The Clinical Problem ( Fig. 6.1 )
Introduction
The primary physical function of the upper eyelids is protection of the eyes but, together with the eyebrows and forehead, they form an expressive aesthetic unit, with significant social function.
Anatomy and Aging
Ideally, the upper eyelid resting position is 1 to 2 mm below the superior border of the corneal limbus and has 12 to 15 mm of lid excursion. Insertion of the levator aponeurosis forms the upper eyelid crease, which in whites usually ranges 8 to 12 mm above the margin (men at the lower end, women at the higher end). The fusion of the levator aponeurosis, orbicularis oculi fascia, and orbital septum forms a pretarsal condensation of fascia that divides the eyelid into tarsal and orbital portions ( Fig. 6.2 ). The aponeurosis takes a higher course medially and is at risk of injury when exposing the medial fat pad during open blepharoplasty.
Traditionally, there are two periorbital fat pads in the upper lid, medial and lateral, although some have reported a third distinct central pad. The medial fat pad is pale yellow and histologically different from the other periorbital fat, with more nerves and vessels within it.
With aging, the soft fullness of youth disappears (see Fig. 6.1 ). Excess eyelid skin and forehead lines develop, the temples hollow with fat atrophy, and the horizontal palpebral aperture narrows. Dehiscence of the levator aponeurosis can lead to involutional ptosis and, paradoxically, the medial fat pad volume appears to increase (or at least become more visible). Lambros believes that this is the legacy of deflation rather than gravitational descent.
Surgical Preparation and Technique
Assessment
In older adults with brow ptosis, it may be enough simply to carry out a reductive skin blepharoplasty to address the worst of the dermatochalasis while accepting a degree of uncorrected brow ptosis. Occasionally, a direct, so-called suprabrow skin excision in a man with severe hooding may be indicated, but the scarring from this surgery limits its usefulness. In more demanding or cosmetically motivated patients, the treatment plan should look beyond simple blepharoplasty to consider the role of brow-lifting procedures, volume augmentation, neurotoxin modulators, and skin resurfacing.
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The brow and upper eyelids are interrelated and form an aesthetic unit. Both must be assessed when planning periorbital rejuvenation.
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The preoperative evaluation includes assessment of skin quality and rhytids, muscle tone, fat pad herniation, lid and brow position, and symmetry.
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Examine for signs of upper eyelid ptosis, including position of the eyelid margin, a high supratarsal crease, and compensatory brow elevation. In unilateral ptosis, Hering’s law of equal innervation may be manifest as a contralateral eyelid elevation.
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Manually elevating the brow while the patient looks into a mirror will demonstrate the contribution of brow position to apparent lid excess. This maneuver is invaluable for educating the patient about his or her condition and explaining the limits of upper eyelid surgery alone.
Preparation and Markings
A full medical and ophthalmologic history is taken, including previous eye trauma or surgery, glaucoma, visual acuity, autoimmune and connective tissue diseases, dry eye symptoms, any bleeding disorders, and anticoagulant medications. Preoperative photography should include a frowning view as well as eyebrows raised and at rest.
Preoperative markings are done with the patient awake and sitting upright, and with the eyes level with the surgeon. Asymmetries and existing crease position are noted ( Fig. 6.3 ).
Mark the new crease line, measuring with calipers 6 to 7 mm above the lash margin (5–6 mm in males) and following the contour of the existing crease to the medial and lateral canthi.
Use forceps to pinch the skin, assess the excess, and plan the upper incision, first at the midpupillary line and then at several further points with the brow held up, when necessary, for exposure. One should create only a gentle upturn of the lashes with a pinch; the lateral part is more forgiving. Preserve 15 to 20 mm of skin between the upper marking and the lower eyebrow, and be careful of being misled by plucked eyebrows.
The eccentric ellipse that is drawn will usually extend laterally to taper upward into an existing rhytid. In younger patients, one does not need to extend beyond the lateral canthus.
Try to avoid extending the incisions beyond the lateral orbital rim. Do not transgress the medial canthus onto nasal skin because this area will tend to form webbed or prominent scars.
Medially, a small (2–3 mm) triangle or vertical wedge at right angles to the lower incision will eliminate the remaining wrinkled excess beyond the main excision pattern and will leave no perceptible extra scarring.
Surgical Technique
Local anesthesia with 2% lidocaine with adrenaline (1 : 80,000) can be supplemented with IV sedation in the anxious patient. The local anesthetic is injected superficially with a small bolus more deeply at the medial fat pad. A skin prep containing chlorhexidine should be avoided.
The skin is incised under retraction, preserving the underlying orbicularis fibers. At the lateral limit, the muscle is thicker, and some fibers are trimmed to assist with a smoother contour on skin closure ( Fig. 6.4 ).
The role of muscle excision in upper blepharoplasty has been debated, but a small strip of muscle may be excised from the upper border of the tarsal plate, just above the lower incision. This can help further define the tarsal crease. In most cases, the orbicularis oculi muscle is otherwise preserved, unless it is hypertrophic and bulky.
Medially, the septum is incised, and the medial fat pad is revealed. This may be gently teased out. Use cautery to ensure absolute hemostasis before allowing any remaining fat to retract. The fat of the central and lateral fat pads is generally preserved for volume unless there is an obvious surfeit ( Fig. 6.5 ).
