34. Upper Blepharoplasty
Relevant Anatomy
Upper Eyelid Layers
Anterior lamella: Skin, subcutaneous tissue (retroorbicularis oculi fat [ROOF] and suborbicularis oculi fat [SOOF]), and orbicularis oculi muscle (OOM)
Middle lamella: Orbital septum
Note:
Problems in this layer most commonly lead to the continuum of cicatricial contraction (more common in the lower lid).
Posterior lamella: Tarsus and conjunctiva
Orbicularis Oculi Muscle
Innervation (Fig. 34-2)
Frontal, zygomatic, and buccal contributions from facial nerve (CN VII)
Medial and lateral innervation points
Three portions (Fig. 34-3)
Orbital
Outermost portion
Superficial to corrugator supercilii muscle (CSM) and procerus muscles
Interdigitates laterally and medially with CSM under dermis and with frontalis muscle fibers
Voluntary action
Functions as tight closure of eye
Preseptal
Directly overlies septum
Voluntary and involuntary components
Assists with blinking mechanism
Pretarsal
Tightly adherent to tarsal plate
Involuntary
Responsible for blink mechanism
Innervation from zygomatic branch of facial nerve
Most involved in proper tear movement
Tip:
Considering the OOM as a sphincter muscle with three segments facilitates understanding the consequences of eyelid surgery, botulinum toxin administration, ligament release, and preservation of muscle innervation.
Tip:
The preseptal orbicularis is adherent to the septum, and careful dissection in the proper submuscular plane is required. No pinkish hue or transverse fibers should be left on the septum, which would indicate retained orbicularis fibers and an improper plane. At least a 6 mm strip of pretarsal orbicularis must be preserved for proper eyelid “sphincter” function.
Tarsoligamentous Complex
Upper tarsus
7-11 mm wide
Müller muscle inserts onto superior border of tarsal plate.
Anterior levator aponeuorosis fibers insert onto superior tarsal border.
Fascial insertions on the upper border of the tarsus 1–4:
Help to form shape, position, and magnitude of upper eyelid crease
Levator aponeurosis
Orbital septum
Orbicularis fascia: Firmly attached at posterior surface of orbicularis “sphincter”; fuses with levator aponeurosis at level of lid fold; offers mechanical and nutritional (possibly lymphatic) support 4
Conjoined fascia: Present between the eyelid fold and lash line (deep to orbicularis and superficial to tarsal plate). This is an extension or fusion of the orbicularis fascia with the levator aponeurosis at a variable location superior to the tarsus.
Lateral raphe
Lateral extension of the OOM along the lateral orbital rim and zygomatic complex
Deep and superficial components of orbicularis insertion form lateral canthal tendon and lateral raphe.
Contributes to “lateral orbital thickening” against the lateral orbital rim, where the ORL fuses 5 – 7
Acts as lateral anchor (fulcrum) for eyelids
Lateral canthal tendon (anterior and posterior limbs) (Fig. 34-4)
Formed by:
Lateral horn of levator palpebrae superioris
Lockwood ligament
Check ligament of the lateral rectus muscle
Deep preseptal and pretarsal orbicularis muscle
Medial Canthal Tendon
Tripartite structure (anterior horizontal, posterior horizontal, and vertical components)
Formed by:
Deep head of pretarsal orbicularis
Medial Lockwood ligament
Check ligament of medial rectus muscle
Whitnall ligament
Orbicularis Retaining Ligament
Also known as orbitomalar ligament 8 or malar septum 9 in lower periorbita
“Near-circumferential” retaining structure encircling upper and lower orbit 7
Lax and longer laterally; more taut (short) medially
Lateral laxity may partially explain lateral hooding.
Medial tightness may be the reason for lack of medial hooding and tear trough phenomenon (medial depression/line at inferomedial periorbita).
Extends from OOM to the periosteum
True retaining ligament
May have lymphatic properties
Protects ocular contents: Semipermeable membrane
Tip:
Blunt or sharp transection/disruption of ORL helps to smooth the tear trough and blend the lid-cheek junction. Release in the upper periorbita is required for effective browlifting. Medial preservation in the corrugator region may minimize medial brow splaying.
Preseptal Fat
Between orbital septum and orbicularis muscle
Can contribute to upper eyelid lateral hooding
Upper lid: ROOF
Lower lid: SOOF
Orbital Septum
Protective function
Extension of orbital periosteum
Fuses with periosteum to form the arcus marginalis in upper and lower periorbita
Upper septum: Extends from superior orbital rim to insertion on levator aponeurosis at varying levels (10-15 mm above superior tarsal border)
Lower septum: Extends from inferior orbital rim to the capsulopalpebral fascia (5 mm below lower tarsal border)
Can have attachments with the ORL
Levator Palpebrae Muscle
Muscle origin: Lesser wing of sphenoid
Insertion: Superior edge of tarsus (conjoined fascia)
Innervation: CN III
Action: 10-15 mm upper lid excursion and sustained lid elevation from contractile tone
Note:
The amount of excursion and function is helpful in selecting an eyelid ptosis procedure.
Whitnall ligament: Fascial condensation 14-20 mm from superior edge of tarsus. translates posterior vector of pull into a superior direction
Tip:
The main cause of postoperative upper eyelid ptosis is “unrecognized” preoperative ptosis. Examination for upper eyelid ptosis preoperatively is essential.
