Cosmetic Blepharoplasty

Medical History

Medical history in the cosmetic surgery patient should take special focus on conditions that put the patient at risk for anesthesia complications, delayed healing, infection, or bleeding complications. Although not an exhaustive list, it is important to remember that history of cardiac or pulmonary disease increases the risks associated with anesthesia, autoimmune disease such as scleroderma or rheumatoid arthritis may affect wound healing, coagulopathies increase the risk for bleeding (which include aspirin and fish oil), and immunosuppression from disease or medication use increases the risk for infection. Thyroid disorders, diabetes, and hypertension must be evaluated and controlled. Smoking cessation for 2 weeks before and after surgery should be encouraged to improve wound healing and reduce the risk for infection. Alcohol use should be discontinued for at least 2 days preoperatively and for 1-week postoperatively to reduce the risk for hemorrhage. Chronic heavy alcohol use can cause liver disease and result in coagulopathies.

During the preoperative evaluation, patients should be queried not just about their prescription medications, but also specifically about any over-the-counter medications, PRN medications, or herbs/supplements because many patients do not consider these to be medications. Because uncontrolled bleeding can cause blind­ness, it is important for patients to refrain from using medications that affect platelet function. A list of medications and supplements that affect platelet or clotting function should be reviewed with the patient preoperatively with instructions to discontinue the medications for an appropriate amount of time before surgery. Although the risk for infection after blepharoplasty is generally low because of high vascularity, immunosuppressive medications can increase the risk for infection, and the risks and benefits of proceeding with surgery while on those medications should be considered.

Finally, it is important to ask directly about any prior facial surgery or filler use. Patients may forget to mention previous cosmetic surgery or cancer reconstruction surgery. Failing to identify prior surgery could make the surgery more challenging by introducing unanticipated skin shortage, scar tissue, foreign material, or abnormal anatomy.

Ophthalmic History

The eyelids serve the very important purpose of protecting the eyes. It is one of the most complex and sensitive organs in the body. Eyelid surgery can lead to life-changing consequences, ranging from chronic dry eye to blindness. Surgeons performing cosmetic eyelid surgery should perform a basic ophthalmic history and examination to assess each patient’s individual risk for ocular complications. If there is ever a concern for factors that could negatively affect the procedure, an ophthalmology consult is in order. A novice blepharoplasty surgeon should obtain a routine ophthalmology consult on their initial series of patients. This helps rule out pathology, teaches the new surgeon what is normal and what is not, and protects the surgeon to some extent medicolegally.

Ocular surface disease must be considered preoperatively as patients with these conditions have less “reserve” and are more likely to experience some worsening of symptoms after all but the most conservative blepharoplasty. It is imperative to ask about dry eye symptoms including burning, irritation, and foreign body sensation. Patients with ocular allergy may experience seasonal itching, irritation, grittiness, and redness. Asking about the use of over-the-counter eye drops including artificial tears or anti-allergy drops will help identify patients that are particularly bothered by their symptoms preoperatively. On a similar note, patients with a history of LASIK refractive surgery are at higher risk for dry eye symptoms postoperatively and should be counseled as such. Patients with severe dry eye symptoms are poor candidates for cosmetic blepharoplasty. If you ever doubted the impact that dry eye can have on quality of life, see how your eyes burn, sting, water, and blur when you hold them open without blinking. This is not a condition that you want to worsen by performing inappropriate or overaggressive blepharoplasty surgery.

Prior glaucoma surgery can change the surface architecture of the superior globe. When the patient is looking downward as you hold up their upper lid, a surgical drain (tube shunt) or filtering bleb may be visible. Additional care should be taken to avoid injury to these structures during surgery or when manipulating internal eye shields. Conjunctival scarring diseases such as ocular cicatricial pemphigoid are rare but can worsen if the conjunctiva is traumatized by surgery. Any unusual appearance to the conjunctiva should trigger a referral to an ophthalmologist. Although exceptional attention to safety is important for every case, patients who are monocular (useful vision in one eye only) should be treated with additional caution.

