The upper eyelid–brow complex should be approached as a series of three interrelated arcs, the shape of which determines the dimensions of the intervening spaces. By following an engineered structural approach addressing all components of the upper periorbital area, the ideal attractive proportions are created, and the eye becomes instantly more beautiful. Combining different techniques to address the three arcs can be done safely and effectively to treat all three upper lid types. The concept of upper lid tension is introduced as a critical component of upper lid rejuvenation, allowing the most important step of the procedure, pretarsal control.
Key points
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Upper eyelid–brow rejuvenation should be approached using the Arcs concept.
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Pretarsal control is the key to success in upper blepharoplasty.
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Upper lid tension should be adjusted first, when needed, before skin excision.
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Brow elevation and shaping establishes the ideal dimensions of the upper lid fold.
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Volume management of the upper lid fold through fat excision, fat shifting, and fat grafting creates the ideal surface contour.
Upper blepharoplasty is one of the most performed and oversimplified procedures in plastic surgery. Many surgeons prefer performing upper over lower blepharoplasty from fear of lower lid complications. Although the lower lid is technically more challenging and less forgiving, its surface topography and aesthetic end goals are simple—a smooth surface with slight concavity that blends well with the cheek. The upper lid, on the other hand, has a complex surface topography requiring several maneuvers to achieve the desired aesthetic goal. Traditional upper blepharoplasty techniques relied heavily on skin excision with various degree of muscle and fat manipulation without any consideration of what makes an eye attractive and the means to achieve it. It is therefore paramount to understand the ideal aesthetic proportions of the upper lid–brow complex in order to engineer an attractive upper periorbital area with its surfaces, arcs, and elevations.
The upper periorbital area is made of three arcs and two surfaces. The arcs are the upper lid margin, the crease, and the inferior boarder of the brow ( Fig. 1 A ). The curvature and elevation of the arcs determine the shape of the intervening spaces, the pretarsal space and the upper lid fold. All three arcs have smooth curvatures except for a soft inflection point in the brow arc at the level of the brow peak (approximately the level of the lateral canthus). In the attractive eye, the lid margin and the upper lid crease are usually parallel to each other, creating a uniform height of the pretarsal space between them. The brow arc has a different shape, starting low medial to the medial canthus and ascending gently where it peaks at the level of the lateral canthus and descends afterward. In the attractive eye, there is a progressive lateralization of the peaks of the arcs, with the lid margin peak located on average 1 mm lateral to the mid-pupillary line, the crease peak 2 mm lateral to the mid-pupillary line, and the brow peak at the level of the lateral canthus. , In the aging and less attractive eye, various degrees of medialization of the peaks occur depending on the pathology. For example, upper lid ptosis and brow descent cause their respective peaks to medialize, whereas an A-frame deformity results in medialization of the crease peak.
In the upper periorbital area, the proportions of a well-defined pretarsal and upper lid fold spaces and their separation by a crisp dynamic crease is what ultimately determines the perception of attractiveness ( Fig. 1 B). The author’s previous research showed that each of the two spaces has a unique surface topography. In the attractive eye, the upper lid fold to pretarsal space ratio averages 1.8 mm medially and increases laterally to 3 at the peak of the brow. The pretarsal space height should be between 2 and 3 mm, and once it exceeds 4 mm the eye becomes less attractive. The upper lid fold has a flat surface medially and transitions into a more convex surface laterally. , ,
Making a beautiful eye
