fixation. Concerns with a lower placed incision included possible visibility of the upper eyelid incision scar, inability to achieve adequate final pretarsal exposure, and risk to the levator aponeurosis insertion to the pretarsal surface, especially when utilizing a full thickness skin muscle excision whether removed in separate ‘layers’ or ‘en-bloc.’ The long-term consequences of the traditional approach, however, can be suboptimal. Deep or ‘hollow’ upper eyelid sulci are common effects, presumably from over-resection of soft tissue (Fig. 8-3), especially fat. In some, the upper eyelid crease scar becomes hypopigmented (Fig. 8-9) and usually more visible with time, usually at a much higher level (15–20 mm). This is especially true in the patient with a prominent globe, negative upper periorbital vector, or in those who habitually elevate their eyebrows for a variety of reasons. The color transition can also at times become quite obvious, as the upper edge of the incision is placed in the darker and thicker sub-brow skin. The pretarsal skin also becomes progressively less taut (more ‘crepey’ in appearance) due to the sliding effect as most original points of fixation have been compromised by over-dissection.

Figure 8-9 This patient, who had surgery performed elsewhere many years prior, exhibits many of the findings of a sub-optimal design for upper blepharoplasty including a high-placed eyelid crease, dyschromia, iatrogenic lid ptosis, and volume depletion.

Comparative anatomy and aesthetics of upper eyelid ptosis and periorbital aging

Some of the changes that can occur in the aging upper periorbita parallel the findings seen with true upper eyelid ptosis at any age. Alternative and improved surgical repair has shed light on the effects that can be created by alterations in the upper eyelid crease. Often in those with significant blepharoptosis, there is an apparent, unusually elevated (from youth), upper eyelid crease, at times >15–20 mm (Fig. 8-10A). This is also typically associated with a deep, hollow, upper eyelid sulcus and apparent volume depletion from either fat atrophy or retraction of the central preaponeurotic fat pad. This is further accentuated by the patient’s subconscious efforts to raise the eyebrow in an attempt to elevate the upper eyelid to enhance visual function (Figs 8-10A, 8-11A). Although the mechanism for these latter changes has been challenged (in both non-surgical and post-surgical¹⁴ states) I believe that it is, in part, a result of atrophic orbital effects causing loss of adherence of the multiple eyelid layers with subsequent loss of the lower positioned upper eyelid crease of youth. With this, the relationship of the levator aponeurosis and orbital septum loses the tight compartmentalization of the central preaponeurotic fat that is normally sandwiched between the levator aponerosis and orbital septum that now can retract into the orbit. Traditional methods of blepharoptosis repair using levator advancement or resection techniques have had much less predictable influences on the eyelid crease. These techniques led to variable excision of the skin and orbicularis oculi muscle, septum, and preaponeurotic fat in order to address the presumed levator aponeurosis dehiscence for repair. I believe this yields less aesthetic results and contributes to the appearance of upper periorbital aging. Minimally invasive surgical solutions to blepharoptosis repair¹⁵ (posterior approach/soft tissue sparing such as the Müller’s muscle conjunctival resection) even combined with skin excisional blepharoplasty may improve the upper eyelid soft tissue plane relationships by recreating supratarsal volume that re-establishes the youthful upper eyelid appearance (Figs 8-10, 8-11, see Chapter 11). The analogy of the aging upper periorbita with upper blepharoptosis and a greater sense of the physiologic and anatomic changes that occur in upper facial aging suggest a more sound and logical approach for rejuvenation.

Figure 8-10 A, This young patient exhibited severe upper eyelid ptosis and lateral canthal dystopia. The upper eyelid crease configuration is similar to that occurring with volume loss with age as well as over-zealous resection of soft tissue (including fat). B, A more youthful and aesthetic appearance is achieved after upper lid ptosis repair by Müller’s muscle conjunctival resection that also lowers the upper eyelid crease.

Figure 8-11 A, Similar to the previous figure, this patient presented for periorbital rejuvenation when she was made aware of her upper eyelid ptosis. B, After four-lid blepharoplasty and Müller’s muscle conjunctival resection for upper lid ptosis correction.

Advanced rejuvenative upper blepharoplasty from technique to aesthetics

A careful analysis of the goals in upper blepharoplasty should include an individualized approach that considers the patient’s desires and appearance in youth. Preoperative planning is essential, as it is to other facial aesthetic surgical procedures. This should include the appreciation of volume shifts manifesting brow and orbital fat malposition, volume loss manifesting either deepening of the upper sulcus or dermatochalasis, position of the upper eyelid crease currently and in youth, and attention to the brow position and contour.

