15.2.1 The Upper Eyelids

The palpebral aperture is almond shaped, with the lateral canthal angle lying slightly higher than the medial canthal angle. The lateral canthal angle is generally slightly higher in women than in men and lies approximately 5 mm from the lateral orbital margin (Fig. 15‑2). The upper eyelid skin crease is usually approximately 5 to 6 mm above the lash line in men and 7 to 8 mm above the lash line in women.

The distance between the inferior aspect of the eyebrow and the upper lid skin crease on downgaze should be approximately two-thirds of the distance from the inferior aspect of the eyebrow to the eyelid margin. Likewise, the distance from the skin crease to the eyelid margin in downgaze should be one-third of the distance from the inferior aspect of the eyebrow to the eyelid margin. In general, a minimum distance of 10 to 12 mm should be left between the inferior aspect of the eyebrow and the upper eyelid skin excision marking when performing an upper lid blepharoplasty, and again, in general, approximately 20 mm of skin should be left between the inferior aspect of the eyebrow and the eyelid margin.

It is important to maintain these dimensions. If an excessive amount of upper eyelid skin is removed, reducing the distance from the skin crease to the brow in the presence of a brow ptosis, an unsatisfactory result will occur, with the appearance of the brow being attached to the eyelashes (Fig. 15‑3a). This may also result in an incomplete reflex blink or frank lagophthalmos (Fig. 15‑3b,c).

It is important to differentiate prolapsed preaponeurotic fat from retro-orbicularis oculi fat (ROOF) that has descended into the upper eyelid (Fig. 15‑4a). This may give rise to the appearance of upper eyelid “fullness” (Fig. 15‑4b). Although this descended fat can be gently debulked in some patients, it is preferable to reposition this as part of a browlift procedure if there is an associated brow ptosis.

Some patients have very prominent superolateral bony margins that can also contribute to upper eyelid “fullness.” These can be exposed and reduced with the use of a diamond burr during the course of an upper eyelid blepharoplasty (Fig. 15‑5).

Subcutaneous thickening of the sub-brow area in a dysthyroid patient must be recognized. This may not be amenable to improvement by standard blepharoplasty surgery. Also, great care should be taken in performing this surgery in such patients, because an overly aggressive upper eyelid blepharoplasty in a patient with thyroid eye disease can markedly worsen symptoms of corneal exposure.

It is important to recognize a prolapsed lacrimal gland that may be responsible for lateral upper eyelid “fullness” or swelling, particularly as the central pre-aponeurotic fat pad can often extend more laterally than usual in some patients (Fig. 15‑6a). Prolapsed glands can be repositioned during the course of an upper eyelid blepharoplasty by suturing the gland to the periorbita of the lacrimal gland fossa (Fig. 15‑6b–d) (Video 15.1).

Some patients develop central upper eyelid fat atrophy with increasing age, creating an upper eyelid sulcus defect. The removal of central upper lid preaponeurotic fat should be avoided in most patients to minimize the risk of the development of a postoperative “cadaveric” appearance. In contrast, a prolapsed medial fat pad can often be debulked and the fat can be transplanted to lie evenly in the central preaponeurotic space, or the fat can be redraped into this position as a pedicle. In general, the removal of central preaponeurotic fat from the upper eyelid should be avoided in most patients.

“Fullness” in the medial aspect of the upper eyelid may be caused by a medial eyebrow ptosis. Elevation of the brow, or the use of botulinum toxin injections in the glabella, can be successful for addressing this problem. Wherever possible, it is important to avoid the temptation to “chase a dog-ear” into this area beyond the medial limit of the skin crease during an upper eyelid blepharoplasty because the subsequent scarring can be very unsatisfactory and can result in webbing. In such patients, a gentle debulking of the medial fat pad can allow the skin to redrape with a more satisfactory aesthetic result, but over-resection of fat should be avoided. The fat should not be discarded, because it may be required for use in the central aspect of the upper lid or may be of use to help to treat a medial tear trough defect in the lower eyelid during the course of a lower lid blepharoplasty.

The upper eyelid skin crease represents the most superior point of attachment between the skin and the levator aponeurosis. This position is just inferior to the insertion of the orbital septum onto the levator aponeurosis. The skin crease lies at a higher level in women, approximately 7 to 8 mm from the lash line, compared with 5 to 6 mm in men. It is important not to raise the skin crease in men to avoid a “feminization” of the eyelid appearance.