Ophthalmic Examination

Baseline visual acuity should be checked and recorded before surgery. It is not unusual for vision to be slightly blurry for the first few days or weeks after blepharoplasty surgery. The ophthalmic ointments melt into the tear film and temporarily blur the vision. Dryness in the early postoperative period from mild lagophthalmos, infrequent blink, or incomplete blink can cause blurring and is typically improved with artificial tear drops. This should improve as swelling resolves and healing brings return of normal orbicularis function. Even mild swelling in the eyelids can push on the globe and cause subtle vision changes. To experience this for yourself, look across the room with one eye and then gently touch the top of your eyelid and note how your vision changes. Snellen chart examination is the standard for visual acuity testing, but a near-vision card with reading glasses if necessary can also be used if a Snellen chart is not available. Recording preoperative visual acuity will provide a point of comparison for vision concerns during the healing process and ensure that the patient cannot blame their long-standing poor vision on your surgery!

In addition to assessing visual acuity, there are several other tests that assist the surgeon in assessing the risk associated with cosmetic blepharoplasty for a specific patient. A pupillary examination to assess for symmetry and reactivity can be performed with a simple pen light. Extraocular motility can be assessed by having the patient follow your finger as you draw an H in the air. Although it is normal to have mild discomfort at far end gaze, any pain or double vision while performing this test should trigger a referral to an ophthalmologist for further evaluation.

Bell’s phenomenon is the reflexive protective upward rotation of the eye when the eyelids are closed ( Fig. 5.17 ). This can be assessed by asking the patient to gently close their eyes as if they are sleeping while the surgeon gently pries open the upper eyelids. With a normal Bell’s phenomenon, the eyeball should roll back and protect the cornea. The examiner should see only the white sclera (see Fig. 5.17 ). A patient with an abnormal Bell’s phenomenon has their corneal surface exposed and visible with their eyes closed and when pried open (see Fig. 5.17 ). A patient without a protective Bell’s phenomenon could have catastrophic corneal damage from corneal exposure and dryness if lagophthalmos (inability to close the lids) should occur post-blepharoplasty.

Dryness can be checked in the office by staining the cornea with fluorescein dye. The simplest way to do this is to wet the tip of a fluorescein strip with a drop of saline. The examiner gently pulls the lower eyelid away from the eye and touches the edge of the fluorescein strip to the inner rim of the eyelid margin. When the patient blinks, the fluorescein dye will be dispersed in the tear film. When a cobalt blue light is shone on the eye, the dye will appear fluorescent yellow green. Any dry areas on the cornea will pick up the dye as bright pinpoints of green, usually on the inferior third of the cornea. A corneal abrasion will light up as a patch of bright green on the cornea. If the patient is in pain from a suspected corneal abrasion postoperatively, instilling a drop of topical anesthetic (proparacaine, tetracaine, or even lidocaine local anesthetic) will dramatically improve the patient’s pain and thus improve the quality of your examination. The anesthetic will sting on instillation but typically provides relief for approximately 15 minutes. Never give topical anesthetic to a patient for home use as it is toxic to the cornea when used repetitively and can cause ulcer or perforation. More discussion of corneal abrasion will be addressed in the “Blepharoplasty Complications” section later in this chapter.

Periocular Facial Examination

When performing a physical examination for cosmetic surgery, a systematic approach is recommended from top to bottom, to guide the surgeon and manage patient expectations. This can be performed with a mirror but is best performed with detailed standardized facial photography or even video to demonstrate dynamic changes that are not seen in static images. In addition to discussing areas of concern, it is also important to discuss facial asymmetries. Over time, the brain acclimates to one’s own asymmetries. Although we may feel that we look symmetric when we see our reflection in the mirror, many people find that they look less symmetric in a selfie photograph as the image is reversed. Composite images of split-faced photography will also demonstrate just how asymmetric we are. Although no human being is perfectly symmetrical, most patients come into the office unaware of their asymmetries. It is the surgeon’s job to discuss and document these asymmetries with the patient because if they do not see these asymmetries preoperatively, they are certain to see them postoperatively, which is a far more difficult conversation to deal with.