The incision placement, plane of dissection, soft tissue excision, and maintenance of orbital volume shifts, all influence the effects achieved in upper blepharoplasty. Surgical maneuvers in each of these areas can dramatically affect outcome. When done in error, these techniques can produce effects that are surgical in appearance, or when appropriately performed, can regain youth without the stigma of surgery.

By keeping the crease incision low (i.e. lower portion of upper eyelid crease incision made at 7–10 mm), there is minimal disruption to the majority of the upper eyelid and crease structures (Fig. 8-12). The lower crease incision, as low as 7 mm, is usually reserved for some males or Asian upper eyelid configurations (see Chapter 9), while a majority of patients benefit from eyelid crease incision in the 8–10 mm range. Those individuals with a deep upper eyelid sulcus either from hereditable factors or related to varying degrees of upper blepharoptosis that defer surgical correction of the lid malposition, are most appropriate for the higher 10 mm or more incision. Since there is commonly no advantage to involving the orbicularis oculi muscle, the excision should therefore include skin only (Fig. 8-13B). Although traditionally, a strip of orbicularis muscle at the lower edge of the wound is excised, there is no enhancement of rejuvenative effects with this maneuver. Theoretic reasons for removing orbicularis to effect a scar at the lower skin edge most often results in disturbances in the existing upper eyelid layer attachments that can cause not only unpredicted cicatrizations, but long-term crepeyness of the pretarsal skin. Preservation of orbicularis also adds to upper eyelid volume enhancement by plicating the bulk of orbicularis muscle with approximation of the skin edges by skin closure (Fig. 8-14). This effect can also be more profound, physiologic, and predictable than that which can be accomplished by injecting autologous fat. Enhancing a limited transorbicularis cicatrix (via electrocautery) may be essential for realignment of the eyelid crease at this lower level by effecting adhesions through orbicularis muscle to the dermis at the lower edge of the incision in a more extensive and permanent way then suture fixation. The suborbicularis fibrosis achieved with cautery may be more important for both effecting an adherent relationship between skin–orbicularis, septum, and levator aponeurosis and drawing skin and orbicularis from the eyelid margin to effect a smoother pretarsal surface (Fig. 8-13).

Figure 8-12 A careful evaluation and particular attention to precise incision planning can lead to a more accurate and youthful result and reduce the stigma of surgery. This serves as a guide to the most common presentations.

Figure 8-13 A, Aging periorbita with loss of crisp upper eyelid crease attachments. B, Skin excision with complete preservation of orbicularis oculi muscle. Diathermy to the lower edge/pretarsal segment allows for a transorbicular cicatrix for re-establishment of the lower placed upper eyelid crease. C, Skin closure with orbicularis muscle intact causes an ‘accordion effect’ whereby volume is improved in the supratarsal segment.

Figure 8-14 A higher magnification view of the prior figure in cross-section shows skin closure with intact orbicularis and the effect of orbicularis ‘bulking’ to improve supratarsal volume.

The upper eyelid and eyebrow relationship, I believe, has also been poorly understood in the traditional approaches to upper blepharoplasty. This may be why browplasty has been so freely offered or performed. The youthful upper eyelid fold in most patients is usually quite distant from the eyebrow. This relationship can be dramatically altered with over-excision of upper eyelid soft tissue in traditional blepharoplasty techniques. For instance, with typical skeletonization of the upper eyelid from over-resection of skin and fat with elevating the upper eyelid crease, individuals with even modest brow ptosis would require browplasty in order to achieve greater aesthetics. This would in effect enhance the distance between the upper eyelid fold and the lower brow edge (brow-fold distance/BFD) (Fig. 8-15).¹⁶ Could we not accomplish however, in these individuals, a similar and possibly more rejuvenative and physiologically (as well as anatomically) correct effect by these more modern/advanced approaches with upper eyelid aesthetic surgery? In other words, by creating or maintaining the lower positioned upper eyelid crease with appropriate rejuvenative techniques we can achieve the same or improved brow-to-fold distance without the need for browplasty.

Figure 8-15 The effect of a brow lift is oftentimes to reduce the diminished brow-to-fold distance (BFD) that is induced by over-zealous excision of soft tissue during traditional upper blepharoplasty. Furthermore, a brow lift will then expose the volume depletion created. This can often be avoided with more accurate incision design, excision, and preservation during upper blepaharoplasty.

