Techniques for Upper Blepharoplasty
Steven M. Levine
DEFINITION
Surgery is the standard treatment to address the aging upper eye.
The aging upper eye can be broken down into excess skin and excess fat.
ANATOMY
Relevant anatomy pertains to the layers of the upper eyelid: notably, the skin, the orbicularis oculi muscle, and the preaponeurotic fat (central fat pad and medial/nasal fat pad).
The lacrimal gland is located laterally and deep to the preaponeurotic fat pad. This gland can become ptotic and be confused as redundant fat.
PATIENT HISTORY AND PHYSICAL FINDINGS
Beyond the usual history, to make sure a patient is an acceptable candidate for facial plastic surgery, certain physical findings should be noted.
Ptosis should always be noted. Ptosis repair is not being addressed in this chapter.
The eyes should be studied carefully to note the exact location of the excess or “hooded” skin.
Ask for photographs of the patient when younger to note whether the upper lids were always “full.”
This will avoid hollowing out a patient who is used to having full lids.
The lateral extent of the excess should be noted and care taken to include that tissue in the resection (even if it falls beyond the lateral orbital rim).
The tarsal insertion should be marked to represent, approximately, the inferior aspect of the surgical excision.
SURGICAL MANAGEMENT
Surgery should be performed in an accredited operating room.
An upper blepharoplasty can be performed under local anesthesia with or without sedation or general anesthesia.
Preoperative Planning
The author requires all patients to be seen by an ophthalmologist and have a Schirmer tear test preoperatively.
Consideration should be given as to whether the surgeon believes the patient will require fat to be removed.
If the operation is “skin only,” it is easier to perform under local anesthesia.
The patient should be marked while sitting upright.
It is important to end the medial extent of resection prior to the medial canthus to avoid creation of a web.
A “pinch test” should be performed on the estimated skin resection to ensure the surgery will not create a lagophthalmos.
Use a ruler to ensure the markings are roughly equal on both sides.
Measure the distance from the lash line to the inferior aspect of resection and the distance from the lateral canthus to the lateral extent of the resection (FIG 1).
The author rarely removes fat from the upper lid.
That said, the medial or nasal fat compartment is more commonly full and can benefit from fat removal.
The globe is balloted to accentuate the excess fat, and a decision is made preoperatively as to where fat will be removed and how much.
Fat is not removed indiscriminately. The surgeon should know roughly how much fat he or she plans to excise.Related posts:
Injection of Botulinum Toxin to the Depressor Anguli Oris
Indications and Technique for Skin Pinch Skin Excision in the Lower Eyelids
Indications and Techniques for Upper and Lower Blepharoplasty With Microfat Injections
Indications and Techniques for Buccal Fat Pad Excision
Technique for Treating the Long Nose
Alar Contour Grafts
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