Ancient medicine

Gather a fold of lid skin between a couple of fingers, or raise it up with a hook, and lay the fold between two small wooden bars or rods as long as the lid and as broad as a lancet. Bind their ends very tight together. The skin between these small pieces of wood, deprived of nutrient, dies in about ten days, the enclosed skin falls off, leaving no scar.

The Tadhkirat of Ali ibn Isa of Baghdad

Cosmetic eyelid surgery today has the benefit of 2000 years of development and refinement of surgical techniques and instruments. Ali ibn Isa (AD 940–1010) described the procedure just quoted more than 1000 years ago (Fig. 1-1), at a time when his medical treatment for ‘oedema of the lids’ was ‘letting blood from the head, and treating the eye with a preparation of celandine, sandlewood, and endives….’¹

Figure 1-1 Early technique of excision of excess skin of the upper eyelid.

Aulus Cornelius Celsus, a Roman encyclopedist and philosopher in the first century, was probably the first to comment on the excision of skin of the upper eyelids when he described the treatment of ‘relaxed eyelid’ in his De re Medica (AD 25–35).² De re Medica was not published until 1478, following its rediscovery by Pope Nicholas V.

Even before Celsus, the Hindus were known to have referred to cosmetic and reconstructive surgery about the face. The accepted form of corporal punishment in India 2000 years ago was amputation of the nose. The surgeons of this time became so skilled in reattaching this appendage that officials began to throw the amputated nose into the fire to ensure their goal of disfigurement. It is interesting that the skilled surgeons who were able to reattach the nose successfully were actually members of the lowly tile makers’ caste.³

Modern cosmetic eyelid surgery

Blepharoplasty (Greek blepharon, meaning eyelid, and plastos, meaning formed) was originally used by von Graefe ⁴ in 1818 to describe a case of eyelid reconstruction that he had performed in 1809. This meaning prevailed for the next 150 years.

In the 1913 American Encyclopedia of Ophthalmology,⁵ blepharoplasty is defined as the reformation, replacement, readjustment, or transplantation of any of the eyelid tissues. In contemporary usage, blepharoplasty refers to the excision of excessive eyelid skin, with or without the excision of orbital fat, for either functional or cosmetic indications. The cosmetic indications have been recognized by physicians only since the turn of the 20th century, but are now the most common reasons for such surgery on the eyelids. This change followed the development of improved operative techniques, better surgical results, and control of sepsis as well as changing social mores.

It is difficult to determine whether the ‘relaxed eyelid’ described by Celsus was a true ptosis or an excess skin fold. In any event, by the late 1700s, reports began to appear in Germany ⁶ specifically identifying the excess fold of the upper eyelid. Beer’s 1817 text is credited with providing the medical literature with the first illustration of this eyelid deformity.⁷ Many different authors from the first half of the 19th century began advocating excision of this excess skin, including Mackenzie,⁸ Alibert,⁹ Graf,¹⁰ and Dupuytren.¹¹

The first ‘accurate’ description of ‘herniated orbital fat,’ written in 1844 by Sichel,¹² did not create a wave of surgical excisions because surgery at that time was performed only for functional reasons. The case of Fetthernien reported in 1899 by Schmidt-Rimpler,¹³ which described herniated orbital fat, was clouded by the later report by Elschnig,¹⁴ who called the same patient’s condition a lipoma.

Near the turn of the 19th century, Ernest Fuchs ¹⁵ attempted to decipher the confusing terminology that had developed in the literature. ‘Ptosis adiposa,’ the misnomer used by Sichel, and ‘ptosis atonica,’ used by Hotz,¹⁶ had been introduced earlier in the 19th century. Sichel¹² had claimed that the excess upper lid fold was filled with fat, which caused it to hang down over the lid margin. Hotz believed that the skin was normally attached to the top of the tarsus, and that the loss of this attachment created an excessive upper lid skin fold with a pseudoptosis. It was Fuchs who recognized the importance of the weakening of the fascial bands connecting the skin and orbicularis with the tendons of the levator in the development of the excess skin fold. In his 1892 text, Fuchs¹⁵ wrote:

So also the ptosis adiposa of Sichel, which consists in the fact that the covering fold of the upper lid is of unusual size, so as to hang down over the free border of the lid in the region of the palpebral fissure, does not belong under the head of ptosis proper. It was formerly assumed that this enlargement was caused by an excessive accumulation of fat in the covering fold, for which reason the name of ptosis adiposa was given to it. Its true cause, however, depends upon the fact that the bands of fascia connecting the skin with the tendon of the levator… and with the upper margin of the orbit are not rigid enough; consequently the skin is not properly drawn up when the lid is raised, but hangs down in the form of a flabby pouch (Hotz). Except for the disfigurement it causes ptosis adiposa entails no disagreeable symptoms. It can be removed by simple ablation of the excess of skin, but it is better, although also more tedious, to attach the skin to the upper border of the tarsus by Hotz’s operation, and thus prevent its drooping.