Finally, volume considerations of the upper eyelid/brow have been confused or mostly ignored. The deflationary effect afforded by soft tissue shifts and volume loss is what I believe contributes more to the appearance of (pseudo-) excessive upper eyelid skin and eyelid fold changes than do gross changes in brow position or true skin excess. Similarly, although for no apparent aesthetic reason, the concept of excision of ROOF fat has been popularized. I believe that in most situations, there is no reason to cause this unaesthetic volume depletion by direct fat excision and we would fare better by a more physiological approach to the descended fat (i.e. repositioning). The debulking of the lateral upper eyelid orbicularis muscle has also been routinely performed with upper blepharoplasty and yields similar unaesthetic effects. Both of these added steps in upper blepharoplasty further reduce the brow-to-fold distance and thereby may compromise the youthful upper periorbital configuration in many patients. Excision of orbicularis oculi also can add to brow ptosis as remaining functioning orbicularis can now more directly effect brow position with contraction that is reduced or nullified by preserving orbicularis muscle. Enhanced volume can also be effectively regained by autologous fat or hyaluronic acid injection (Fig. 8-7) to this area that can also have illusionary effects of eyebrow position.¹³

Fixation of the lateral periorbita and prevention of postoperative lateral brow descent can also be afforded by suspension of the lateral orbicularis to the adjacent orbital rim similar to the description by Zarem.¹⁷ A browpexy effect is also achieved through creative use of the lateral retinacular suspension⁴ (Fig. 8-16; see Chapter 15). Volume preservation yields the most aesthetic surgical remedy and combined with effective lateral browpexy achieved with retinacular suspension allows for rejuvenation of the lateral brow, crease, and commissure relationship afforded by enhanced blepharoplasty techniques.

Figure 8-16 A & B, Although lateral retinacular suspension is performed primarily for lower eyelid and canthal support with lower blepharoplasty, precise and accurate placement with exit of the suture at a higher level of the orbital rim through the periosteum can facilitate a browpexy effect with stabilization of the tail of the brow to avoid postoperative descent. The invagination and bolstering effect by this maneuver, also aids in a small way to give the illusion of enhanced volume in the infrabrow region.

Technique

See Figure 8-17.

Figure 8-17 A, Skin demarcation for crease creation; here placed at approximately 9 mm centrally and tapering medially and laterally. The lateral extent will usually be around 10 mm or so depending on patient presentation. B, A ‘skin pinch’ technique is used to determine the amount of skin to excise. The endpoint is NOT the appearance of eversion of the lid/lash margin and is usually the (maximum) amount that does not cause any change in the lid position with the pinch. C, The upper demarcation usually follows the contour of the eyebrow. This amount would be far too much if skin AND muscle were to be excised. D, After infiltration with local anesthetic the incision is followed closely and precisely to the demarcations. E, Diathermy is applied for hemostasis and especially to inferior wound edge to create a transorbicular cicatrix which is felt by the author to be even more effective than deeply placed crease sutures. Note: orbicularis oculi is completely intact. F, Through the intact orbicularis muscle, accurate and appropriate amounts of medial/orbital or (if necessary) medial/central preaponeurotic fat can be excised through a small ‘button hole’ incision.

My approach to upper blepharoplasty in the appropriate patient who has crease and volume alterations as described is as follows:

1. Fig. 8-17A: The design of the upper eyelid crease is determined by several factors including position of the native or senescent crease, brow position, and upper periorbital vector analysis. Typically, the crease demarcation is at 7–10 mm centrally in contrast to traditional approaches that have been at 10 mm or above and tapers slightly toward the eyelid margin medially and laterally. In the presence of any degree of brow ptosis, an attempt is made to lower the crease as much as possible. This allows for the effective (but conservative) skin excision with the upper edge of the elliptical demarcation, to be as distant from the thicker skin of the brow as possible. The brow-to-fold distance is thereby maximized to reduce the ptotic brow appearance. In the presence of the protuberant eye, the crease height is also set low as there is a tendency to have an accelerative cephalad crease migration in this situation. The medial extent of the crease demarcation is usually the upper lacrimal punctum and courses inferiorly toward the eyelid margin. The lateral extension of the upper eyelid crease that will serve as the lateral extent of the final elliptical demarcation is dependent on similar conditions that determine the height of the crease. Lateral brow ptosis that will be more obvious and applicable in males, will require a more lateral extension of the crease/ellipse to remove the lateral ‘hood.’ The lateral extent of the demarcation is rarely greater than 10–12 mm from the lateral commissure. The protuberant eye will usually have less lateral hooding and therefore the lateral extent will be more conservative.