Here we will review the periocular anatomic features and clinical findings for consideration during a blepharoplasty consult.

Orbit

Although not a discrete facial feature, the orbital bones provide the foundation to our soft tissues, and orbital bone size, shape, and symmetry greatly affect appearance. Some patients have large orbits in which the pupil is more distant from the superior orbital rim and eyebrow, and other patients have small, tight orbits in which the globes sit crowded near the rim and brow. As we age, the floor of the orbit gradually moves inferolaterally away from the globe as the midface rotates posteriorly.

The orbital bones are rarely perfectly symmetrical. When examining the face as a whole, usually one pupil sits slightly higher than the other ( Fig. 5.18 ). This can be noted as orbital dystopia or globe dystopia and is estimated in millimeters. This is important to note because the orbit with a lower globe often has a more hollow superior sulcus that is important to mention to the patient and to document.

Eyebrow Position

The eyebrows provide aesthetic framing for the eyes and are a focal point of facial expression. The female brow sits at or above the superior orbital rim and has a gentle arch temporally. The male brow is flatter in shape and sits lower, either on or below the superior orbital rim.

Eyebrows can demonstrate either medial ptosis, lateral ptosis, or both. Medial brow ptosis results in an angry appearance. Lateral brow ptosis can result in a sad or concerned appearance. Browlifting can be performed to restore not only a more youthful appearance, but a happier appearance as well. Care should be taken to avoid overlifting the brow, which can result in a surprised look. Excessive temporal browlifting in male patients should be avoided as it can be feminizing.

Patients with brow ptosis at rest often show an elevated brow position from frontalis contraction when animated in conversation, which can mask the brow ptosis. It is important to assess brow position both at rest and during animation.

Any asymmetry of the brow is critical to discuss. Almost all patients demonstrate some degree of brow asymmetry (see Fig. 5.18 ). This sometimes results from greater strength of the seventh cranial nerve on one side of the face in comparison with the other. Patients who exhibit a broader or more accentuated smile on one side often show more wrinkles and a lower brow on that side. Another cause of brow asymmetry is levator ptosis. Patients with unilateral ptosis of the eyelid will often demonstrate a compensatory brow hike on that side. In these cases, it is best to address the levator ptosis before undertaking a browlifting procedure as correcting the levator ptosis often changes the brow position. In cases of mild asymmetry in which browlifting is not desired, it is important to remember that the lower brow can weigh down the upper eyelid, making the eyelids appear asymmetric, even after blepharoplasty surgery. In these cases, slightly more skin removal or a higher crease can be placed on the side with brow ptosis to give the appearance of a symmetric eyelid platform.

If a patient is a browlift candidate and the surgeon does not perform the procedure, the patient should be informed and given the opportunity of a referral to a surgeon who does perform browlifts. I have seen numerous patients who were not informed of their candidacy for browlift surgery because their surgeon did not perform this procedure. These patients, instead, received numerous blepharoplasties over several decades. When these patients desired a browlift, it was impossible because lifting the brow would produce lagophthalmos because of the previous multiple skin-removal procedures. Ethics trump everything else in surgery, and if a patient is a candidate for a procedure, whether or not the surgeon performs it, they should be notified and appropriately offered a referral.

Upper Eyelid

The amount of dermatochalasis, the presence of ptosis, eyelid crease height and symmetry, fat prolapse versus hollowing, lacrimal gland prolapse, and lash ptosis all must be considered when performing cosmetic blepharoplasty.

Upper-lid dermatochalasis, or extra skin, typically begins laterally as the lateral brow begins to drop with age. Care should be taken to differentiate extra eyelid skin from ptosis of the brow. Prolapse of the nasal fat pad is evident in most patients, and its removal is generally aesthetically favorable. The nasal fat pad is in close approximation to the trochlear arteries that can lead to significant orbital hemorrhage if not managed properly. The preaponeurotic fat serves as a glide plane for the levator muscle and can either show atrophy, or in some patients, show hypertrophy. In cases of atrophy, a hollow superior sulcus (called an A-frame deformity ) is often noted. The nasal fat pad can be transplanted into the preaponeurotic space to correct this hollowing and restore youthful fullness to the lid. In cases of hypertrophy, the central fat pad can be conservatively reduced. It is important to avoid overresection in this area as it can create an undesirable surgical look or an A-frame deformity, discussed later in this chapter. Functionally, overresection of preaponeurotic fat, especially when aggressive cautery is used, can result in middle lamellar scarring and lagophthalmos.

