Upper Eyelid Blepharoplasty

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Article initiated by:

Manoj Thakker M.D

All contributors:

Paul O. Phelps, MD, FACS, Manoj Thakker M.D, Alex Kozak, Anna Kupcha, Michael T Yen, MD, Marcus M. Marcet, MD, Louise A. Mawn, MD, FACS, Rona Z Silkiss, MD FACS, Cat Nguyen Burkat, MD FACS, Shannon S. Joseph, M.D.

Assigned editor:

Shannon S. Joseph, M.D.

Review:

Assigned status Up to Date

 by Shannon S. Joseph, M.D. on December 2, 2024.

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Contributing Editors:	add

Introduction

Before and after upper blepharoplasty. Images courtesy of Dr. Paul O. Phelps, MD.

This article describes the indications, preoperative evaluation, surgical management, and postoperative care for upper eyelid blepharoplasty patients. Other considerations such as complications will also be described.

Indications for upper eyelid blepharoplasty

Indications for upper eyelid blepharoplasty include redundant and lax eyelid skin (dermatochalasis), preaponeurotic fat herniation (steatoblepharon), or simply excess upper eyelid tissues that result in either functional visual symptoms or cosmetic concerns in affected patients. Dermatitis of the redundant skin may also be an indication for surgery. Patient's who wish to undergo blepharoplasty should consult an expert in this type of surgery, such as an experienced oculofacial plastic surgeon

Factors which contribute to upper eyelid dermatochalasis and preaponeurotic fat prolapse

• Genetics
• Actinic changes to skin due to sun exposure that result in loss of collagen, elastin, and ground substance
• Weakening of the orbital septum resulting in herniation of fat
• Weakening of the levator aponeurosis causing associated involutional ptosis may be co-existing but is non-contributory to dermatochalasis
• High body mass index
• Smoking

Risk Factors

• Aging
• Inflammatory diseases affecting the eyelids (i.e. Thyroid orbitopathy, blepharochalasis syndrome)
• Chronic lid swelling/edema associated with systemic disease or allergy
• Family history
• Male sex

Anatomy of the upper eyelid

A thorough understanding of the upper eyelid anatomy is essential when evaluating patients for possible upper blepharoplasty. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the levator aponeurosis. The point of attachment of the orbital septum to the levator aponeurosis varies in different ethnic populations, with Caucasians having a higher insertion than Asians. The level of the attachment of the septum to the aponeurosis influences the descent of the pre-aponeurotic fat and the fullness of the upper eyelid. Anterior fibers of the levator aponeurosis attach to the skin and create the position of the upper eyelid crease which also varies among ethnicities. Immediately posterior to the orbital septum resides 2 pre-aponeurotic fat pads (nasal and central) as well as the lacrimal gland laterally. The levator aponeurosis is posterior to the preaponeurotic fat and measures approximately 10-15mm in length. Deep to the levator aponeurosis lies Muller's muscle, which is a sympathetically innervated elevator of the upper eyelid. The tarsus, composed of dense connective tissue, is located posterior to the orbicularis at the eyelid margin and measures approximately 25 mm x 10mm. The rigidity of the tarsus is important in maintaining the structural stability and proper orientation of the eyelid margin and eyelashes. The conjunctiva lines the posterior aspect of the eyelid.

Diagnosis

History

Patients often report drooping, sagging, tired appearing eyelids that interfere with various activities of daily living. In severe cases, patients may have to manually lift the skin upward to improve their visual field. A complete medical and ophthalmic history should be obtained that includes:

• Impact of upper eyelid changes on activities of daily living
• Previous ocular conditions and surgeries
• Systemic disease which will influence the outcome of the surgery such as rheumatologic conditions, collagen vascular diseases, rosacea, and diabetes
• Prior cosmetic procedures
• Dry eye symptoms and treatments
• Complete list of medications including blood thinners and herbal supplements
• Tobacco and alcohol use
• Psychiatric history.

Patients who are interested in surgery for cosmetic purposes should be asked about their motivation for the surgery and their expectations of the surgical results prior to considering if they are appropriate candidates. Most health insurance companies and the Centers for Medicare Services do not cover blepharoplasty when the motivation for surgery is cosmetic in nature.