2. Fig. 8-17B: The determination of excessive skin is made by the ‘pinch technique’ and serves only as a guide to the maximum allowable skin resection. The endpoint is that of skin tautness without the eversion of the lash-margin.

3. Fig. 8-17C: The design of the ellipse is facilitated by drawing the upper elliptical edge that closely follows the contour of the brow. Usually, the amount of skin excision should ultimately be less than this specified amount.

4. Fig. 8-17D: The injection and infiltration of local anesthesia with epinephrine should be limited to the subcutaneous space, since this will be plane of dissection (aided by hydraulic expansion by local anesthetic injection) and will limit ecchymoses by avoiding transorbicularis injury. The incision should be through skin only and dissection begins at the lateral ellipse with skin excision only.

5. Fig. 8-17E: Hemostasis is accomplished by monopolar cautery. Liberal application at the lower edge of the wound allows for creation of an adhesive interface at the lower edge of the wound. This facilitates establishment of the crease at this position, enhanced by transorbicularis fibrosis that aids in crease establishment and causes a cephalad subcutaneous/muscular and septal/aponeurotic adhesion. This ultimately maintains the tautness of the pretarsal soft tissue.

6. Fig. 8-17F: A small ‘button-hole’ through orbicularis muscle and orbital septum is made at the medial extent of the elliptical wound to accommodate medial orbital fat excision when necessary. Minimal, or none, of the preaponeurotic fat is reduced or excised and if necessary can also be retrieved from this small wound. In a rare situation, the orbicularis muscle of the upper eyelid, more centrally, can be incised (not excised) at the highest portion nearest to the upper edge of the wound for further manipulation of the preaponeurotic fat.

7. Figs 8-18, 8-19: The upper eyelid wound is then closed with multiple interrupted 6-0 nylon sutures. If retinacular suspension is to be performed, the outer one-fourth of the wound remains ‘open’ until the lower blepharoplasty and canthopexy is performed and skin closure is then completed using the same nylon suture. Due to enhanced inflammation produced by cautery and the fact that skin is closed over a greater degree of upper eyelid bulk since the orbicularis muscle is plicated producing a desirable volume-enhancing effect with greater tension on the skin wound, the sutures remain for seven days with an opportunity to leave one or two of the interrupted sutures intact for 2 or 3 days longer. This is to avoid wound dehiscence.

Figure 8-18 Orbicularis muscle is entirely intact. This is one of the few areas in facial surgery where skin (only) excision and closure is aesthetically performed.

Figure 8-19 Skin closure with orbicularis muscle intact yields a volumetric enhancing effect.

Results

The results using these concepts and techniques for rejuvenation of the upper periorbita are shown in Figures 8-20 to 8-33.

Figure 8-20 A, This patient presented for surgical correction of periorbital aging. Volume loss and shifts created a more visible medial pretarsal area and ‘hooding’ of the lateral upper eyelid. B, After volume enhancing upper blepharoplasty (and lower blepharoplasty).

Figure 8-21 A, This patient presented with periorbital aging at age 48. B, Volume enhancing upper blepharoplasty with lowering of the upper eyelid crease and lower blepharoplasty via lateral retinacular and orbicularis muscle suspension established youthful contours.

Figure 8-22 A, This patient presented with awareness of volume loss of the upper periorbita left greater than right. B, Repositioning of the upper eyelid crease with volume enhancing upper blepharoplasty restored the (illusion) of ‘full’ upper eyelids that she had in younger years.

Figure 8-23 A, This patient of part Asian descent noted profound hooding and ‘skin excess.’ She recalls ‘never’ having significant ‘pretarsal show’ but desired a slightly higher upper eyelid fold to place cosmetics. B, Surgery is performed as described with slightly higher placement of the crease incision.

Figure 8-24 A, This patient, also of part Asian descent, noted a ‘flatness’ to the upper eyelids with ‘hanging’ upper eyelid skin. B, Careful crease placement reduces ‘flatness’ and regains the youthful upper eyelid volume.