Prolapse of tissue in the lateral eyelid is either a result of lacrimal gland prolapse, brow fat pad hypertrophy or descent, or orbicularis muscle redundancy. Prolapsed lacrimal glands can be tucked back inside the orbit during blepharoplasty, but tenderness in the area of the lacrimal gland can signal pathology and should be evaluated by an ophthalmologist. Occasionally, a patient may have a large brow fat pad that when reduced, enhances aesthetics.

Marginal reflex distance (MRD) is an important measurement in the blepharoplasty examination. The upper marginal reflex distance (MRD 1) is the distance in millimeters from the upper-lid margin to the pupillary light reflex (center of the pupil) ( Fig. 5.19 ). A normal eyelid sits about 2 mm beneath the superior limbus of the cornea, which corresponds to the normal MRD 1 being about 3–4 mm. If the MRD 1 is <4 mm or asymmetrical, the patient must be made aware that a ptosis repair may be indicated. If the cosmetic surgeon does not perform functional surgery, the patient should be given the option of a referral for ptosis surgery evaluation. Many patients do not care about the small amount of ptosis they have had for years and simply desire cosmetic treatment, but they should always be given the option of correction. It is also worth noting that ptosis can be a sign of neurologic disease. Any patient presenting with ptosis, pupillary asymmetry, or double vision should receive an urgent ophthalmology consult.

The eyelid crease is typically 10–12 mm in women and 8–10 mm in men but tends to increase slightly with age and the presence of involutional, or age-related, ptosis. When the eyelid crease is asymmetric, the surgeon should examine carefully for the presence of mild ptosis on the side with the higher lid crease. In the absence of ptosis, asymmetric creases should generally be set to a more symmetric position in surgery. Placing the lid crease in a slightly lower position will make the eyelid appear fuller, while raising the crease will increase tarsal platform show (TPS).

The angle of the lash as it emerges from the anterior lamella of the eyelid margin and the degree of bend as the lashes curve upward is greater in Caucasian patients compared with Asian patients. Lash ptosis occurs when the lashes project straight outward or downward. Lash ptosis can be associated with obstructive sleep apnea, floppy eyelid syndrome, and ptosis.

From an aesthetic standpoint, an upward tilt of the eyelashes is considered aesthetically pleasing and can be improved during blepharoplasty by placing incisional CO ₂ laser ablation spots 2–3 mm above the lash follicles to contract the anterior lamella.

Lagophthalmos and Impaired Blink

Lagophthalmos is the inability to completely close the eyelids. It is traditionally measured as the number of millimeters of eye exposure that is seen when the patient tries to gently close the eyes in the upright position. It is uncommon for a patient without any previous surgery or pathology (such as lower-lid ectropion or facial palsy) to exhibit lagophthalmos in the upright position because gravity pushes the eyebrows downward and helps close the eyelids. However, lagophthalmos in the reclined position or during sleep (nocturnal lagophthalmos) is much more common. Although some patients have symptoms from nocturnal lagophthalmos including irritation or dryness in the morning, many do not thanks to the Bell’s phenomenon mentioned earlier. During the examination, it is worth taking a moment to recline the patient in the chair to assess for lagophthalmos in the reclined position as well. It is also helpful to inquire if the patient has been told they sleep with their eyes open. Findings should be documented and discussed with the patient. Those who demonstrate lagophthalmos in any position are at risk for worsened lagophthalmos from blepharoplasty and should be counseled about the risk for worsening dry eye or corneal damage. Patients with lagophthalmos in the upright position should have an ophthalmic examination to elucidate and potentially treat the etiology of their poor eyelid closure. Although some patients may have mild lagophthalmos in the immediate postoperative period, lagophthalmos after blepharoplasty is an undesirable result and one that may cause a range of sequelae from discomfort to corneal ulcer, perforation, and blindness.

