Key points

Introduction

Upper blepharoplasty is one of the most frequent facial cosmetic surgical procedures for periorbital rejuvenation. The natural esthetic and youthful appearance of the periorbital region is characterized by soft tissue fullness framing the eye, whereas the aging eye is typically hollowed and surrounded by a deep upper lid sulcus with variable amounts of upper lid skin laxity with or without pseudoherniation of periorbital fat. When considering upper eyelid rejuvenation, it is imperative to consider all factors that may contribute to the aging upper eyelids. Standard treatments for upper lid dermatochalasis have focused on resection of redundant tissue, including skin, muscle, and fat from the upper eyelid. This may lead to hollowing of the upper lid sulcus from overresection of soft tissue, resulting in an unfavorable appearance.

In recent years, the concept of periorbital volume restoration and augmentation, instead of reduction, has gained increasing popularity among cosmetic surgeons. Improved understanding of periorbital physiology from aging has led to modified techniques using fat conservation and repositioning, orbicularis oculi muscle preservation, and increasing lateral upper eyelid fullness to achieve esthetic enhancements in upper blepharoplasty. These concepts in conjunction with adjunctive procedures, including internal brow elevation, lacrimal gland resuspension, and glabellar myectomy performed through an upper blepharoplasty approach, can provide a myriad of esthetic enhancements to standard upper blepharoplasty.

Anatomy

The upper eyelid crease is located approximately 8 to 10 mm from the palpebral margin in the typical Caucasian eye. Loss of fascial attachments of the orbicularis oculi, levator aponeurosis, and orbital septum into the dermis can contribute to skin laxity and displacement of the crease inferiorly. In the brow, the frontalis muscle interdigitates with the procerus muscle medially, orbicularis oculi muscle laterally, and corrugator and orbicularis oculi muscles in the central portion of the brow. The galeal layer that gives rise to the fascia overlying these muscles contributes to brow height, symmetry, and shape.

Upper Eyelid Aging

Recent studies on anatomic, chemical, and biologic characteristics of the upper eyelid have shown that the central fat pad seems to diminish in volume with aging, whereas the nasal fat pad increases in volume with advancing age ( Figs. 1 and 2 ). This disparity seems to begin in the early fourth decade of age, with the most significant change after age 70 years. This disparity may be explained by differences in vascularity and connective tissue composition. The nasal fat pad is similar in composition to intraconal orbital fat, whereas the more yellow central fat pad is similar to adipose tissue found elsewhere throughout the body. Korn and colleagues reported that there was a 2-fold increase in the number of adult stem cells derived from human orbital adipose tissue in the nasal fat pad compared with the central fat pad. The authors suggest that the relative abundance in progenitor stem cells in the nasal fat may explain the relative increase in nasal fat pad volume during an individual’s lifetime.

Preoperative view of a patient who presented for periorbital rejuvenation. Note the redundancy of the nasal fat compartment and significant lateral hooding from excess skin laxity and lateral brow ptosis.

Postoperative view of the same patient 2 years after upper blepharoplasty with conservative nasal and central fat excision and bilateral subcutaneous temporal lift.

Evaluation

When determining a surgical treatment plan for a patient who presents with excess periorbital tissue and heaviness in the upper eyelids, it is important to consider all of the factors that may contribute to the redundancy of the upper eyelids. The surgeon must evaluate the patient’s individual periocular features, both in the present and in his or her past youthful state. The gradual loss of skin elasticity, with or without pseudoherniation of periorbital fat, is primarily responsible for the aging look of the upper eyelid. Dermatochalasis in the older population can impair peripheral vision as a result of an excessive fold of upper eyelid skin. Preoperative ophthalmologic consultation is recommended for documentation of visual field impairment in this patient population.

It is also important to consider less common etiologies for upper eyelid redundancy when evaluating a patient for upper blepharoplasty. Excessive bulging in the lateral third of the upper eyelid may be caused by a prolapsed lacrimal gland, which can be identified preoperatively with manual compression over the globe, which may show a slightly movable defined mass in the lacrimal fossa. A prolapsed gland can be observed in approximately 10% of patients at the time of surgery. Unintentional resection of the lacrimal gland as a result of erroneously mistaking the gland for periorbital fat can lead to disruption of lacrimal secretory function. Another condition that can present with upper eyelid heaviness is blepharochalasis, a recurrent inflammatory condition resulting in intermittent edema and erythema of the upper eyelid skin because of an increased histamine and immunoglobulin E response. Unlike dermatochalasis, blepharochalasis is often difficult to correct.

A complete evaluation of the upper eyelid includes an assessment of the brow shape and its position relative to the eye. Upper blepharoplasty performed alone in the presence of significant brow ptosis can result in further lowering of brow position. It may also lead to excessive skin excision, which can overly narrow the space between the palpebral margin and the brow. Additionally, this may introduce the heavier thick brow skin into the upper eyelid, potentially worsening brow ptosis and lid function. Medial brow ptosis may be associated with deep glabellar rhytids, particularly as a result of the strong depressor action of the corrugator and depressor supercilii muscles.

A thorough medical and ophthalmologic history must be obtained from the patient, including a history of diabetes, hypertension, cardiac disease, thyroid disease, bleeding disorders, problems with dry eyes or excessive tearing, and prior periorbital or ocular surgery. Old photographs of patients in their youth are particularly helpful in determining the approach to upper eyelid rejuvenation. These photographs enable the surgeon to evaluate eyelid crease height, palpebral fissure size, periorbital asymmetries, brow position, and brow shape in the patient’s youthful state. All of these factors must be considered before selecting the surgical plan that best suits the patient’s needs.