Upper blepharoplasty is used to clear the visual axis and to rejuvenate and restore the effects of aging on the upper eyelid. At the same time, the goal is to preserve the blink mechanism, insure adequate eyelid closure, and preserve a nonsurgical or natural postoperative appearance. These goals are accomplished by employing conservative techniques, such as moderate skin excision, tailored fat removal, and preservation of the orbicularis oculi muscle whenever possible. Preservation of the orbicularis not only preserves a nonsurgical appearance but allows for proper eyelid closure to circumvent postoperative dry eyes.¹

A tailored, individualized approach to upper blepharoplasty is essential in patients of African descent. Some African American patients may have prominent globes with shallow orbits and relative exophthalmos,^2,3 which require special consideration. In patients with prominent globes, the fuller upper eyelid will help mask any relative exophthalmos. Thus, all aspects of the upper blepharoplasty must be conservative or the globes will appear even more prominent postoperatively in comparison with the paucity of skin, orbicularis, and orbital fat. Skin excision should be very conservative to prevent postoperative lagophthalmos; lid crease incisions should also not be above 8 mm from the lashes in women or above 5 to 7 mm in men to maintain a fuller fold; no orbicularis should be excised to maintain upper eyelid fullness and proper eyelid closure; and fat excision should be minimal or none to avoid a scaphoid or skeletonized appearance.

In black patients without prominent globes, the amount of skin excision and fat removal or sculpting may be increased as necessary. Keloid formations from eyelid incisions are exceedingly rare. In fact, one author has reported uneventful blepharoplasty in a known keloid former.⁴ Occasionally, minor scar hypertrophy may occur in any ethnic group, including Caucasians, and may be treated with steroid injections.

In Latinos, an individualized approach is essential as well. Some Latino patients may have a rounder face, so the incision design, skin excision amount, and fat excision amount is tailored to match the patient’s facial anatomy to preserve a nonsurgical or natural postoperative appearance. A skeletonized eyelid on a rounder face will look “surgical” and may alter the patient’s appearance so significantly that he or she doesn’t look like “himself/herself” anymore.

During the preoperative planning, the height of the lid creases and the amount and location of fat to be excised are determined. Brow asymmetry, margin-to-fold asymmetry, and crease asymmetry are noted and are taken into account when determining the amount of skin to remove from each upper eyelid. Preoperative photos are hung in easy view.

The height of the lid crease incision is measured from the lashes and marked. The authors prefer a lid crease height of 6 to 8 mm in women and 5 to 7 mm in men. Skin excision is estimated by a modified “pinch” technique (Fig.25-1A). The design varies with the patient’s age, anatomy, and ethnicity. The amount of skin to be excised is measured and compared with each side; asymmetrical brow heights or asymmetrical skin overhang will need asymmetrical skin excision amounts. After the skin is marked, local anesthesia consisting of a mixture of 1% lidocaine with epinephrine, 0.5% Marcaine with epinephrine, and hyaluronidase (Vitrase, Amphadase) is injected. Skin incision is made with a diamond blade, the author’s preference (Fig. 25-1B), or a

Bard Parker No. 15 blade. CO₂ laser can be used; however, darker skin tones may be more subject to pigmentary disturbance after laser incision, and there is no proven advantage to do so. The skin-only flap can be removed with a diamond blade (the author’s preference), No. 15 blade, scissors, or Colorado needle monopolar cautery. The orbicularis muscle is preserved (Fig. 25-1C). Preserving the muscle helps to ensure adequate blinking and closure and preserves the normal bulk of the upper eyelid sulcus. A buttonhole incision through the orbicularis and septum are made medially to remove the medial fat pad. This incision can be extended laterally to remove the central pad, if needed (Fig. 25-1D). This approach preserves the innervation and function of the orbicularis muscle. An appropriate amount of fat is excised (Fig. 25-1E) and sculpted. Meticulous hemostasis is obtained with monopolar cautery to prevent orbital hemorrhage. The skin incision is closed with running 6-0 Prolene suture (Fig. 25-1F), which is removed in 1 week. Supratarsal fixation is not recommended and will result in a more surgical appearance in these patients. Keloid formation is exceedingly rare. Occasionally, minor scar hypertrophy may occur in any ethnic group and may be treated with steroid injections.