Part III Periorbital Rejuvenation

Rod J. Rohrich and Yash J. Avashia

Abstract

The upper eyelid blepharoplasty focuses on eyelid reshaping with skin reduction, lateral retinacular canthopexy, and fat compartment restoration. Detailed preoperative analysis coupled with well-executed operative technique help to achieve consistent results. The five steps presented by the senior author in upper eyelid blepharoplasty include skin excision, lateral orbicularis window, lateral retinacular canthopexy, fat restoration with fractionated fat, and differential skin closure.

Blepharoplasty – dermatochalasis – canthopexy – fat augmentation – ptosis

30 Eyelids: Upper Blepharoplasty

Key Points

Upper eyelid blepharoplasty should focus on upper eyelid shaping with skin reduction, lateral retinacular canthopexy, and fat compartment restoration.
Fat grafting is an important aspect of restoring a youthful upper eyelid and eyebrow.

30.1 Preoperative Steps

Patient evaluation:
- Chapter 29 discusses at length the steps involved in a thorough patient evaluation and physical examination for periorbital rejuvenation.
Upper eyelid blepharoplasty markings (Fig. 30.1):
- The patient is marked in the upright position with a neutral gaze.
- The brow is relaxed and positioned appropriately at the level of the supraorbital rim prior to marking.
- At the midpupillary line, an inferior mark is placed just inferior to the supratarsal fold. This is located 8 to 9 mm above the ciliary margin in women and 7 to 8 mm in men.
- The superior mark is placed at least 10 mm from the lower edge of the eyebrow. A skin pinch test may also be performed to determine the superior point.
- The medial mark should not extend beyond the medial canthus as this may cause webbing.
- Two points are noted laterally: The lateral orbital skin crease and the lateral canthus.
- The skin excision shape should include the four borders defined above and may be shaped in a lenticular or trapezoidal shape.
- Laterally the inferior incision line should be 6 mm superior to the ciliary margin at the level of the lateral canthus before curving inferiorly to join the lateral orbital skin crease.

**Fig. 30.1** Upper eyelid blepharoplasty marking. The lower incision is made roughly 1 mm below the supratarsal crease or at 6 to 7 mm from the eyelid margin. The superior incision follows the curve of the eyebrow, preserving a minimum of 10 mm of upper eyelid skin (X). The medial extent should not cross the punctum, nor should the lateral extent reach 5 to 10 mm beyond the lateral canthus.

30.2 Operative Steps

See Video 30.1.

30.2.1 Incision

Subcutaneous injection of 3 to 5 mL of 1% lidocaine with 1:100,000 epinephrine with a 27-guage, 1.5 inch needle is performed 7 minutes prior to incision.
Using a #15 blade scalpel, the presurgical marking is incised beginning with the inferior incision.

30.2.2 Excision

Using a fine pair of scissors, the skin is excised while preserving the underlying orbicularis muscle.
A minimal portion of the lateral orbicularis muscle may be excised if there is lateral redundancy or laxity.

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