During the consultation, the surgeon observes the patient’s blink rate and blink integrity. The normal blink rate is approximately 12 blinks per minute. Blink rate does not need to be formally measured, but if simply matching your blink rate to your patient’s makes your eyes burn and sting, it is likely they have a decreased blink rate. Although it is normal for patients to exhibit some incomplete blinks, a healthy blink allows the cornea to be fully rewetted with each blink. Older adult patients and those with movement disorders such as Parkinson’s disease often exhibit decreased and incomplete blinking. This finding puts patients at increased risk for dry eye complications post-blepharoplasty.

Lower Eyelid

Assessment of lower-lid aesthetics includes evaluation of fat prolapse, infraorbital hollowing, skin laxity, skin quality, eyelid tone, appropriate positioning, midface volume, and festoons.

The soft tissue of the aesthetically pleasing lower-lid contours smoothly to the cheek. Prolapse of the three lower-lid fat pads is what most patients note when they complain about “eyelid bags” or “puffy eyelids.” This fat will be more prominent in upgaze and less prominent in downgaze. The nasal and central fat pad appear as a contiguous bulge under the skin. There is often a visible distinction between the central and lateral fat pads created by the arcuate expansion. The far-lateral component of the lateral fat pad is the area that is most commonly undertreated, and patients with prior lower-lid blepharoplasty may complain of fat prominence after their surgery.

The area of hollowing commonly referred to as the tear trough is created by the orbitomalar ligament, which connects the inferior orbital rim to the overlying skin and orbicularis. Although this is normal anatomy present even in smooth and youthful eyelids, a number of factors make this area more pronounced with age including loss of subcutaneous fat, fat prolapse above the orbitomalar ligament, and laxity of the overlying skin. In mild cases, the depression in this region can be treated with filler. The hollow appearance of this area improves when the prolapsing fat from above is removed in traditional subtractive blepharoplasty surgery. In patients who have a very pronounced depression in this area, additional improvement can be seen with orbitomalar ligament release and fat repositioning, although this additional manipulation of tissue does slightly increase the rate of complications and prolong healing compared with traditional subtractive blepharoplasty.

The aesthetic lower-lid margin sits just at or above the lower limbus. The MRD 2 is the measurement from the pupil center to the lower lid in neutral gaze and is approximately 6 mm. Lower-lid retraction is defined as an MRD 2 > 6. The palpebral fissure is the sum of MRD 1 and MRD 2 (see Fig. 5.19 ). Inferior scleral show is noted when the white sclera is visible below the cornea. Although some young patients have a small amount of inferior scleral show as a natural anatomic trait, it is generally more aesthetically pleasing to have the lower eyelid meet the inferior limbus in primary gaze.

Laxity of the lower eyelid should be carefully assessed preoperatively as lower-lid laxity greatly increases the risk for postoperative ectropion or retraction. Lower-lid ectropion is defined as a lower eyelid that rolls or sags away from the eye and exposes the inner surface of the lower eyelid ( Fig. 5.20 and Fig. 5.21 ). Lower-lid retraction is defined as a downward malposition of the eyelid without eyelid eversion.

Lower-lid integrity should be assessed preoperatively with the lower-lid distraction test and snap-back test. In the lower-lid distraction test, the surgeon gently pulls the eyelid away from the globe and measures the distance between the eyelid and the globe ( Fig. 5.22 ). Young patients will often demonstrate tight eyelids, sometimes so much that a transconjunctival blepharoplasty is challenging because of the lack of space during surgery. Lower-lid distraction of 6–7 mm is considered normal, with slightly greater distraction found in older patients and male patients. Patients with frank ectropion often exhibit lower-lid distraction closer to 10 mm. Patients with distraction >8 mm typically benefit from some form of canthal tightening during blepharoplasty.