The skin crease shows racial differences. In the Asian eyelid the orbital septum attaches to the levator aponeurosis at a lower level, allowing the preaponeurotic fat to descend into the lower reaches of the eyelid, preventing the levator aponeurosis from forming a high skin crease. A great deal has been written about the Asian eyelid and blepharoplasty. However, this extends beyond the scope of this textbook.

The skin of the upper eyelid is very thin, without any subcutaneous fat. Beneath the skin lies the very vascular orbicularis muscle. Local anesthetic injections should be placed immediately beneath the skin, avoiding the orbicularis muscle, to prevent the occurrence of a hematoma. Deep to the orbicularis muscle above the skin crease lies the orbital septum. This originates from the arcus marginalis along the superior orbital margin. This firm attachment can be used to differentiate it from the levator aponeurosis. The orbital septum is a multilayered structure with a very variable thickness.

Posterior to the septum centrally lies the preaponeurotic orbital fat. Pressure applied to the lower eyelid can force the fat to prolapse, which helps to differentiate this from descended retro-orbicularis fat and from fatty degeneration of the levator muscle or Müller’s muscle. The preaponeurotic fat is a key landmark in upper eyelid surgery. The levator aponeurosis lies immediately beneath it (Fig. 15‑5; Fig. 15‑7).

There are two main fat pads in the upper eyelid, a central fat pad and a medial or nasal fat pad. The medial fat pad is generally paler than the central fat pad (Fig. 15‑8).

It is extremely important to be able to distinguish the lacrimal gland from the orbital fat (Fig. 15‑9).

The levator muscle gives rise to the levator aponeurosis at the level of Whitnall’s ligament. The aponeurosis inserts onto the anterior surface of the superior two-thirds of the tarsus. The medial and lateral horns of the aponeurosis insert in the region of the medial and lateral canthal tendons. The lateral horn divides the lacrimal gland into orbital and palpebral lobes. Intraoperative damage to the medial horn can give rise to a lateral shift of the tarsus, with an eyelid peak lying temporal to the pupil.

Whitnall’s ligament supports the levator muscle complex, acting as a fulcrum for the action of the levator muscle, and should not be disturbed during surgery. It is a variably developed structure that runs from the lacrimal gland to the region of the trochlea (Fig. 15‑10).

15.2.2 The Lower Eyelids

The lower eyelid can be considered to consist of three lamellae:

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  Anterior—skin and the orbicularis oculi muscle.

  
  
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  Middle—the orbital septum and the lower eyelid retractors.

  
  
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  Posterior—the tarsus and conjunctiva.

The lower eyelid skin crease is variable but is usually situated approximately 4 to 5 mm below the eyelid margin. The lateral canthal angle normally sits approximately 1 mm higher than the medial canthal angle.

The orbicularis oculi muscle is immediately deep to the skin of the lower lid. This muscle extends from just below the ciliary margin, past the inferior orbital rim, and onto the cheek.

Ptosis of the orbicularis oculi muscle commonly occurs over time and is partly responsible for the typical appearance of the malar crescent or malar mound in the aged face.

Deep to the orbicularis oculi muscle lies the orbital septum, which serves to retain orbital fat within the orbit. The septum is composed of inelastic fibrous tissue. Atrophy of the septum with age permits orbital fat to herniate anteriorly, creating typical lower lid “bags” (Fig. 15‑1b). The suborbicularis fascia, a plane of loose, fibrous connective tissue, lies between the orbicularis oculi muscle and orbital septum and provides a very good, relatively bloodless dissection plane. The orbital septum extends from the inferior border of the tarsus to fuse inferiorly with the periosteum of the infraorbital margin. This inferior attachment of the orbital septum to the periosteum, where there is a condensation of tissue, is referred to as the arcus marginalis (Fig. 15‑11).

The arcus marginalis is strongest and best defined medially, where it attaches to the anterior lacrimal crest. As it extends laterally, the arcus marginalis becomes thinner and weakens. It also assumes a more inferior and anterior insertion; thus, medially, it runs along the inner aspect of the rim, but laterally, it attaches approximately 2 mm inferior to the rim on the facial aspect of the zygomatic bone.

The tarsus in the lower eyelid is approximately 4 to 5 mm in height. The lower eyelid retractors are analogous to the levator aponeurosis in the upper eyelid. The smooth inferior tarsal muscle is analogous to Müller’s muscle in the upper eyelid. The lower eyelid retractors, collectively referred to as the capsulopalpebral fascia, run from the inferior rectus muscle and split to envelop the inferior oblique muscle. This fascia then inserts into the inferior border of the tarsus (Fig. 15‑11; Fig. 15‑12). A deep layer of the fascia attaches to the conjunctival fornix as the suspensory ligament of the fornix.