Once the blueprint for the ideal upper periorbital area is clear in our minds, then we can design, plan, and execute upper lid rejuvenation to create a beautiful eye. We start with shaping the arcs as they form the structural foundation. Flat arcs give the patient a sad and tired appearance. When the arcs are lifted and shaped, the eye immediately looks more vibrant and youthful. Attention is first directed toward the first and third arcs, the lid margin and brow, respectively, because the shape of each determines the shape of the second arc, the upper lid crease. Patients usually present with either of three different aging patterns. In the first group patients present with complete obliteration of the pretarsal space where the skin is descending over the lid margin and eyelashes. Group 3 presents with complete pretarsal show with the excess skin accumulating in the upper lid recess. Group 2 is somewhere in between and has partial show of the pretarsal space. It is very important to recognize the difference between the aging patterns, particularly groups 1 and 3, as they both require different surgical approaches. Traditional upper blepharoplasty techniques work well for group 1 but lead to unsatisfactory results in group 3. It is imperative to know that group 3 is the most common presenting aging pattern. The main difference between the two is what the author calls “upper lid tension.” Upper lid tension is defined as the degree of elevation of the upper lid; underelevation translates into different degrees of ptosis, whereas overelevation causes upper lip retraction. A perfect upper lid tension corresponds to a margin-reflex distance 1 (MRD-1) of 4 mm. The degree of upper lid tension is inversely proportional to the amount of pretarsal show ( Fig. 2 ). High upper lid tension results in less pretarsal show and better arc shape when compared with low upper lid tension. Additionally, when the upper lid tension is high, it pushes against the brow and creates vertical compression of the upper lid fold, resulting in crowding of the skin, which descends over and covers the pretarsal space. On the other end, as the upper lid tension decreases, pretarsal show increases, the upper lid becomes more exposed, and the skin excess does not descend over the lid margin. If skin excision alone is performed in type 3 upper lid, it leads to more pretarsal show potentially reaching or exceeding the 4 mm mark and immediate deterioration in the cosmetic score. Another contributing factor to the difference in the aging morphology is the periorbital fat volume. Many type 3 upper lids have less volume and more hollowing compared with types 1 and 2. Upper lid tension has direct impact on the shape of all three arcs. In cases of low tension, the lid margin is more flat, the crease is not well defined and many times absent, and the brow shape could be affected as the brow peak tends to be more medialized due to frontalis muscle strain targeted at lifting the upper lid to improve the visual field.
Controlling pretarsal show
The key to success in upper blepharoplasty is mastering control of pretarsal show. In order to do so, one must be able to shape the two adjacent arcs, the lid margin and the crease. If both arcs have a good shape, then attention must be shifted to the third arc to evaluate if there is brow ptosis contributing to dermatochalasis. This situation is a more straight-forward one where conventional techniques have proved to be successful. The excess skin is excised, the upper lid fold is shaped with volume control, and the pretarsal space is restored to its original shape ( Fig. 3 ). However, if the pretarsal space is already exposed and the crease is not well defined, then upper lid tension should be evaluated, and ptosis has to be ruled out before skin excision. In many of these instances, the upper lid has no defined features, and the spaces have to be constructed ( Fig. 4 ). It is almost a “reverse upper blepharoplasty” in a sense. Skin excision alone will definitely make things worse, and the patient has to be counseled about this before surgery.
The first step is to evaluate upper lid tension clinically and photographically. If the MRD-1 is less than 4 mm, a phenylephrine 2.5% test should be conducted by applying one drop to the upper conjunctival fornix. Phenylephrine 2.5% stimulates Muller muscle and causes the upper lid to elevate, mimicking the effect of Mullerectomy. Most of the time, the response appears within seconds; however, if unsatisfactory response is observed, another drop of phenylephrine 2.5% can be applied. When patients have a favorable response, the eye opens almost immediately, and the shape improves. Both the patient and the surgeon can observe together in real time an improvement in the eye opening, upper lid tension, lid margin arc shape, and less visibility of the pretarsal space ( Fig. 5 ). Overcorrection and undercorrection should be noted and documented on each side to determine the amount of excision needed to achieve symmetry and the ideal upper lid tension.
The second step is to determine the brow shape and position (third Arc). Any deviation from the ideal shape and position requires attention for correction. Lateral hooding and short upper lid fold are indicators of a low positioned brow. Generally, brow lift is a powerful adjunct procedure in upper lid rejuvenation, and the author finds it beneficial in most cases, particularly in patients presenting in their 40s and beyond, as there is often some degree of brow relaxation that occurs with time. Brow shaping and elevation help establish the height of the upper lid fold medially and laterally and reduce the vertical skin compression that results from upper lid ptosis repair.
