Surgical management of the aging upper face has taken on a critical role in total facial rejuvenation, with a variety of techniques available. The hallmarks of the aging upper third of the face and periorbital region most commonly manifest as rhytids, brow descent, prolapse of periorbital fat, dermatochalasis, and volume loss and hollowing. The surrounding structures should be assessed individually and their relationships carefully analyzed to guide selection of the appropriate treatment. In this article, the authors explore the various approaches and techniques available for rejuvenation of the upper face, including the upper periorbital region.
Key points
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The surgeon must be meticulous when marking the patient for upper eyelid blepharoplasty before surgery, and the surgeon should make use of a fine-tip marker and small calipers.
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The age-related changes in the eyelid and eyebrow continuum are multifactorial, with volume loss or deflation (bony and fat atrophy) taking on an equivalent contribution in the aging process as the classically described tissue descent and skin changes.
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The frontal hairline, slope of the forehead, and structure of the underlying frontal bone should be considered when preparing for and choosing any surgical intervention to ensure proper approach selection and incision placement.
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The key to guiding and stabilizing brow position is releasing the periosteum at the arcus marginalis.
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Patients with hairlines that prevent a standard endoscopic approach may benefit from a combination procedure using trichophytic or transverse mid-forehead incisions to address medial brow ptosis.
Introduction
The periorbital region and upper third of the face are often the first facial areas to show signs of aging, with patients presenting with subjective complaints of having an unrested, angry, or sad appearance. Upper facial aging commonly manifests as brow ptosis, upper facial dynamic and static rhytids, volume loss and periorbital hollowing, with associated prolapse of periorbital fat, and dermatochalasis.
The brow and upper lid anatomy, as well as the aging and esthetic analysis, are described in further detail within the earlier portions of this issue. When evaluating a patient for surgical intervention, the relationship of the upper eyelids relative to the other structures forming the upper third of the face, including the eyelid margin position, eyebrows, forehead, and the location of the frontal hairline should be analyzed in continuity. The expression, brow-eyelid continuum, has been accepted by surgeons, and can be used to counsel patients and draw attention to the fact that treatment of these structures relative to each other, as opposed to in isolation, will allow the surgeon to achieve a more harmonious and esthetically pleasing rejuvenation.
The age-related changes in the eyelid and eyebrow continuum are multifactorial, similar to other regions of the face. Several philosophies describe aging as a 3-dimensional process, with volume loss, deflation, and bony and fat atrophy taking on an equivalent contribution in the aging process, as the classically described tissue descent and skin changes. These changes include the rhytids, skin thinning, and laxity seen with loss of dermal collagen and solar damage.
The surgeon must carefully assess each factor individually and recognize the interrelationship between the characteristic aging patterns and the surrounding anatomic structures to select the appropriate treatment. In this article, the authors explore the various approaches and techniques available for surgical rejuvenation of the upper face, including the upper periorbital region.
Introduction
The periorbital region and upper third of the face are often the first facial areas to show signs of aging, with patients presenting with subjective complaints of having an unrested, angry, or sad appearance. Upper facial aging commonly manifests as brow ptosis, upper facial dynamic and static rhytids, volume loss and periorbital hollowing, with associated prolapse of periorbital fat, and dermatochalasis.
The brow and upper lid anatomy, as well as the aging and esthetic analysis, are described in further detail within the earlier portions of this issue. When evaluating a patient for surgical intervention, the relationship of the upper eyelids relative to the other structures forming the upper third of the face, including the eyelid margin position, eyebrows, forehead, and the location of the frontal hairline should be analyzed in continuity. The expression, brow-eyelid continuum, has been accepted by surgeons, and can be used to counsel patients and draw attention to the fact that treatment of these structures relative to each other, as opposed to in isolation, will allow the surgeon to achieve a more harmonious and esthetically pleasing rejuvenation.
The age-related changes in the eyelid and eyebrow continuum are multifactorial, similar to other regions of the face. Several philosophies describe aging as a 3-dimensional process, with volume loss, deflation, and bony and fat atrophy taking on an equivalent contribution in the aging process, as the classically described tissue descent and skin changes. These changes include the rhytids, skin thinning, and laxity seen with loss of dermal collagen and solar damage.
The surgeon must carefully assess each factor individually and recognize the interrelationship between the characteristic aging patterns and the surrounding anatomic structures to select the appropriate treatment. In this article, the authors explore the various approaches and techniques available for surgical rejuvenation of the upper face, including the upper periorbital region.
Preoperative planning and preparation
The optimal results begin with appropriate preoperative planning and preparation. The surgeon should have a clear understanding of the surgical and nonsurgical techniques available to achieve the desired outcome and meet the expectations of the patient and surgeon alike. Considerations into the etiology of each patient’s complaints and anatomic findings should be weighed against the effect that the procedure will have on the brow-lid continuum. This will allow the surgeon to accomplish the shared goals, while avoiding or reducing the need for revisions or further corrective procedures.
