History

That versions of the aphorism “the eyes are the windows on the soul” date back at least to Roman times is testimony to the emotional significance that the eyes possess. More precisely, it is the periorbital tissues surrounding the relatively inert and unindividualistic globes that convey information spanning both the expressive and physiologic gamut.

As a person ages, a constellation of changes gradually, albeit variably, occur in the periorbital tissues ultimately culminating in a patient concerned about a “tired, unhappy look” which can belie an otherwise normal emotional state. The changes that occur include descent of the brow, glabellar prominence with vertical rhytids, development of asymmetrical and redundant upper eyelid skin and lateral upper lid skin “hooding”, elevation of the upper lid crease, hollowing of the upper orbit due to soft tissue atrophy, lower lid laxity, pseudoherniation of lower lid fat resulting from orbital septum attenuation, development of lower lid rhytids, accentuation of the tear trough, and the development of lateral “crows feet”.

Although these changes are commonly seen together, it should be emphasized that many of the underlying etiopathologies are distinct and often subtle and, therefore, require a very individualized approach. Furthermore, more often than not, these changes accompany age-related changes affecting the rest of the face ideally requiring expertise in the various facets of facial rejuvenation.

An ever-improving understanding of the dynamic nature of facial anatomy accompanied with a more holistic approach to facial aging has altered the surgical treatment of age-related periorbital changes. Conceptually, trends point towards decreasing tissue removal in favor of tissue rearrangement and repositioning. Standard blepharoplastic incisions now allow for effective treatment of all of the aforementioned age-related changes. Increasingly limited upper eyelid fat excision and minimal lower lid orbicularis occuli violation has helped avoid exacerbation of orbital hollowing and minimized ectropion, respectively. Moreover, precise soft tissue augmentation (autologous and non-autologous) of the upper lid can help recreate a more youthful appearance.¹ Similarly, these techniques can be quite useful in blunting the tear trough deformity. Complementing these trends is the use of botulinum toxin (Botox, Allergan) to help decrease rhytids that characterize aging.

Note should be made of other periorbital conditions, the discussions of which are beyond the scope of this chapter, that require recognition as distinct from age-related changes, and therefore specific treatment. A short, non-comprehensive list includes blepharochalasis, blepahrophimosis, Graves’ disease, and myasthenia gravis.

Physical examination

Excess skin

See Fig. 29.1. A common presenting complaint of patients, excess eyelid skin, or dermatochalasis, should be noted on physical evaluation and precisely assessed especially regarding extent and location. Occasionally, the upper eyelid skin redundancy is excessive enough to impact the visual axis and/or result in pseutoptosis. Asymmetry, the correction of which is a central goal of blepharoplasty, must be also identified. Excess skin resulting from blepharochalasis may, ultimately, be treated similarly to age-related skin excess but the risk of ptosis and other disease-specific conditions require recognition of this entity. Lower lid skin excess is less common than lower lid wrinkling which invites a more conservative surgical approach particularly in light of the possibility of ectropion. Pre-tarsal skin fullness is more often due to the underlying orbicularis occuli than to skin excess.

Fig. 29.1 Periorbital age-related changes. Upper lid: A, Skin excess and septal attenuation with fat herniation; B, Hooding with brow ptosis; C, Asymmetry; 1, compensatory brow elevation (not evident in this patient: hollowing, upper lid crease elevation). Lower lid: D, Tear trough; E, Fat herniation and septal attenuation; F, lower lid laxity; 2, descent of lateral canthus. (Not evident in this patient: vertical glabellar creases.)

Fat pseudoherniation

Frequently found in conjunction with skin excess, orbital fat pseudoherniation contributes significantly to the “tired look” of age-related periorbital changes (Fig. 29.2). The size and shape of the medial and middle fat pads of the upper lid and the three lower lid fat pads should be noted. Upward and downward gaze in an upright patient will accentuate the fat pads. The configuration of the lower lateral fat pads, should be documented, since they are easily underappreciated, particularly in the sedated, supine patient.

Fig. 29.2 Location of fat pads and upper and lower lid incisions (dotted lines).

Technical steps

Intraoperative referral to standard medical photographs is very valuable in blepharoplasty since intense operative lighting, the recumbent position, and the edema from both local anesthetic and surgical trauma can easily obscure subtle anatomic derangements requiring correction.

The patient’s upper lid is marked with a fine-tip, water insoluble marker while sitting upright (Fig. 29.2

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