The final step is sculpting the upper lid fold, including skin excision, fat manipulation, and muscle contouring, to achieve the ideal crease shape and surface topography. This step is very important and where most of the traditional upper blepharoplasty techniques are applied. Excisional approach is performed in heavy upper lids and to the nasal fat pad whenever a nasal bulge is present. Partial excision of the retro-orbicularis oculi fat (ROOF) compartment is performed when the bulk of the ROOF is pushing down on the lid laterally. Fat shifting can be performed when indicated and is most commonly performed of the nasal fat pad, which is transposed into an A-frame deformity. In the type 3 patient who presents with hollowed upper lid, micro fat grafting is used to build the upper lid fold curvature.
Preoperative evaluation and surgical planning
Thorough evaluation of the three arcs should be performed in every patient presenting for upper lid rejuvenation regardless of the age, gender, or complaint. There are two main questions that a surgeon should ask when evaluating the patient: what type of an upper lid do they have? Do they need a single-arc, double-arc, or triple-arc surgery? An isolated upper blepharoplasty is a single-arc surgery, and when combined with either ptosis repair or brow lift, then it is a double-arc surgery, and when the three are performed together, then the procedure is a triple-arc surgery. Following the Arcs concept assures establishing the ideal aesthetic proportions and therefore achieving better outcomes and more satisfactory results. Taking professional standardized photographs while the patient’s face is relaxed is critical for evaluating the upper periorbital area, because the patient can mask brow and upper lid ptosis very easily through brow elevation. Photographs also unmask upper lid asymmetries. Pre- and postphenylephrine photographs must be taken for two reasons: the patient has to see the effect on a photograph to appreciate the change and to be in agreement with the surgical plan and they must be used during surgery to guide the amount of Muller muscle excision (see Fig. 5 ).
If the patient has a suboptimal upper lid tension, a decision should be made on whether it can be improved with a Mullerectomy, which is the author’s preferred method of tensioning the upper lid. It works on mild to moderate upper lid ptosis with good levator function, , although the author has used it successfully many times in cases of severe blepharoptosis with good levator function. It is important to understand that although full correction of the upper lid tension is desirable, it is unnecessary. The goal is aesthetic, to improve the shape of the arc and reduce the pretarsal show, as the patient rarely complains of a droopy upper lid. However, in many circumstances, the patient does not know what is causing the upper lid heaviness, and given its multifactorial cause, an improvement in the upper lid tension will improve the visual field and will help alleviate the feeling of heaviness.
Surgical technique
Creating a dynamic crease is one of the goals of upper lid rejuvenation, particularly in type 3 patients who do not have a well-defined crease. Even in patients with hollowed upper lids, once the upper lid tension and fold volume have improved, the excess skin between the pretarsal space and upper lid fold presents itself, and it has to be removed to create a well-defined crease (second arc). The crease must be marked in its existing location if it falls within 10 mm from the lid margin at the mid-pupillary line. If the existing crease is located above 10 mm in the presence of ptosis, then tarso levator dehiscence should be suspected and the crease position adjusted accordingly. The existing crease is revealed by gently opening the lid with one’s index finger if the patient is asleep or asking the patient to partially open their eye if they are awake. The entire width of the crease is marked carefully, making sure to draw a gentle smooth curve with no acute angles ( Fig. 6 ). The medial and lateral tapering of the crease must be adjusted carefully. The medial end of the crease should not extend beyond the upper lid punctum and should not get close to the nasal side wall. The lateral end should be adjusted if a brow lift is being done at the same time. After the crease is drawn, the brow is lifted, and the lateral taper is adjusted and often lowered further to minimize overriding of the scar. The excess skin is assessed using a pinch test while visualizing the upper lid fold left behind. The amount to be excised is determined by pinching the skin while observing the effect on the lid margin. One of the rules the author still uses to date is leaving behind at least 10 mm of the upper lid fold skin at the level of the lateral canthus and at the level of the medial edge of the brow. It is critical to understand that although pinch and measurements are important for safety, the ultimate aesthetic result depends on the shape and smoothness of the arcs. Both the crease and upper curve drawings should be parallel, and the end closure should have no acute inflection points no matter how minimal they are as this will affect the shape of the crease (see Fig. 6 ).