The lower-lid snap-back test assesses laxity and orbicularis muscle tone in concert. Orbicularis muscle tone can be weakened by age, prior surgery, trauma, or neurologic conditions. A decrease in resting orbicularis tone will make the lower eyelid more susceptible to downward gravitational forces. It is important to remember that surgical trauma from incision or resection of the orbicularis fibers during transcutaneous blepharoplasty can lead to a temporary or permanent weakening of the orbicularis muscle. During the snap-back test, the surgeon uses one finger to pull the lower eyelid downward and away from the globe, releases the eyelid, and observes the amount of time it takes for the eyelid to return to its normal position. An eyelid with excellent tension and muscle tone will immediately reposition itself against the globe ( Fig. 5.23 ).

In cases of moderate laxity and loss of tone, the eyelid will slowly return back to its normal position against the globe, typically within a few seconds. These patients are at some risk for lower-lid malposition complications post-blepharoplasty if the laxity is not addressed and usually benefit from some level of eyelid tightening during blepharoplasty surgery such as canthopexy or orbicularis sling. In cases of severe laxity and poor tone, the eyelid will remain gapped away from the eye until the patient blinks ( Fig. 5.24 ).

These patients are at high risk for post-blepharoplasty complications and benefit from a more invasive functional eyelid-tightening procedure such as a lateral tarsal strip. An additional test to evaluate lower-lid laxity is to observe the position of the lacrimal punctum when pulling the lower eyelid laterally. In a normal situation, the lacrimal punctum should not exceed an imaginary line dropped from the medial limbus of the cornea when pulled laterally. With lower-lid laxity, the punctum can be distracted well lateral of this point ( Fig. 5.25 ).

Many patients have eyelids that appear to be in good position but demonstrate laxity during these tests. Making these maneuvers an integral part of one’s preoperative examination will help identify and treat patients who would not seem to be at risk on a cursory examination. Never try to be the hero with cosmetic surgery. If you are unsure, refer!

Midface

The relationship between the globe and the midface should also be assessed during the lower-lid blepharoplasty evaluation. Not only is a smooth lid-cheek contour a sign of youth and beauty, this area should be evaluated because the midface provides crucial support to the lower eyelid. Ideal facial structure has a positive vector relationship in which the projection of the globe is posterior to the cheek prominence. When the anterior aspect of the globe protrudes further than the midface, a negative vector is present that reduces support to the lower eyelid and increases the risk for lower-lid retraction after blepharoplasty surgery. A negative vector in youth is a result of development and can be related to gender, genetics, or ethnicity. A negative vector can also develop with age as the midface rotates posteriorly, further reducing support to the lower eyelid ( Fig. 5.26 ). The oblique lengthening of the orbit occurs with age and results in a downward shift in the periosteal attachment of the lateral canthal tendon, further accentuating descent of the lateral lower eyelid with age. One avenue of correction includes cheek implants to restore the anterior projection of the midface (covered elsewhere in the text).

Malar mounds or festoons are located in the superolateral cheek between the orbitomalar ligament and zygomatic cutaneous ligament, and they can be one of the most challenging areas to treat in the upper face. Some young and healthy patients have a subtle malar mound as a normal anatomic finding; however, the soft tissue laxity and skeletal changes that occur with age make this region more pronounced. Skin and orbicularis laxity essentially become stuck between the two ligaments and drapes down over the zygomatic cutaneous ligament (see Fig. 5.15 ). Festoons can be “dry” and simply caused by excess skin and muscle, or they can be “wet” in which edema results from allergy, fluid retention, or sleep apnea. Patients often falsely believe that these are pockets of fat. It is prudent to point out this area out to patients in consultation. Failing to manage this area will often result in patient dissatisfaction. Options for treatment include CO ₂ laser, radiofrequency micro­needling, skin peels, midface lifting, face lifting, skin muscle flap transcutaneous lower-lid blepharoplasty, direct excision, and sclerotherapy injections, all with varying levels of satisfaction.

