24 Upper Eyelid Blepharoplasty
The overall goal of surgery is to create a natural, nonoperated appearance.
For patients with visual field loss due to blepharochalasis and upper eyelid skin redundancy, an additional goal is to alleviate visual field obstruction.
The emphases in technique have shifted to skin removal with conservation of fat and the avoidance of eyelids with an overoperated appearance.
If a browlift and upper eyelid blepharoplasty are performed together, care must be taken to avoid excessive excision of upper eyelid skin to avoid lagophthalmos.
The eyes are the windows…. Most adults of the Western world can finish this common expression, and in many ways, the expression is true. Given their central location, the eyelids’ contours and movements account for a large part of the expressiveness of the face and convey much of a person′s nuances of communication. These factors have motivated both men and women to seek to maintain a healthy, youthful appearance and expressiveness through eyelid enhancement surgery.
Background: Basic Science of Procedure
The term blepharoplasty was coined by Von Graefe in 1817 to describe a reconstructive technique. In the late 1920s, French surgeons, such as Bourget, advocated removal of herniated orbital fat for cosmetic reasons. In 1951, Castenares described the fat compartments of the upper and lower eyelids. Until recently, fat removal had remained an integral part of blepharoplasty. During the last decade, the emphases in technique have shifted to skin removal with conservation of fat and the avoidance of eyelids with an overoperated appearance.1,2
Upper eyelid blepharoplasty is usually performed for cosmetic concerns, functional impairment of vision, or both. Each situation is frequently accompanied by an excess or prominence of eyelid skin, fat, or orbicularis muscle. This tissue redundancy is caused by the aging process or secondary to a familial propensity. Lid malposition and ptosis may also be concerns. In most situations, management of the excessive tissues of the upper eyelid includes some consideration of brow position; to ignore the close anatomical relationship between the brow and the upper eyelids in performing surgery of the region potentially jeopardizes the final aesthetic and functional outcomes. The goal is to achieve facial harmony and optimal function while maintaining latitude for individual variation.3–5
That the face on frontal projection can be divided into vertically oriented thirds is a well-recognized concept ( Fig. 24.1 ). In this model, the upper facial third is bordered by the anterior hairline above and the glabella below.6 Definitions and boundaries of the facial thirds are somewhat inconsistent from author to author, but in general, the brows and the upper eyelids are included in the upper third of the face and should be considered as a unit. More specifically, the position of the brow and its symmetry should be assessed whenever considering alteration of the upper eyelid. If a browlift and upper eyelid blepharoplasty are performed together, care must be taken to avoid excessive excision of upper eyelid skin, because the patient can develop lagophthalmos.
Eyebrow ptosis and asymmetry are frequent contributing factors to undesirable features of the upper eyelid. In general, it is considered acceptable for the male brow to be at the level of, or just superior to, the orbital rim. The male brow is usually more horizontally oriented and straighter, thicker, less defined, less refined, and without the curved elegance of the female brow. In females, it is considered more aesthetically pleasing if the brow is positioned higher than the orbital rim, with an arching elevation at either the lateral level of the lateral canthus or the limbus. Most of these gender-based differences should be preserved when one is performing surgical correction7 to avoid an undesirable feminizing or masculinizing effect ( Fig. 24.2a,b ).
The upper eyelid, as is the lower eyelid, is a trilamellar structure. The anterior lamella is composed of skin and the orbicularis muscle. The middle lamella of the eyelid is the orbital septum, which fuses with the posterior lamella as it attaches to the tarsal plate. The posterior lamella is composed of the levator aponeurosis, Müller′s muscle, and the conjunctiva.8 The inferior portion of the posterior lamella is the tarsal plate, measuring 10 to 11 mm wide. The levator aponeurosis of the upper eyelid fuses to the orbital septum ~ 2 to 3 mm above the superior margin of the tarsus. This fascial structure is in continuity with the conjunctiva at the fornix, and, in combination with Müller′s muscle, retracts the conjunctiva and the tarsus on upward gaze ( Fig. 24.3 ).9
The visible external anatomical landmarks of the upper eyelid include the ciliary margin, the supratarsal crease, and the superior palpebral sulcus. In occidental patients, the mid–upper border of the tarsal plate is marked by the presence of the supratarsal crease. In the adult male, the supratarsal crease lies 8 to 10 mm superior to the lid margin and can be less defined than in females, where the distance is 10 to 12 mm ( Fig. 24.4 ).10
The upper eyelid skin is the thinnest skin on the body. There is usually an absence of subcutaneous fat and only limited skin adnexal structures. The dermis is thin, and at times the skin is almost translucent. These qualities of the skin predispose it to laxity and redundancy with aging. Alternatively, some of these same structural features make the eyelids particularly good surgical sites, and incisions generally heal very well.
The orbicularis muscle lies immediately under the dermis, with only a loose layer of connective tissue separating the two. It is innervated by the temporal, buccal, and zygomatic branches of the facial nerve. The muscle is commonly described as consisting of three parts: the orbital part, the preseptal aspect, and the pretarsal part. The pretarsal orbicularis is contiguous with the medial and lateral canthal ligaments ( Fig. 24.5 ).
Management of bulging orbital fat is central to the topic of blepharoplasty. On a familial or involutional basis, a laxity of support structures occurs, thus allowing a bulging or prominence of orbital fat to occur. Clinically, this produces varying bulging of the orbital fat that is seen as baggy or swollen eyelids. This is commonly referred to as orbital fat pseudoherniation because the fat remains behind the orbital septum; no true hernia occurs. The orbital fat is semicompartmentalized. Although the orbital fat shares a common space posterior to the globe, in the context of blepharoplasty this fat is clinically described as occupying distinct compartments in the anterior orbit. There are two upper eyelid fat compartments and three lower eyelid compartments ( Fig. 24.6 ). In the upper eyelid, the compartments are the nasal and the central or middle compartments. The lacrimal gland occupies the lateral aspect of the superior orbit. In the course of performing upper eyelid blepharoplasties with the removal of pseudoherniated fat, the anterior eyelid skin, the orbicularis muscle, and the medial orbital septum are entered.
Because this is elective surgery, it is extremely important that patients are proper candidates for surgery. The patients’ motivations must be sound, they have to be willing to accept imperfection, they have to possess realistic goals, and they have to be willing to accept the prospect of additional surgery. The management of patients with cosmetic eyelid concerns is guided by the careful assessment of the patient, the establishment of a “diagnosis” based on anatomical and aesthetic parameters, and an approach based on sound surgical principles. A thorough evaluation of the patient is therefore necessary, as it would be in any other aspect of medicine and surgery. Both psychological and medical issues should be explored.
The overall goal of surgery is to create a natural, nonoperated appearance. For patients with visual field loss due to the blepharochalasis and upper eyelid skin redundancy, the other goal is to alleviate the visual field obstruction.11–13 Problems that can be addressed at the time of upper blepharoplasty routinely include brow malposition and asymmetry, excess skin, and pseudoherniation of orbital fat. Problems that cannot be addressed through blepharoplasty alone include rhytids, pigmentation abnormalities, malar bags, and ptosis. Other features of the patient′s eyelid and adjacent structures or surgery that should be noted and discussed with the patient include skin lesions, lacrimal gland ptosis, prominent orbital rims, edema, or any other abnormality or asymmetry. These associated conditions and their adjunctive treatments should be discussed with the patient before undergoing blepharoplasty ( Fig. 24.7a,b ; Fig. 24.8a,b ; Figs. 24.9 and 24.10 ).