And so Fuchs was the first to recognize the cosmetic value of reformation and elevation of the eyelid crease. Fuchs ¹⁷ is also credited with originating the often misused term blepharochalasis in 1896. Sometimes used to describe the changes associated with herniated orbital fat, this term should be reserved for those cases of thickened and indurated eyelids, most often found in younger women, and associated with recurrent episodes of idiopathic edema.^18,¹⁹ The term dermatochalasis was introduced 56 years later by Fox²⁰ to describe the apparent excess eyelid skin associated with aging.

In the early 1900s, the historical focus on cosmetic eyelid surgery shifted to the United States, where Conrad Miller,²¹ in 1907, produced Cosmetic Surgery: The Correction of Featural Imperfections, the first published book on cosmetic surgery. This edition, which covered many aspects of plastic surgery, contained the first photograph in medical history to illustrate the lower eyelid incision for removing a crescent of excess skin. It is interesting to note Miller’s surgical technique. In his discussion of the lower eyelid incision, Miller stated that ‘just sufficient skin is left along the margin of the lid to permit the stitches being passed in closing. The line of union is brought in this way under the shadow of the lashes, and is entirely invisible.’ On excision of the fold above the eye, Miller wrote that ‘the fold above the eye after infiltration is picked and trimmed away. The line of closure here is at the upper extremity of the lid so that the slight line of the union is hidden in the fold between the lid and the brow when the eye is open, and only shows slightly when the eye is closed.’ Miller’s enlarged text,²² which followed in 1924, provided diagrams of incision sites for upper and lower eyelid blepharoplasty that are remarkably similar to those commonly used today (Fig. 1-2).

Figure 1-2 A, An upper eyelid incision. B, An upper eyelid closure. C, A triangular resection modification to lower eyelid incision to prevent ectropion. D, A lower eyelid closure.

From Miller CC: Cosmetic Surgery: The Correction of Featural Imperfections. Philadelphia, FA Davis, 1924. With permission.

Frederick Kolle,²³ in a 1911 text on plastic and cosmetic surgery, wrote about wrinkled eyelids in a chapter on blepharoplasty. He probably was the first to recognize and note the safety and value of marking the skin preoperatively to determine the amount of excess skin to excise.

Adabert Bettman ²⁴^–²⁶ added to the contributions by Miller and Kolle in his publications in the 1920s, in which he described precautions, specifically related to surgery about the eyelids, to be taken in minimizing postoperative scarring. He emphasized gentle treatment of the tissues, exact apposition of wound edges, elimination of tension on all wound edges, and timely suture removal. These, of course, are concepts that are still important today.

The first work in English devoted solely to oculoplastic surgery was written by Edmund Spaeth.²⁷ Newer Methods of Ophthalmic Plastic Surgery, published in 1925, deals entirely with eyelid reconstruction and does not mention cosmetic surgery.

By the late 1920s, still no mention had been made in the United States of the excision of herniated orbital fat for cosmetic reasons. Although advances and progress in medicine (including antibiotics, finer suture materials, improved technology, and better control of sepsis) allowed for the beginnings of the public desire for and acceptance of cosmetic surgery, it was still frowned on by the majority of physicians.

In the same decade in Europe, Julian Bourguet ²⁸ was also developing new techniques in cosmetic eyelid surgery. In 1924, he was probably the first to describe transconjunctival resection of the pockets of herniated orbital fat. In the following year, he published probably the first before and after photographs of patients who had undergone cosmetic lower eyelid surgery (Fig. 1-3).²⁹ In 1929, Bourguet³⁰ described the two separate fat compartments of the upper lid and advocated their removal. Many surgeons followed his lead, including Claoué³¹ and Passot.³² Passot^32,³³ is also credited as being the first to name the supraciliary brow incision for the correction of brow ptosis. It is also quite interesting that Passot expressed his objections to the secrecy of techniques practiced by some of his contemporaries: ‘By keeping their methods secret, they allow a certain suspicion to exist about their procedures.’^34,³⁵ These ‘suspicions’ for many procedures can be related to the present.

Figure 1-3 Earliest photographs illustrating preoperative (A) and postoperative (B) appearances of lower eyelid blepharoplasty.

From Bourguet J: Chirurgie esthétique de la face: Les nez concaves, les rides et les ‘poches’ sous les yeux. Arch Franco-Belges Chir 1925; 28:293. With permission.

