Upper Eyelid Blepharoplasty

From EyeWiki


Introduction

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

Indications for upper 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

Risk Factors

  • Sun exposure
  • Aging
  • Smoking
  • Inflammatory diseases affecting the eyelids (i.e. Thyroid orbitopathy, blepharochalasis syndrome)
  • Family history

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. Immediately posterior to the orbital septum resides 2 preponeurotic 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.[1]

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 ophthlamic history should be obtained that includes:

  • Previous ocular conditions and surgeries
  • Prior cosmetic procedures
  • Dry eye symptoms and treatments
  • Complete list of medications including blood thinners and herbal supplements
  • 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 preponeurotic 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)
  • Measurement of brow position as patients with significant brow ptosis should be considered for a concurrent brow lifting procedure at the time of blepharoplasty
  • Lagophthalmos on attempted eyelid closure
  • Presence of intact Bell's phenomenon
  • Evaluation of lower lid laxity/eyelid or eyelash malposition
  • Orbicularis strength
  • 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 untaped can be used to quantify the degrees of visual field obstruction present in patients with severe dermatochalasis and preaponeurotic fat herniation.


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 20mm 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 is performed through the orbital septum to the preaponeurotic fat pads
  • Excess preaponeurotic fat is conservatively sculped and/or excised
  • Meticulous hemostasis is achieved
  • If necessary, the levator aponeurosis can be advanced to address preexisting 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
  • Antibiotic ointment is prescribed for the incision sites 3-4 times/day
  • 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 week of surgery for a postoperative evaluation

Complications

  • Scarring at incision site
  • Asymmetry
  • Overcorrection
  • Undercorrection
  • Medial canthal webbing
  • Lagophthalmos
  • Ocular surface exposure
  • Retrobulbar hematoma/loss of vision
  • Perforation of globe
  • Ptosis
  • Numbness beneath incision
  • Patient dissatisfaction with outcome


Additional Resources

References

  1. Shorr N, Seiff S. Cosmetic Blepharoplasty: An Illustrated Surgical Guide. Thorofare, New Jersey. Slack, 1986, p. 39-51.