Figure 8-25 A, Although skin quality is rarely if ever improved with any surgical endeavor, the general appearance can be positively influenced, as shown here in a patient with arguable mild brow ptosis and severe periorbital elastosis. B, After volume-enhancing upper blepharoplasty combined with lower blepharoplasty.

Figure 8-26 A, This patient, too, exhibits significant brow ptosis and it was recommended to her to have a brow lift (which she refused) by several surgeons on various consultations. B, Volume enhancing upper blepharoplasty (with lower blepharoplasty) was performed that re-established her youthful configuration.

Figure 8-27 A, This patient presented for periorbital rejuvenation. She had mild Graves’ exophthalmos with minimal symptoms and desired a youthful, yet undetectable enhancement. B, After upper and lower blepharoplasty; maintaining a lower positioned upper eyelid crease and volume in individuals like her avoids the postoperative appearance of accentuated exophthalmos and the stigma of surgery.

Figure 8-28 A, This 40-year-old female had no concerns of an aging appearance with any other facial regions except ‘hooding’ of the upper eyelids. B, Volume enhancing upper blepharoplasty afforded a more youthful and aesthetic appearance without the stigma of surgery.

Figure 8-29 A, This patient presented for upper blepharoplasty. She complained of progressive ‘hanging’ of her upper eyelid skin. She was aware that she has always had only modest visibility of her upper eyelids due to ‘fullness’ that was present at youth. Nonetheless, she was strongly desirous of having more ‘pre-tarsal show’ than she had in youth, but felt after reviewing her options that this would be an aesthetic improvement that she would be happy with. B, After upper blepharoplasty with complete orbicularis preservation with placement of the eyelid crease at a higher (11 mm) level. Note despite the elevated lid fold that she has still regained a volumetric convexity in the supra-tarsal/infra-brow region.

Figure 8-30 A, Upper eyelid crease/fold asymmetry is more common and disconcerting with aging. B, Differential excision and crease placement is administered.

Figure 8-31 A, This patient presented for improvement of the appearance of her upper periorbita. She also disliked the asymmetric appearance and liked her ‘left eye appearance much better than right.’ B, A higher crease placement was made with differential surgical excision to satisfy her requests.

Figure 8-32 A, This patient with dark skin presented for upper blepharoplasty 10 years after satisfaction with lower blepharoplasty performed with orbicularis and lateral retinacular suspension. She was bothered by progressive upper eyelid ‘hooding.’ B, After upper blepharoplasty. Accurate incision/crease placement and orbicularis muscle sparing allowed for symmetric youthful upper eyelid folds.

Figure 8-33 A, This 35-year-old female disliked the appearance of her upper eyelids which she described as ‘puffy and hanging.’ B, After upper blepharoplasty.

Discussion

Unfortunately, as in many other areas of the face, the traditional approach to upper blepharoplasty has involved over-excessive incision/excision/dissection, disinsertion, and mobilization. This approach had also been customary in traditional browplasty, facelift, canthoplasty, lower blepharoplasty, and blepharoptosis repair. Similar and related results in upper blepharoplasty are thereby encountered, such as an exaggerated postoperative regression from what appears to be an initially satisfactory result. Disappointment may then follow. Over-dissection of the anterior upper eyelid structures (orbicularis, levator aponeurosis, and septum) can result in loss of a tight adherences and conjoined fascial relationships of the anterior lid lamellar structures that are replaced by cicatrix of soft tissue layers that are not normally in contact with each other (skin to septum/tarsus etc.). This sometimes results in loss of normal upper eyelid function (including but not limited to blepharoptosis and lagophthalmos), incarcerative brow descent, late cephalad migration of the upper eyelid crease, irregularity and loss of crispness of the eyelid crease and crepeyness of the pretarsal skin. The illusion of volume depletion can also result by disruption and manipulation of the preaponeurotic fat pad, even when direct excision is avoided. Additionally, excision of orbicularis muscle has other potential detrimental changes including disruption of the deeper structures, the orbital septum and levator aponeurotic insertions. This can also result in a loss of the usual dynamic sliding/gliding¹⁴ effects only present in the non-operative or minimally traumatized state that can manifest as problematic cicatricial interface changes such as lagophthalmos or blepharoptosis. Lagophthalmos is usually due to a cicatrix involving the orbital septum. Blepharoptosis is often secondary to either simple levator aponeurotic disinsertion or a limiting mechanical effect from superior migration of the cicatrized orbital septum, orbicularis oculi, or over-excised skin. Disruption or excision of the preaponeurotic fat pad may also have effects on the native cushioned interaction of these multiple and complex soft tissue layers. Some dynamic function of the upper eyelid that could have potential effects on ocular lubrication may be lost. Lastly, whether addressing upper or lower blepharoplasty, the potential adverse effects to patients with borderline or manifest tear deficiencies by altering orbicularis function whether by cicatrization or denervation, must be borne in mind.

