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Introduction

This article reviews the indications, preoperative evaluation, surgical management and postoperative care for upper eyelid blepharoplasty patients.

Indications for upper eyelid blepharoplasty

Indications for upper eyelid blepharoplasty include redundant and lax eyelid skin (dermatochalasis) and preaponeurotic fat herniation (steatoblepharon) that result in either functional visual symptoms or cosmetic concerns in affected patients. Dermatitis of the redundant skin can also be an indication for surgery.

Contributing factors to upper eyelid dermatochalasis and preaponeurotic fat prolapse

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 levator aponeurosis causing associated involutional ptosis may be co-existing but is non-contributory to dermatochalasis
Genetic variants
High body mass index
Current 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 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.

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.

Management

Surgical steps

Marking of the upper eyelid creases: In Caucasians, measurements should be 7-9 mm in men and 8-10 mm in women.
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 with 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, laser, or needletip cautery unit.
Skin with or without orbicularis muscle is excised
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 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

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

References

Chen, W. (2016). Asian blepharoplasty and the eyelid crease (Third edition.). Edinburgh, Scotland ;: Elsevier.
Massry, M., Murphy, M., & Azizzadeh, M. (2011). Master Techniques in Blepharoplasty and Periorbital Rejuvenation. New York, NY: Springer New York. https://doi.org/10.1007/978-1-4614-0067-7
Dutton, J., & Waldrop, T. (2013). Atlas of oculoplastic and orbital surgery . Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. Chapter 9
Nerad, J. (2009) Techniques in Ophthalmic Plastic Surgery. Saunders. Chapter 6

Upper Eyelid Blepharoplasty

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