Assessment of the patient’s brow should include the brow position, height, brow curvature or arch, and the brow’s relationship to the upper eyelids and hairline. The surgical techniques in brow elevation or stabilization aim to reshape the brow position relative to the adjacent forehead and upper eyelid skin. The surgeon should be conscientious that an overly elevated brow may not only result in a surprised look but also impart an aged appearance.
The frontal hairline, slope of the forehead, and structure of the underlying frontal bone should be considered as well when choosing the appropriate surgical approach and incision placement ( Table 1 ). Additionally, documenting hyperfunctional brow musculature (corrugator supercilii, procerus, frontalis, orbicularis) may persuade the surgeon to consider myotomies or myectomies during their surgical intervention to reduce skin wrinkling.
| Type of Lift | Incision | Dissection | Suspension | Selection | Advantages | Disadvantages |
|---|---|---|---|---|---|---|
| Coronal | Parallels frontal hairline (5–7 cm back) | Subgaleal | No | Classic operation for most women unless they have a high frontal hairline, not good for male patients | Incision hidden in hairline, good exposure to forehead muscles | Elevation of frontal hairline, scalp anesthesia behind incision |
| Endoscopic | Paramedian 2 cm posterior to hairline, and lateral aligned with lateral canthus | Subperiosteal | Suspend using bone tunnel or fixation device | Best operation for men or women, unless they have a high frontal hairline, may use combination approach | Incisions hidden in hairline, good exposure to forehead muscles, shorter operative time, minimal closure time | Elevation of frontal hairline, scalp anesthesia, necessitates specialized equipment |
| Pretrichial or trichophytic | Beveled posterior to anterior, incision just at or anterior to frontal hairline | Subgaleal or subperiosteal | No | Good option for women with thick hair, high frontal hairline, may be combined with endoscopic approach for patients with high hairlines | Does not raise hairline, direct access to forehead muscles, good scar camouflage is possible | Scalp anesthesia behind incision, technically more difficult, scar may be visible if not executed correctly |
| Combination mid-forehead transverse incision with endoscopic approach | Midline forehead crease, between neurovascular bundles; standard lateral endoscopic incisions | Subperiosteal | Laterally similar to endoscopic approach | Good option for men with prominent forehead rhytids, and significant male pattern baldness or shaved head | Direct access to forehead muscles, good scar camouflage is possible | Incision may leave obvious scar in area not easily camouflaged |
| Traditional mid-brow | Hidden in forehead creases, not a straight line | Subcutaneous | Suspend upper orbicularis muscle to periosteum at upper skin margin | Good when scar can be hidden in deep forehead crease, or patients with male pattern baldness | Selective skin excision, precise brow elevation | Incision may leave obvious scar in area not easily camouflaged |
| Direct | Skin excision in forehead crease just above eyebrow | Subcutaneous | Suspend transverse orbicularis muscle to subgaleal tissue above brow | Elderly patient with deep furrows over the brows, functional elevation of brow, unilateral brow ptosis | Precise brow elevation, minimal edema or ecchymosis | Incision is difficult to camouflage, no change in mimetic function so brow may descend with time, can distort existing forehead furrows |
Blepharoplasty of the upper eyelid is indicated when the eyelids require contouring due to excessive or redundant upper eyelid skin, or when herniated periorbital fat calls for resection and redistribution. The preoperative evaluation should include critical evaluation of the skin, orbicularis muscle, prolapsed fat, the size and position of the lacrimal gland, levator palpebrae superioris function, and the position of the upper eyelid relative to the pupillary light reflex. The limitations of blepharoplasty and the role of adjuvant procedures must be discussed with the patient. Nonsurgical management using botulinum toxin would be a more suitable treatment for the patient with significant crow’s feet requesting periorbital rejuvenation. Similarly, the patient with fine wrinkling and “crepe paper” skin may achieve significant improvement with skin resurfacing, as opposed to blepharoplasty. For those patients with volume loss contributing to the signs of periorbital aging, volumizing the brow with hyaluronic acid fillers or autologous fat may help give a more youthful appearance to the brow and periorbital region.
The preoperative assessment of the patient seeking rejuvenation of the brow and upper eyelid complex should include a complete medical history to evaluate for systemic disease processes, such as autoimmune or collagen vascular diseases, endocrinopathies with ocular manifestations, dry eye symptoms, and visual acuity changes. Often ocular physical examination findings can be a manifestation of a systemic disease process, such as allergy or thyroid-associated exophthalmos, and it is important to distinguish whether the changes to the brow and upper eyelids are truly related to hereditary or age-related changes (dermatochalasis and steatoblepharon). Comorbidities may have ocular consequences as well, and the appropriate workup should be completed, including blood levels of thyroid-stimulating hormone if thyroid-related endocrinopathies are suspected, in addition to consultation with an endocrinologist or ophthalmologist when indicated. Any patient with history of dry eye or visual acuity changes should be evaluated by an ophthalmologist.