Physical examination

Eyelid examination

• Quality, quantity and relative symmetry of redundant skin
• Eyelid crease height and symmetry
• Grading of medial and central preaponeurotic fat pad herniation
• Evaluation for lacrimal gland prolapse
• Evaluation for presence of concurrent ptosis (palpebral fissure width, margin reflex distances, levator function, eyelid crease height)
• Assessment of brow position (patients with significant brow ptosis may need concurrent brow lifting as brow position can exacerbate upper eyelid changes)
• Lagophthalmos on attempted eyelid closure
• Presence of intact Bell's phenomenon
• Evaluation of lower lid laxity/eyelid malposition
• Evaluation of eyelash position
• Orbicularis strength
• Corneal sensation or other assessment of the quality of the corneal tear film
• Orbital symmetry

Ocular vital signs Visual acuity, pupillary examination, extraocular motility, intraocular pressure

Anterior segment examination Including evaluation of corneal surface and basal tear secretion testing

Fundus examination

Diagnostic procedures

Automated or manual (Goldmann visual field, tangent screen) visual field testing with the eyelids untaped and taped can be used to quantify the degrees of visual field obstruction present in patients with severe dermatochalasis and preaponeurotic fat herniation. External photos are also taken to document the eyelid position before surgery to identify pre-existing issues. Photos in the acute postoperative phase and after complete healing is accomplish can help the surgeon and patient monitor progress.

Management

Surgical steps

Surgeons may vary in exact steps that they pursue to achieve successful upper blepharoplasty. Detailed anatomic and illustrative descriptions may be found in several excellent textbooks and online videos. In general the steps of upper blepharoplasty are as follows:

• Marking of the upper eyelid creases: In Caucasians, measurements may be approximately 7-9 mm above the lash line in men and 8-10 mm in women. An in-depth discussion about patient goals prior to surgery are paramount to achieving patient goals with surgery.
• Marking of an elliptical area of skin to be excised: Using a smooth forceps, redundant skin is grasped superior to the previously marked eyelid crease and the superior limit of the skin to be excised is marked nasally, centrally and temporally, taking care not to open the eyelids. A curved line connecting the marks is made with a surgical marking pen. Care is taken to leave at least 20 mm of skin between the eyelid margin and the thicker brow skin. Both eyelids are measured with calipers to ensure that a symmetric amount of eyelid skin remains prior to injection of anesthetic.
• Injection of local anesthetic: Local anesthetic, typically 1% lidocaine with 1:100,000 epinephrine is injected subcutaneously in the area of skin to be excised.
• The patient is prepped and draped: Care should be taken to avoid tension and distortion of the tissues with the drapes.
• An incision is made along the previously outlined markings: This can be performed with a standard Bard Parker #15 blade, CO2 laser, or needle tip cautery unit.
• Skin with or without orbicularis muscle is excised: Generally orbicularis oculi muscle is left intact to reduce the risk of dry eye disease.
• Dissection may be performed through the orbital septum to address the preaponeurotic fat pads
• Excess preaponeurotic fat is conservatively sculpted and/or excised if warranted
• Meticulous hemostasis is achieved
• If necessary, the levator aponeurosis can be advanced to address co-existing ptosis
• Incisions are sutured: Eyelid crease reformation can be performed if desired

Postoperative Regimen

Patients should follow the instructions of the surgeon who will perform their surgery. Generally, patients are instructed to:

• Use ice compresses frequently for the first 3 days after surgery and warm compresses afterward

• Ophthalmic antibiotic ointment is prescribed for the incision sites 3-4 times/day
• Topical lubrication with artificial tears and/or night time gel or ointment as needed

• Avoid lifting, bending, straining, exercise during the first 10 days after surgery

• Call if experiencing loss of vision, double vision, bleeding, severe swelling or pain

• Follow up within 1-2 weeks of surgery for a postoperative evaluation

Complications

A detailed discussion about the risks, benefits, and alternatives of upper blepharoplasty surgery will occur between the patient and their surgeon prior to surgery and informed consent should be on file prior to surgical intervention. Possible complications that will be discussed include risks of bleeding, infection, poor healing, need for additional surgical interventions, and the rare risk of vision loss. Other possible complications include:

• Scarring at incision site

• Asymmetry

• Overcorrection

• Undercorrection

• Medial canthal webbing

• Lagophthalmos

• Ocular surface exposure/dry eye

• Retrobulbar hematoma/loss of vision
• Infection
• Bleeding

• Perforation of globe

• Ptosis

• Numbness of eyelid and/or eyelashes
• Skin discoloration

• Patient dissatisfaction with outcome
• Anesthesia risks

Additional Resources

• ASOPRS Information for Patients on Blepharoplasty