Upper Lid Blepharoplasty

Chapter 35. Upper Lid Blepharoplasty

Jerry W. Chang, MD; Sumner A. Slavin, MD

INDICATIONS

Upper lid blepharoplasty can be performed for patients who seek upper eyelid rejuvenation because of skin excess secondary to dermatochalasis of the upper eyelids. Steatoblepharon or fat protrusion in the upper eyelids caused by weakening of the orbital septum is also another indication. This chapter does not address correction of ptosis.

Blepharochalasis, which is a condition of the eyelids characterized by edema, erythema, and thin/excess skin, is a recurrent, inflammatory condition caused by increased immunoglobulin (Ig) E and subsequent histamine release. This condition is unlikely to be corrected surgically and must be distinguished from the other indications.

PREOPERATIVE PREPARATION

All patients undergoing upper lid blepharoplasty should have a complete history and physical evaluation. Special attention to ophthalmologic conditions should be given; these conditions include prior surgery, trauma, allergic reactions, excess tearing, thyroid disease, and dry eyes, as these may alter the surgical plan. Medications, including aspirin/anticoagulants, should be reviewed carefully; any medications that may affect clotting, including dietary supplements, should be discontinued at least 2 weeks preoperatively.

ANESTHESIA

Upper-lid blepharoplasty can be performed under local, monitored anesthesia care (MAC), or general anesthesia. It is our preference to perform this procedure under MAC or general anesthesia, in conjunction with local infiltration of 1% lidocaine with epinephrine.

POSITION AND MARKINGS

Preoperative markings should be made with the patient sitting upright in neutral gaze. It is important to slightly elevate the eyebrows manually while marking to avoid possible overresection. The eyelid crease (supratarsal fold) incision is marked first, usually just caudal (1 mm) to the existing crease. The supratarsal fold is approximately 8 to 9 mm superior to the ciliary margin in females and 7 to 8 mm in males. Next, the upper incision line is marked based on the amount of excess skin to be resected, which can be confirmed with a pinch test. The upper incision line should be at least 10 mm from the lower edge of the eyebrow as to not include any thick brow skin, which will lead to prominent scarring. The shape of the skin resection is lenticular with slightly fuller dimensions laterally. Ensure markings do not extend past the lateral orbital rim to prevent noticeable scarring laterally. Likewise, the medial markings should not extend past the medial canthus to avoid webbing in the nasal sidewall area (Fig. 35-1).

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