Upper lid blepharoplasty is a procedure associated with a high level of patient and surgeon satisfaction. New insights into the anatomic underpinnings of the periorbital aging process have enabled more successful and reproducible surgical results. The authors provide a detailed discussion of the relevant anatomy and integrate this into their surgical philosophy for upper lid blepharoplasty. Special focus is given to presurgical planning.
Key points
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Upper lid aging is characterized by changes in the curvature of the upper lid and the position of the lateral canthus. Periorbital volume loss and skin elasticity changes result in the characteristic dermatochalsis and smaller visible palpebral aperture associated with the aging upper lid.
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Accurate preoperative assessment of the anatomic problem is critical.
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Precise incision marking will in large part determine a successful upper lid blepharoplasty.
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Fat-sparing techniques are most commonly used to avoid a hollow upper lid and excessive pretarsal show.
Introduction
Upper lid blepharoplasty was first described by the Hindu surgeon Susruta in approximately the second century ad , in the Susruta Samhita . Eyelid surgery was largely forgotten for centuries but experienced a revival in the eighteenth and nineteenth centuries via the work of Beer and Von Graafe. Slowly there evolved a more detailed understanding of upper lid anatomy and the correction of age-related changes. Early approaches focused on the excision of redundant soft tissue. It was not until recently that surgeons gained an appreciation of the esthetic benefits of conservation of periorbital fat. In the past 15 years, many authors have decried the skeletonized and hollow upper lid as the stigmata of overaggressive fat resection during upper lid blepharoplasty.
Introduction
Upper lid blepharoplasty was first described by the Hindu surgeon Susruta in approximately the second century ad , in the Susruta Samhita . Eyelid surgery was largely forgotten for centuries but experienced a revival in the eighteenth and nineteenth centuries via the work of Beer and Von Graafe. Slowly there evolved a more detailed understanding of upper lid anatomy and the correction of age-related changes. Early approaches focused on the excision of redundant soft tissue. It was not until recently that surgeons gained an appreciation of the esthetic benefits of conservation of periorbital fat. In the past 15 years, many authors have decried the skeletonized and hollow upper lid as the stigmata of overaggressive fat resection during upper lid blepharoplasty.
Anatomy and age-related changes in the upper eyelid
Perhaps the most critical component to performing consistently successful upper lid blepharoplasty is accurate facial analysis during the presurgical consultation. As is widely known, the upper lid is analyzed simultaneously with the brow and the entire periorbital region. As such, the eyebrows should be at or above the orbital rim, with the medial brow at a vertical line drawn through the alar-facial sulcus and the medial canthus. The lateral margin terminates at a line drawn from the ala, through the lateral canthus ( Fig. 1 ). The lateral canthus should be 2 mm cephalad to the medial canthus, creating a positive canthal tilt of 3° to 4° in the women and 1° to 2° in the men.
Supratarsal Crease
The essential landmark of upper lid blepharoplasty is the supratarsal crease. The supratarsal crease is commonly 7 to 10 mm from the palpebral margin, usually 8 to 9 mm above the lid margin in women and 7 to 8 mm in men. It is thought that the supratarsal crease is created by the fusion of the levator aponeurosis with the orbital septum and the insertion of the fascia of the orbicularis oculi into the dermis. Recent anatomic studies reveal that the levator aponeurosis has 2 distinct layers. The anterior layer reflects upward and inserts on the orbital septum. The posterior layer inserts onto the tarsal plate and the subcutaneous tissue superficial to the tarsal plate’s lower third.
Age-Related Changes in the Periorbital Area
The tarsal portion of the orbicularis is thought to be particularly susceptible to age-related changes, and the involution of the pretarsal soft tissue causes a concomitant elevation in height in the supratarsal fold and increased skin laxity in this location. As attachments to the thin dermis at the supratarsal crease are lost, the soft tissue herniates inferiorly, creating the characteristic dermatochalasis of the aged upper lid ( Fig. 2 ).
The orbital fat of the upper lid is thought to comprise the medial (nasal) and preaponeurotic (“prelevator”) fat pads. Anteriorly, there is a relative demarcation between the 2, whereas posteriorly the fat pads comingle with little distinguishing features. The preaponeurotic fat traverses the lateral portion of the superior periorbita, curling behind the posterior aspect of the lacrimal gland. There is a clear demarcation between the preaponeurotic and medial fat pads. The medial horn of the levator aponeurosis and the lateral fascia on the superior oblique muscle both serve to separate the central compartment from the medial compartment. The medial compartment is pale yellow or white due to a greater percentage of connective tissue, thereby imbuing this tissue with paler hues. The central/preaponeurotic fat has a higher concentration of carotenoids, which gives this fat a yellow hue, in contrast to the pale medial compartment fat.
General loss of skin elasticity and loss of soft tissue volume combine to increase upper lid skin redundancy. Oh and Colleagues demonstrate a relative increase in the subjective volume of the nasal fat pad during the aging process. The central fat pad, in contrast, seems to diminish in terms of its apparent volume as patients age. This is the driving factor in the skeletonized or hallowed look of the superior periorbital region. The supratarsal crease often migrates cephalad as the eye ages; it is thought that relative volume loss may either cause or exacerbate this cephalad repositioning of the supratarsal crease ( Fig. 3 ).
As summarized by Lambros, the 2 key stigmata of periorbital aging include :
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Upper lid “arc shift” from medial to lateral
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Apparent decrease in size of palpebral fissure
The arc of the upper lid has its peak on the medial aspect of the lid in the youthful face in both men and women (see Fig. 1 ; Fig. 4 ). As patients age, the peak of the upper lid’s arc migrates to a more lateral position. Depending on the method of study, it has been assumed that the periorbital retaining ligaments lose elasticity as patients age, which may contribute to migration of the lateral canthal angle. This is a matter of some debate. A cross-sectional study of 320 patients found little to no migration of the lateral canthal angle with respect to other lid photogrammetric landmarks. Contrary to conventional assumption, the lateral canthal angle did not descend inferiorly with age with respect to the pupil and lid surface reference landmarks. Instead, the lateral canthus was found to be migrating anteriorly with respect to the anterior corneal surface on lateral view. The end sum of this migration is the perception of a smaller palpebral aperture and a smaller surface area of conjunctiva in the aging eye, which seems to be a point of consensus in the literature. It is worth noting that the medial canthal angle, by contrast, is thought to be relatively stable throughout the aging process. Also, the globe itself does not change size as patients age, nor is globe descent a prominent part of the aging process.
Related posts:
Advances in Esthetic Surgery from Four Specialties
Brow and Upper Lid Aesthetics and Rejuvenation: Views from Four Disciplines
Contemporary Concepts in Brow and Eyelid Aging
Technical Considerations in Endoscopic Brow Lift
Adjunctive Fat Grafting to the Upper Lid and Brow
Asian Upper Lid Blepharoplasty Surgery
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