Isolated shortening of the anterior lamella of the lower eyelid results in ectropion, shortening of the middle lamella results in eyelid retraction with scleral show (Fig. 15‑13), and shortening of the posterior lamella results in entropion.

There are three fat compartments in the lower eyelid: medial, central, and lateral. Many delicate fibrous septa invest these compartments. The fat compartments lie between the capsulopalpebral fascia and the orbital septum. Because the capsulopalpebral fascia (the lower eyelid retractor) is analogous to the levator aponeurosis in the upper eyelid, the fat lying in front of the capsulopalpebral fascia can be considered to be analogous to the preaponeurotic fat in the upper eyelid. As in the upper eyelid, locating this fat is key to locating the eyelid retractor.

The inferior oblique muscle, originating from the anteromedial orbital wall, separates the medial and central fat compartments as it extends posterolaterally under the globe (Fig. 15‑14). In this position it is vulnerable to injury during the course of a lower eyelid blepharoplasty.

The arcuate expansion, an extension of the fascial sheath of the inferior oblique, continues laterally to attach to the lateral orbital rim and separates the central and lateral compartments (Fig. 15‑15). Subtle differences exist among the three orbital fat pads. The fat of the medial compartment is typically white and membranous, whereas that of the central and lateral compartments appears yellow and soft. The lateral fat compartment contains more septa than the medial and central compartments and is therefore less prone to herniate anteriorly. It is important to note that inferior palpebral vessels travel directly through the medial fat compartment.

Fat that lies below the inferior orbital margin posterior to the orbicularis oculi muscle and just anterior to the periosteum is the SOOF (Fig. 15‑16).

With increasing age, the orbicularis oculi muscle and the SOOF move inferiorly, leading to a double convexity of the lower eyelid. The superior convexity is caused by a herniation of orbital fat through a weakened orbital septum above the inferior orbital margin (Fig. 15‑17). The orbital margin itself is responsible for the horizontal concavity, and the SOOF, which has moved inferiorly, is responsible for the second convexity.

15.2.3 The Midface

Knowledge of the anatomy of the midface is essential for the understanding of the morphological changes that occur at the lower eyelid–cheek junction with advancing age.

The prezygomatic space is a triangular space overlying the zygomatic and maxillary bones with its apex toward the nose and is limited superiorly by the orbitomalar ligament. It contains the following:

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  Fat overlying the orbital part of the orbicularis muscle.

  
  
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  The orbital part of the orbicularis muscle.

  
  
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  The SOOF.

  
  
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  Preperiosteal fat deep to the origin of the lip elevator muscles.

  
  
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  Retaining ligaments.

There are a number of retaining ligaments in the face that are condensations of fibrous connective tissue and act to anchor the superficial tissue layers to firmer underlying structures. These ligaments are divided into true and false retaining ligaments.

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  True retaining ligaments link the dermis to the underlying periosteum (zygomatic, orbital, orbitomalar, and mandibular ligaments).

  
  
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  False retaining ligaments link the deep facial fascia to the superficial facial fascia and the subcutaneous tissue (masseteric and platysma-auricular ligaments).

The zygomatic retaining ligament (McGregor’s patch) arises from the zygomatic arch and from the body of the zygoma, passes through the superior aspect of the malar fat pad, and inserts into the dermis of the overlying skin. The ligament is well defined (Fig. 15‑18). The orbital retaining ligament lies over the frontozygomatic suture.

The orbitomalar ligament arises from a thickened area of periosteum a few millimeters below the inferior orbital margin and passes through the superficial musculoaponeurotic system and overlying fat to insert into the dermis.

The orbitomalar ligament, the levator labii superioris, and the levator alaeque nasi muscles are responsible for defining the tear trough (Fig. 15‑19). The tear trough extends into the upper central cheek as a triangular groove between these muscles as the malar fat descends with age.

Malar mounds are the result of edema within the fat of the prezygomatic space (Fig. 15‑20). The malar fat pad is subcutaneous, triangular, and distinct from the “malar mounds.” This fat pad contributes to the fullness of the midface. Elevation of the malar fat pad and the malar mounds contributes greatly to the aesthetic appearance of the midface and can improve the appearance of the tear troughs.

15.3.1 Pathophysiology

The tissue changes seen in dermatochalasis are similar to the normal aging changes of the skin that occur elsewhere in the body. There is thinning of the epidermal tissue with a loss of elastin, resulting in laxity, redundancy, and hypertrophy of the skin. The tissue changes of dermatochalasis appear to be related to repeated facial expressions combined with the effects of gravity over many years. A number of systemic disorders such as thyroid eye disease, Ehlers-Danlos syndrome, cutis laxa, renal failure, and amyloidosis may hasten the development of dermatochalasis. In addition, some patients may have a genetic predisposition toward the development of dermatochalasis at a younger age.

