Introduction

The history of cosmetic blepharoplasty dates back more than 2,000 years when it was first described by Susruta. In the late 10th century, Arabian surgeons described cauterization of the redundant eyelid skin to restore a more youthful appearance. In the late 15th century, Celsus described skin excision in the upper eyelid in his publication De re Medica. However, it wasn’t until 1818 that the term blepharoplasty was coined by von Graefe to describe a case of eyelid reconstruction after addressing a cancer. Descriptions and illustrations of eyelid deformities caused by fat herniation, excess skin, and aging continued to inspire further investigation into eyelid anatomy and surgical approaches for both skin and fat excision.

In the 1950s, Costañares detailed the anatomy of the eyelid fat compartments and described the concept of what is generally considered the modern blepharoplasty. McIndoe became the first to perform excision of periorbital fat via a transcutaneous approach, and many others have made contributions that further characterize the lower lid fat compartments and aging. By the late 20th century, a significant transformation began to emerge, whereby the benefits of fat preservation and translocation, rather than resection, were advocated. Today, a state-of-theart approach to blepharoplasty therefore must consider both the presence and absence of fat, and the role this plays in periorbital pathology and an aged appearance. Moreover, with the increasing popularity of nonsurgical modalities, surgeons routinely offer a multimodal approach to periorbital rejuvenation. The following chapter offers a stepwise, multi-modal approach to male periorbital rejuventation, which includes upper traditional blepharoplasty, with canthal manipulation and fat grafting .

Physical Evaluation

• 
  

  A baseline ophthalmologic history and examination should be performed, including examining visual fields, acuity, pupillary response, extraocular muscles, presence of a Bell’s phenomenon, and preexisting amblyopia or keratoconjunctivitis sicca. The physical examination should always be performed with the patient in an upright, relaxed position.

  
  
• 
  

  Evaluating premorbid photographs cannot only reveal periorbital changes over time, but also aid in formulating a surgical plan that maintains respect for the individual’s unique appearance.

  
  
• 
  

  Periorbital evaluation of skin quality, degree of excess and hooding, soft-tissue positioning, and skeletal support should be combined with evaluation of asymmetries and relation to the midface.

  
  
• 
  

  Dermatochalasis of the upper and lower lids should be assessed in addition to noting the possibility of blepharochalasis. Malar edema in the male patient must be evaluated carefully, as it may be related to cardiac, renal, or hormonal malfunction.

  
  
• 
  

  Orbicularis oculi and ligamentous relaxation resulting in festoons or malar crescent at the inferior lid must be noted.

  
  
• 
  

  Presence and extent of herniated orbital fat pads can be localized in addition to noting the degree of midface volume loss.

  
  
• 
  

  Scleral show, as well as canthal position, tilt, and tone or laxity can be combined with vector and midface analysis when approaching the lower lid. The senior authors have previously described a seven-step checklist that is performed on all patients to stratify high-risk patients and optimal approaches ( Table 5.1 ).

  
  
• 
  

  Ptosis is evaluated by the relation of the lid margin to the superior limbus in central gaze. The amount of levator function in millimeters is measured and classified as mild (1–2 mm), moderate (2–3 mm), or severe (≥ 4 mm).

  
  
• 
  

  In contrast to the female patient, whose brow should be above the superior orbital rim, male patients’ brows generally should be at a level just at or above the rim with a gentle arch and minimal peak.

  
  
• 
  

  The longer male forehead with horizontal rhytids and posteriorly displaced hairline must be noted in addition to hyperactive corrugators and brow depressors in the glabellar region.

Note: A seven-step preoperative checklist for patients undergoing blepharoplasty. Patients who score to the right on the examination checklist are generally at an increased risk for postoperative lower eyelid malposition.
Source: Adapted from O.M. Tepper, D. Steinbrech, M.H. Howell, E.B. Jelks, G.W. Jelks. A retrospective review of patients undergoing lateral canthoplasty techniques to manage existing or potential lower eyelid malposition: Identification of seven key preoperative findings. Plast Reconstr Surg. 2015;136 (1): 40–49.

Relevant Anatomy

A thorough understanding of anatomy is vital to achieve optimal results and avoid complications in eyelid surgery. The eyelids are typically described as three lamellae: anterior, middle, and posterior. The skin of the upper eyelid is among the thinnest throughout the human body and composes the anterior lamella in conjunction with the orbicularis oculi. This muscle is divided into pretarsal, preseptal, and orbital components depending on what structure lies posterior to it. The pretarsal and preseptal portion make up the palpebral segment, which provides involuntary blink, while the orbital portion provides voluntary eyelid closing.

The orbital septum, an extension of periosteum, accounts for the middle lamella and spans from the orbital rim to insert on the levator aponeurosis above the superior tarsal border of the upper lid. The lower lid septum extends from the inferior orbital rim to insert on the analogous capsulopalpebral fascia approximately 5 mm below the lower tarsal border. The lower tarsus is approximately 3 to 4 mm in height and approximately 1 mm in thickness. The posterior lamella consists of both tarsus and conjunctiva. The upper tarsus is 8 to 10 mm in height and both Müller’s muscle and levator aponeuroses insert onto its superior border. The levator palpebrae and Müller’s muscle act as upper eyelid retractors and are innervated by the oculomotor nerve and the sympathetic nervous system, respectively. The lower eyelid retractors include the capsulopalpebral fascia and inferior tarsal muscle.

Retroseptal orbital fat in the upper lid is separated into two distinct compartments (nasal and central), separated by the trochlea of the superior oblique muscle. Fat in the lower eyelid lives in one of three compartments (medial, central, and lateral), separated by the inferior oblique medially and the arcuate band laterally. In both the upper and lower eyelids, medial fat is distinctly more vascular with a paler color and more fibrous texture. With age, the nasal fat pad herniates, often requiring some amount of debulking. The central fat pad is often less herniated and must be assessed preoperatively to indicate the need for debulking.

The supratarsal crease is formed by the insertion of the levator onto the dermis, just above the level of the tarsus. The position of the septum influences the contour of the eyelid fold. Both crease and fold are important aesthetic landmarks. In Caucasian men, the crease is usually 6 to 9 mm above the eyelid margin. The Asian eyelid has more upper lid fullness with a lower lid crease and narrower palpebral fissures and a medial epicanthal fold. Patients who have a dehisced levator muscle typically present with varying degrees of ptosis, with an elongated or absent upper lid crease. A lower lid crease is a result of the insertion of the orbital septum onto the capsulopalpebral fascia around the anterior surface of the tarsus.