Skin Evaluation

Eyelid skin is the thinnest on the face and first to show signs of aging and photodamage. Skin texture, pigmentation, and laxity all play a role in aesthetic rejuvenation. The Fitzpatrick photo typing scale classifies skin based on its pigmentation and response to ultraviolet radiation. Classification ranges from type I (very fair, always burns, never tans) to type VI (deeply pigmented, never burns). The Fitzpatrick scale provides a broad-brush stroke by which to evaluate the risk for complications to energy, laser, and light-based devices. Patients with higher Fitzpatrick scores generally have a greater melanin content in the skin and are therefore at higher risk for complications from laser treatments that target melanin as their chromophore (e.g., IPL). In theory, patients with a higher Fitzpatrick score are also more likely to experience postinflammatory hyperpigmentation after treatments such as CO ₂ or Erbium laser. However, this does not work out perfectly in practice as some patients with Fitzpatrick skin type III or IV will have a robust hyperpigmentation response, and others will not. The Lancer ethnicity scale (discussed in Chapter 14 ) can be a helpful tool for determining risk factors based on ethnic background and genetics. The higher the number on the Lancer scale, the higher the risk for complications from an ablative laser or chemical peel.

Skin texture and thickness are also important to assess. Patients with thin skin with many rhytids will respond well to laser. Other patients have thicker skin with rhytids that are caused more by the orbicularis muscle insertions beneath the skin. These patients will not see as much improvement from laser resurfacing because they need neurotoxins to relax the muscles beneath the skin. Very thin skin promotes the appearance of dark circles because the skin is so thin that one can see through to the orbicularis muscle that is dark. Laser can create more collagen that is opaque and will help hide the dark circles. Pigment, hemosiderin extravasation, and vascular structures can also contribute to dark circles, and simple blepharoplasty may not remedy them. The patient must understand this.

Consultation Wrap-up

Before and after images and images of patients during the acute postoperative period should be shown to the patient to provide an idea of what to expect after the surgery. Having a list of previous patients that will serve as references to discuss their surgical experience with prospective patients is also a very useful adjunct. Any additional information such as brochures, websites, social media videos, and slide shows can be very useful to the patient. The consultation also includes providing fee quotations, signing consents, obtaining forms for physician history and physical examination and laboratory work (if necessary), postoperative prescriptions, and finalizing surgery plans and questions. If the patient desires to schedule surgery at this time, a down payment is made to hold the surgical spot. This process can be overwhelming for some patients and may require several appointments. I also prefer to take a set of preoperative photos at this appointment, so we ask patients to come without makeup. We often take another set of photos on the actual day of surgery. It is impossible to have too many patient photos.

It is important during the preoperative evaluation to remind the patient about any medications that may affect coagulation. This cannot be overstressed. There are many over-the-counter medications that contain aspirin or other ingredients that can affect platelet activity, and continual reinforcement is important. We provide an extremely detailed list of medications that may affect bleeding. Dr. Langelier provides her patients with the following succinct list of medications to avoid preoperatively with a variable timetable. Although this is a small portion of an exhaustive and ever-changing list, it does cover some of the more common medications to consider.

The following medications must be discontinued 10 days before surgery:

• 1.

  Ecotrin

• 2.

  Fiorina

• 3.

  Excedrin

• 4.

  Aggrenox/dipyridamole

• 5.

  Alka Seltzer

• 6.

  Headache powders (e.g., BC, Goody’s)

The following medications must be discontinued 2 weeks before surgery:

• 1.

  Advil

• 2.

  Aleve

• 3.

  Arthrote

• 4.

  Daypro

• 5.

  Diclofenac

• 6.

  Feldene

• 7.

  Fish oil/omega 3

• 8.

  Flaxseed oil

• 9.

  Garlic

• 10.

  Ginkgo

• 11.

  Ginseng

• 12.

  Ibuprofen

• 13.

  Indocin

• 14.

  Lodine/etodolac

• 15.

  Mobic/meloxicam

• 16.

  Motrin

• 17.

  Naprosyn/naproxen

• 18.

  Relafen

• 19.

  Ticlid/ticlopidine

• 20.