By contrast, blepharochalasis stems from recurrent bouts of painless eyelid swelling, each instance of which may persist for several days. The swelling most likely represents a form of localized angioedema, although this remains speculative. Ultimately, after numerous episodes, the skin of the lids becomes thin and atrophic, and damage to the levator aponeurosis ensues. Blepharoptosis then develops (Fig. 15‑22). Blepharochalasis is idiopathic in most cases, although it has been linked to kidney agenesis, vertebral abnormalities, and congenital heart defects in rare instances.

15.3.2 Surgical Goals

The goals of an upper eyelid blepharoplasty are to achieve the best cosmetic and functional result for the patient through the following:

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   Removing an appropriate amount of excess upper eyelid skin alone, or skin and orbicularis muscle.

   
   
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   Debulking, sculpting, or repositioning herniated orbital fat only where appropriate.

   
   
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   Creating a symmetrical upper lid skin crease at an appropriate height for the individual patient.

   
   
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   Avoiding visible scarring.

   
   
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   Avoiding a secondary lagophthalmos or an incomplete reflex blink.

   
   
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   Avoiding exacerbating an associated brow ptosis.

The goals of a lower eyelid blepharoplasty are to achieve the best cosmetic and functional result for the patient with the following:

1. 
   

   Repositioning or debulking herniated fat where appropriate.

   
   
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   Removing an appropriate amount of excess lower eyelid skin and muscle if required.

   
   
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   Avoiding middle lamellar scarring and eyelid retraction.

   
   
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   Addressing any associated lower eyelid or lateral canthal tendon laxity.

   
   
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   Avoiding a postoperative ectropion and secondary epiphora.

Preoperative Patient Evaluation and Counseling

Because patients who request such surgery for aesthetic reasons are generally seeking a “rejuvenation” of their face rather than a radical change in their appearance, photographs of the patient at different stages of life can be very helpful in documenting the changes that have developed over time. It is always helpful to request that these are brought to the consultation when the patient schedules an appointment. Altering a patient’s appearance in a way that is not expected by the patient will inevitably lead to significant dissatisfaction.

History

A careful history should be obtained. The patient’s presenting complaints, goals, and expectations should be determined. The patient may be concerned about several characteristics:

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  An overhang of excess upper eyelid skin causing a loss of the superior visual field.

  
  
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  Excess upper lid skin causing cosmetic problems.

  
  
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  Upper lid fat herniation.

  
  
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  Upper lid “fullness.”

  
  
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  Hooding of the upper eyelids.

  
  
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  Drooping eyelids.

  
  
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  Headaches from frontalis muscle fatigue.

  
  
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  A tired appearance commented on by friends or relatives.

The complaint of droopy upper eyelids may simply be related to severe dermatochalasis causing a pseudoptosis, with the underlying eyelid height being normal. The lid position should be carefully evaluated, however, because a true blepharoptosis may also be present. If a true blepharoptosis is present, the patient must be carefully evaluated to diagnose the underlying cause of the blepharoptosis, such as an aponeurotic dehiscence from contact lens wear, Horner’s syndrome, myasthenia gravis, or chronic progressive external ophthalmoplegia (Chapter 7). Similarly, a severe dermatochalasis, often combined with a brow ptosis, may obstruct the patient’s superior visual field.

Patients who have a moderate to severe brow ptosis and dermatochalasis are obliged to use their frontalis muscle to overcome the superior visual field defect. Such patients commonly develop deep forehead furrows (Fig. 15‑23). This leads to fatigue of the frontalis muscle, which in turn can cause a headache.

Occasionally, upper eyelid dermatochalasis and a lateral brow ptosis can lead to a secondary mechanical misdirection of eyelashes, causing chronic ocular discomfort.

The cosmetic effects of upper eyelid dermatochalasis and brow ptosis can lead to complaints of a tired appearance. Lower eyelid fat herniation can also lead to similar complaints (Fig. 15‑1b).

Patients should be specifically questioned about previous eyelid surgery. Patients who have previously undergone a cosmetic blepharoplasty or a facelift may omit such information, particularly if accompanied by a new partner. A revision blepharoplasty, particularly of the lower eyelid, is much more challenging and associated with an increased incidence of postoperative complications. Patients should also be asked about contact lens wear or previous corneal refractive surgery.