Upper eyelid rejuvenation
Patient Marking and Positioning
The surgeon must be meticulous when marking the patient for upper eyelid blepharoplasty before surgery, and the surgeon should make use of a fine-tip marker and small calipers. The patient may be marked in a seated or supine position, as long as the surgeon accounts for the tissues of the brow being drawn artificially higher in a supine position compared with when the patient is seated.
A difference of 1 to 3 mm from one eyelid to the next may create perceptible asymmetries. The surgeon’s contralateral hand is used to reposition or brace the eyebrow superiorly, isolating the perceived contribution of brow ptosis from true upper eyelid dermatochalasis. Alternatively, if a forehead lift is indicated at the same time as the upper eyelid blepharoplasty, the surgeon may elect to perform the forehead lift first, and then measure and mark the appropriate amount of upper eyelid skin excision necessary to provide rejuvenation of the upper eyelid complex, so as to minimize the risk of lagophthalmos.
The marking begins with the patient looking up, and the supratarsal crease is identified and measured from the eyelid margin using small calipers; this denotes the location of the inferior limb of the surgical marking. This measurement ranges from 8 to 10 mm from the lid margin (8–10 mm in women; 8–9 mm in men) ( Fig. 1 ).
The inferior limb of the marking is curved gently and parallels the lid margin; the inferior limb of the marking is carried medially to within 1 to 2 mm of the punctum and laterally to the lateral canthus. Medially, the nasal-orbital depression should not be violated, as an incision in this area may result in a webbed scar; ending the incision medially within 1 to 2 mm of the punctum avoids this result. If the marking is carried along the curve of the eyelid crease lateral to the lateral canthus, the final closure scar line will bring the upper eyelid tissue downward, thus resulting in a hooded appearance. In an effort to avoid this unsightly result, the marking sweeps diagonally upward from the lateral canthus to the lateral eyebrow margin ( Fig. 2 ). This modification of the lateral incision resists lateral hooding and can be easily camouflaged with makeup.
Next, the superior limb of the surgical marking is made. This is facilitated by using smooth forceps to pinch the excess amount of upper eyelid skin so that the lashes roll upward ( Fig. 3 ). This conservative maneuver avoids over-resection of upper lid skin and reduces the risk of lagophthalmos as a long-term complication.
The authors elect to sit while performing brow and eyelid surgery. The patient is placed in a supine position with the surgeon on the side of the eye to be addressed and the assistant is seated across. Stabilization of the skin in the eyelid is paramount to making the skin-only incision of the upper eyelid; therefore, it is the assistant’s role to place tension on the skin. At the time of the brow lift, the surgeon and assistant should position themselves at the head of the bed ( Fig. 4 ).
Surgical Technique for the Upper Eyelid
Generally, isolated upper eyelid blepharoplasty can be performed under local anesthesia with or without intravenous sedation for patient comfort, or a general anesthetic may be instituted during concomitant rejuvenative procedures, including forehead or brow lift. Lidocaine 2% with epinephrine (1:50,000) is infiltrated deep to the skin but superficial to the orbicularis oculi muscle, thus minimizing the risk of ecchymosis caused by the injection of local anesthesia.
A round-handled scalpel with a #15 Bard-Parker blade is ideal for following the curves of the surgical markings in the upper eyelid. Once the skin incision is made, the skin is then sharply dissected from the underlying orbicularis oculi muscle with a scalpel blade or dissecting beveled scissors. The preseptal orbicularis oculi muscle is then evaluated. If it is atrophic or very thin, then the muscle need not be excised; however, most often, a thin strip of preseptal orbicularis oculi muscle is excised medially, thus exposing the fat compartments. If the muscle is robust and contributing to the aged appearance, then a narrow excision is performed along the entire length of the eyelid.
Attention is then directed to the pseudoherniation of orbital fat. If there is fullness of the upper eyelid, a conservative excision, if any, can be performed, with care to avoid the late sequela of the hollowed or sunken appearance to the upper eyelid from over-resection. A small opening is made in the orbital septum overlying the middle and medial fat compartments. Attentiveness is needed to avoid the intervening trochlea and superior oblique muscle separating these compartments. Gentle pressure on the globe can reveal redundant fat from each compartment. Using Griffiths-Brown forceps, the herniated fat is grasped from its respective compartment, and the fat is infiltrated with local anesthesia to minimize discomfort associated with subsequent electrocautery and excision of the redundant fat, unless the patient is under general anesthesia ( Fig. 5 ). Meticulous hemostasis is of utmost importance, not only to maintain a clear operative field, but also to minimize the risk of postoperative bleeding. Once fat removal from both compartments is completed, bipolar electrocautery is used to ensure hemostasis before wound closure.