At the same time, one of the first female surgeons to appear in the history of cosmetic surgery was perfecting her techniques in Paris.^36,³⁷ Suzanne Noel’s 1926 book on cosmetic eyelid surgery³⁸ was the earliest to include numerous preoperative and postoperative photographs.³⁶ Noel also initiated the emphasis, for the benefit of other surgeons, on the advantages and the importance of looking at these photographs and showing them to one’s patients. She was also the first to be photographed performing a blepharoplasty. Thanks to the contributions of Noel and others and to the development of photography as an art and science, photographic documentation is now an integral part of the practice of the cosmetic oculoplastic surgeon. In addition, Noel must certainly be credited for recognizing the importance of the psychological implications of cosmetic surgery for both the patient and the patient’s family. She distinguished between the attitudes of American and European men: ‘American men are anxious to encourage their wives to have such an operation…. [S]uch is not the case with the European male; as a result, French women have the operation performed and do not talk about it.’

In the first two decades of the 1900s, a surgical technique widely used in Europe for elevation of the eyebrow was commonly known as the ‘temporal lift.’ Its benefits remained controversial. Bourguet,³⁹ in 1921, was the first to condemn this type of surgery. In 1926, Hunt⁴⁰ described a coronal skin resection to achieve a forehead lift. Joseph,⁴¹ in 1931, described hairline and forehead crease incisions to raise the brows. The coronal brow lift, as described by Hunt, lost favor because the results with the methods performed in a matter similarly ascribed by him were thought to be too transient.

A number of authors then recognized the importance of manipulating the frontalis and other muscle activity to achieve better results with the forehead lift.^35,⁴²^–⁴⁵ The importance of attenuating the action of the procerus and corrugator muscles was recognized by Salvadore Castanares in 1964.⁴⁶

Since the 1930s, additional individual contributions have been made to cosmetic eyelid surgery. An offering in 1951 by Castanares ⁴⁷ of a detailed description of the fat compartments of the upper and lower orbit and their relationship to the eyelids cannot be overlooked. It was also Castanares⁴⁸^–⁵⁰ who recognized the importance of the orbicularis muscle (including its hyper-trophy and excision, when indicated) as part of the overall evaluation and technique in cosmetic blepharoplasty.⁴⁸^–⁵⁰ Furnas⁵¹^–⁵³ later elaborated on the origin of eyelid and cheek contour abnormalities (including festoons) in his landmark chapter in Clinics of Plastic Surgery edited by Flowers.

In 1954, Sayoc ⁵⁴ reported on the use of the Hotz trichiasis procedure for the cosmetic alteration of the Asian upper eyelid crease/fold complex. Pang’s 1961 report on the Far Eastern method of the surgical formation of the upper lid fold⁵⁵ was the first to advocate the technique of supratarsal fixation, although this term was reintroduced 13 years later by Jack Sheen.⁵⁶ Khou Boo-Chai’s 1963 report⁵⁷ was the initial description of eyelid crease elevation with upper eyelid blepharoplasty, but he advocated dermal fixation to the tarsal plate and referred only to the Asian eyelid.

Significant contributions to cosmetic eyelid surgery in the 1970s focused on the levator aponeurosis and crease-fold complex.⁵⁸ In 1974, Sheen⁵⁶ recognized the low eyelid crease as the cause of apparent failure in many Caucasian patients undergoing upper lid blepharoplasty. He advocated orbicularis fixation to the levator aponeurosis 16 mm above the lid margin; 3 years later, iatrogenic postoperative ptosis prompted him to lower it to 12 mm.⁵⁹ At that time, observing postoperative lid retraction, he inadvertently dis-covered a way to strengthen the levator aponeurosis by tucking it. The next year, Dryden and Leibsohn⁶⁰ reported on intentional levator advancement for simultaneous blepharoplasty and repair of ptosis. The cur-rent thinking for the next 20 years for a high-definition and enhanced upper eyelid ‘invagination’ with blepharoplasty were in part due to contributions from Flowers^61,⁶² and Siegel.^63,⁶⁴

Putterman and Urist ⁶⁵ recognized the role of the crease-fold complex in upper eyelid asymmetry associated with ptosis, trauma, and other eyelid abnormalities. Sheen⁶⁶ also advocated tarsal fixation in the lower eyelid to achieve a ‘youthful’ appearance.

In the last 25 years, there have been significant additional contributions to the development of cosmetic oculoplastic surgery. With the increased frequency of operations, there has been a growing awareness of potential complications. The importance of the pre-operative evaluation has been emphasized as essential to minimizing complications; this also has resulted in the development of adjunctive surgical procedures.

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