Müller Muscle
Posterior lamella of levator palpebrae muscle
Origin: Levator muscle
Insertion: Superior edge of tarsus
Innervation: Sympathetic system
Action: 2-3 mm of upper lid lift
Tip:
If inadvertent lid ptosis is caused by diffusion of botulinum toxin as a result of improper technique (i.e., violation of the ORL), then the use of pharmacologic eyedrops that stimulate the Müller muscle can help until full levator function returns.
Orbital Fat Pads
Distinct compartments (Fig. 34-6)
Two compartments in upper lid (medial and middle)
Medial is more pale, vascular, and fibrous.
Trochlea of superior oblique muscle separates the medial and middle compartments.
Minor lateral fat pad (Eisler fat pad) is present in some.
Three in lower lid (medial, central, and lateral)
Inferior oblique muscle separates medial and central compartments.
Lacrimal Apparatus
Palpebral and orbital segments separated by levator aponeurosis
Located posterior to lateral portion of superior orbital rim
Lacrimal drainage system
Punctum drains to canaliculus, which drains to lacrimal sac, which drains to nasolacrimal duct.
Active pump mechanism
Blinking creates negative pressure in lacrimal sac, allowing tears to pass through the punctum and canaliculus into the sac.
Eye opening increases sac pressure and passes tears into the nasolacrimal duct.
Tears
Function
Lubrication for lid excursion
Antibacterial properties
Oxygenation of corneal epithelium
Smooth, refractive globe surface
Three layers
Lipid layer: Superficial and thin; reduces evaporative loss; secreted by meibomian glands and accessory sebaceous glands of Zeiss and Moll
Aqueous: Thicker, secreted from lacrimal gland and accessory glands of Wolfring and Krause
Mucoid: Maintains lid contact with globe; produced by mucin goblet cells
Basic secretion
Accessory lacrimal glands of Wolfring and Krause, mucin goblet cells, and meibomian glands
Reflex secretion
Main lacrimal gland, parasympathetic
Indications and Contraindications
Classic Indications (Upper Eyelid)
Excess upper eyelid skin
Upper eyelid fold excess
Lack of upper eyelid fold
Asian ethnicity with indistinct lid crease (see Chapter 34)
Note:
The fold may be present but masked by excess fat and poorly formed or positioned conjoined fascia.
Fine periorbital or eyelid rhytids
Tip:
A brow evaluation is critical in all patients (see Chapter 33). Often, a browlift unmasks a poorly defined or visible upper lid crease.
Eyelid Pathology and Deformities
Dermatochalasis: True excess of upper eyelid skin
Steatoblepharon: Excess fat protruding through septum
Blepharochalasis
Thin upper and lower lid skin allows presentation of cyclical lid edema (with or without erythema).
IgE and histamine are released.
In 80% of patients, onset is before 20 years of age.
Edema is refractory to antihistamines and steroids.
Blepharoptosis
Drooping of upper eyelid
Measured by distance to light reflex of pupil (marginal reflex distance [MRD])
See Chapter 39 for further details.
Pseudoblepharoptosis
Eyelid margin is in normal position; however, excess upper lid and/or brow weight is ptotic (MRD is within normal limits).
This may indicate blepharoplasty in conjunction with a browlift procedure.
Ptosis adipose: Excess attenuation of canthus and septum
Tip:
Blepharoptosis is not a contraindication to blepharoplasty, but it must be fully evaluated, informed, discussed, and treated.
Senior Author Tip:
Eyelid ptosis should be corrected during blepharoplasty.
Preoperative Evaluation
History
Patient expectations
Functional versus aesthetic
Detailed discussion is needed to inform patients of the cause of the problem (with the aid of a handheld mirror) and what can be done to correct it.
Unrealistic expectations are unmasked and discussed.
Video imaging has been most helpful in discussing patients’ expectations and whether they are realistic.
Senior Author Tip:
With the Internet and media as a prevailing “pseudoeducational” force, patients may come in telling the doctor what procedure they need or want, as if ordering at a restaurant (e.g., “I don’t want a browlift or anything fancy, just a little of this excess skin removed.”) Patient education is more and more critical in today’s practice environment. Surgeons should always recommend and do what they think is correct. Our job is to inform patients, make the recommendations that we think are best, and discuss the procedure or procedures, risks, and expected outcomes, including the quality of the result and the expected recovery. With this information, patients can make a truly informed decision.
Pertinent Medical Conditions
Eyelid inflammatory conditions (Reiter syndrome)
Grave disease
Benign essential blepharospasm
Dry eye syndrome
Ask about eyedrop use and probe for details about dry eye symptomalogy.
Contact lens use
Bell phenomenon test
Consider Schirmer test
Tip:
A history of dry eyes with decreased tear production (frequent use of eye lubricants), combined with postblepharoplasty tear film loss from lagophthalmos, can lead to corneal exposure (keratoconjunctivitis or ulceration). An abnormal Bell phenomenon increases the risk of corneal complications. A more conservative blepharoplasty with possible temporary tarsorrhaphy may be best versus no surgery at all for this group of patients.
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