Key Point

A revision lower lid blepharoplasty is much more challenging, even for an experienced surgeon, and is associated with an increased incidence of postoperative complications.

A history of a dry eye, facial palsy, or thyroid dysfunction identifies a patient at risk of exposure keratopathy symptoms after an upper lid blepharoplasty.

Key Point

A history of a dry eye, facial palsy, or thyroid dysfunction identifies a patient at risk of exposure keratopathy symptoms after an upper lid blepharoplasty.

It is important to exclude a bleeding disorder, because a postoperative hemorrhage after a blepharoplasty can be potentially sight-threatening. The use of aspirin or nonsteroidal anti-inflammatory agents should be discontinued if the patient’s medical status permits this. Any other nonprescription medications or dietary supplements that may predispose to excessive bleeding should also be discontinued (e.g., vitamin E supplements).

Key Point

It is important to exclude a bleeding disorder, because a postoperative hemorrhage after a blepharoplasty is potentially sight-threatening. The use of aspirin or nonsteroidal anti-inflammatory agents should be discontinued 2 weeks preoperatively.

Any allergies should be carefully noted.

Examination

Careful note should be made of a patient’s eyebrow shape, position, asymmetry, and fullness, and the upper eyelid pretarsal skin show, both in the resting position and with facial animation during the course of the consultation.

The patient should undergo a complete ophthalmic examination with a record made of the following:

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  The patient’s best corrected visual acuity.

  
  
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  The size of the palpebral fissures.

  
  
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  The position of the skin creases documented after lifting the upper lid excess skin.

  
  
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  The marginal reflex distance-1 (MRD-1) and marginal reflex distance-2 (MRD-2), looking for any evidence of true blepharoptosis or involuntary frontalis overaction.

MRD-1 is the distance between the center of the pupillary light reflex and the upper eyelid margin with the eye in primary gaze. A measurement of 4 to 5 mm is considered normal. MRD-2 is the distance between the center of the pupillary light reflex and the lower eyelid margin with the eye in primary gaze (Fig. 7‑29b).

Key Point

A patient seeking or referred for a blepharoplasty should undergo a complete ophthalmic examination.

The following should be assessed and documented:

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  The amount of pretarsal skin “show” along with the amount of skin present from the lash line to the lowermost portion of the eyebrow, medially, centrally, and laterally. This can be difficult in patients who pluck or tattoo their eyebrows (Fig. 15‑24). Failure to recognize the true position of the eyebrow skin can lead to an over-resection of upper lid skin during the course of an upper lid blepharoplasty.

  
  
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  Any asymmetries. (It is important to make the patient aware of any preoperative asymmetries, which the patient may not have noticed. The patient will certainly notice asymmetries postoperatively. Many patients also tend to forget about preexisting asymmetries, which is why preoperative photographs are very important.)

  
  
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  Any frontalis overaction and the position and shape of the brows observed after asking the patient to relax the frontalis muscle as much as possible. The secondary effects of brow ptosis on the upper eyelids must be recognized (Fig. 15‑24) (Chapter 17).

  
  
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  An assessment of the tear meniscus using a slit lamp, and the tear film break-up time after the instillation of a drop of fluorescein.

  
  
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  The presence of any subtarsal lesions on upper lid eversion, such as papillae seen in patients with atopy or from contact lens wear.

  
  
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  The presence or absence of a Bell’s phenomenon.

  
  
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  The degree of upper eyelid laxity to ensure that a “floppy eyelid syndrome” is not overlooked. This is done by pulling downward on the eyelid after grasping the eyelid margin and the eyelashes in the lateral aspect of the eyelid. Excessive eyelid laxity is also evident if eversion of the upper eyelid is very easy to perform.

  
  
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  Any herniation of the medial and central preaponeurotic fat pads in the upper eyelids and of the medial, central, and lateral preaponeurotic fat pads in the lower eyelids.

  
  
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  The degree of excess upper eyelid skin.

  
  
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  The degree of any associated brow ptosis along with any asymmetry. Any overaction of the eyebrow depressor muscles is also determined by noting the extent of glabellar frown lines and lateral canthal rhytids.

  
  
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  The skin quality and degree of actinic damage. Specific dermatological disorders should be excluded, such as atopic dermatitis. The presence of sub-brow soft tissue swelling or loss of the outer third of the eyebrows should raise the suspicion of the patient having thyroid dysfunction.

  
  
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  The ocular motility along with cover and alternate cover tests to exclude any horizontal or vertical ocular muscle imbalance.

  
  
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  Any signs of a lacrimal gland prolapse.

Key Point

The secondary effects of a brow ptosis on the upper eyelids must be recognized.

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