Other aesthetic and functional considerations include the seemingly paradoxical effect of enhancing vertical palpebral aperture by extirpating orbital orbicularis. This is as a result of disturbing the antagonist relationship with the levator muscle and subsequent elevation of the upper eyelid margin (that has been also shown with chemodenervation¹⁰) as careful analysis of many postoperative photos may reveal an increase in the upper eyelid margin to pupil distance (MRD) of a small but significant proportion. Fortunately, in many instances, this potential effect is probably coincidently nullified by a slight disinsertion or cicatrization (by septum) of the levator aponeurosis with this maneuver. The application of supratarsal fixation, in the traditional sense, utilized these concepts with creation of adherences of the advancing edge of the levator aponeurosis to skin.^18–21 On the other hand, the native fascial relationship can be almost entirely preserved or restored (even in situations of significant asymmetry [Fig. 8-21]) by minimal dissection and excision with the added advantage of the improved real or apparent volume.

Finally, aesthetics have been traditionally influenced by trendsetters, sometimes without anatomic basis. A high lid crease and deep upper sulcus may have at one time been the desired aesthetic effect (Fig. 8-1), however currently most fashion/supermodels display a ‘full’ upper eyelid with retained youthful volume and a lower positioned upper eyelid crease. Eyebrows have been traditionally and routinely elevated, in part, to raise the upper eyelid skin fold in keeping with this trend.

Figure 8-1 A & B, These ‘movie stars’ of the past exhibit what was felt at the time to be an aesthetically pleasing appearance to the upper eyelid. Both exhibited mild degrees of upper eyelid ptosis that accentuated the deep supra-tarsal fold/sulcus. Many surgical procedures were derived in an attempt to duplicate this appearance even in the patient that did not exhibit lid ptosis.

A, With permission from Corbis. Copyright © Bettmann/Corbis; B, With permission from Corbis. Copyright © Underwood & Underwood/Corbis.

I believe the recent change in appeal actually reflects what is characteristic of the youthful eye and the desire to reproduce what we see on young faces. Simply visualize the periorbita of an adolescent youth or even a younger child. What is so strikingly apparent when carefully analyzed is the youthful volume that conceals any concern of the position of the (typically low) upper eyelid fold or brow.

Despite these observations, we must consider whether these youthful characteristics are possible and/or appropriate in some individuals. For instance, the elderly female with a dramatic loss of skin elasticity and volume loss of the upper periorbita, individuals with a normally elevated eyelid crease, or those that simply prefer a higher lid fold, may simply be interested in improvement and symmetry rather than reversal. For a host of reasons, true rejuvenation may be difficult and sometimes less preferable, and these individuals may be happier with an elevated eyelid crease with more ‘pretarsal show’ (Figs 8-30, 8-31) than a lower positioned upper eyelid crease.

As in other areas of the face, a prospective analysis of the changes that occur in the upper periorbita and a greater appreciation of the anatomy of facial aging has provided for sound concepts and techniques toward rejuvenation. Precise patient selection and modifications based on presentation will always yield greater aesthetic effects.²²

Conclusion

We must educate all those who present for aesthetic surgery on what procedures will yield particular effects, which they may or may not be pleased with. This is influenced by preconceived notions of not only what to expect from surgery, but possibly what they have already been told, read, or seen in others. Some individuals will be understanding and completely convinced and satisfied and ultimately pleased with the results, while others may not. Despite all of our efforts to relay this useful information, there may still be the necessity for compromise as even enlightened patients may still desire and request effects that are not necessarily rejuvenative.

Over 15 years of experience with this technique for upper eyelid aesthetic surgery suggests that this approach best considers the physiologic changes that occur in the aging of this region, and delivers results that are the most rejuvenative, with less stigmata of surgery. The illusion and reality of volume replacement are successfully achieved by surgical methods that are mindful of the necessity of enhancing and preserving the youthful eyelid crease and fullness of the periorbita that has been lacking with traditional excisional methods.