  Tolmetin

• 21.

  Toradol

• 22.

  Turmeric

• 23.

  Vitamin E

• 24.

  Voltaren

The following medications also must be discontinued before surgery . Please ask your prescribing doctor if it is safe for you to stop these medications. Please notify your surgeon if you are unable to stop these medications:

• 1.

  Aspirin: 10 days preoperatively

• 2.

  Coumadin/warfarin: 4 days preoperatively

• 3.

  Effient: 7 days preoperatively

• 4.

  Eliquis/apixaban: 48 hours preoperatively

• 5.

  Peltal/cilostazol: 3 days preoperatively

• 6.

  Plavix/clopidogrel: 7 days preoperatively

• 7.

  Pradaxa/dabigatran: 3 days preoperatively

• 8.

  Xarelto: 2 days preoperatively

Treatment Planning

Blepharoplasty surgery is an extremely sophisticated surgical procedure that is reliant on many factors for success. Much of what determines this success has little to do with the scalpel and much to do with patient selection, marking technique, and especially the ability to accurately judge what stays and what tissue is excised. In general, blepharoplasty is more about what stays behind than what is to be removed.

Occasionally, a patient who only desires isolated upper or lower blepharoplasty will present, but in general, if a patient has aging changes in the lowers, they also have them in the uppers and vice versa. I encourage patients to do upper and lower lids simultaneously. One reason is that I have done many isolated cases only to have the patient look in the mirror and love the treated lids but the untreated lids are more apparent, leaving the patient wishing they had done upper and lower lids at the same time. On the other hand, experienced surgeons will remind novice surgeons never to push a patient into a surgery.

Although some patients will present for only eyelid procedures, many patients will request four-quadrant blepharoplasty with browlift and possibly other cosmetic facial procedures. I do over 100 facelifts per year, and probably 80% of these patients have simultaneous blepharoplasty. In general, if they have enough lower facial aging for a lift, they have enough upper facial aging for lids.

Upper-lid blepharoplasty is a relatively standard technique, but lower-lid procedures vary in internal and external approaches to the fat. For decades, external skin/muscle approaches with a subciliary incision was standard technique. This involved incising and excising skin and muscle using the external approach with an incision several millimeters below the lower-lid lash line. When using this approach, the surgeon also incises the orbital septum (middle lamella). Between excessive skin removal and septal contraction from violating the middle lamella, this approach is more prone to producing lower-lid malposition. This approach is still utilized, but most contemporary oculoplastic surgeons maintain that violating the middle lamella can be a prime cause of lower-lid malposition, which can result in lid retraction with scleral show, ectropion, and dry eyes ( Fig. 5.28 ).

Transconjunctival approaches have become more popular as the orbital septum is spared, there is no external incision, and lower-lid malposition is less of a concern. The conventional transconjunctival approach is a retroseptal surgical approach and spares disturbance of the orbital septum. When dealing with transconjunctival approaches, alternate methods are used to address excess skin. In young patients, no ancillary skin removal may be required. In older patients, CO ₂ laser resurfacing of the eyelid skin is my treatment of choice; 30% TCA is my second choice, and skin-pinch techniques are my third choice and can address the skin excess without invading the lower septum. These techniques are discussed in detail in the following sections.

In terms of comprehensive treatment planning, brow position must be addressed preoperatively. If concomitant endoscopic or open browlift with upper blepharoplasty is planned, the sum of both procedures can stretch the upper-lid skin to a point where the eyelids cannot be closed, so both procedures must be tempered to account for adequate residual upper-lid skin for normal function. The average amount of skin I remove from the upper lid is approximately 9–12 mm. Some patients may only require a 7-mm reduction, while others may require a 15-mm reduction. When performing simultaneous upper-lid blepharoplasty and browlift, this amount of skin resection is reduced dramatically to 3–4 mm. If skin resurfacing of the eyelids is planned with blepharoplasty and browlift, even more caution is required. The golden rule of cosmetic surgery is that more skin can be taken away later, but it is difficult to replace! For the novice surgeon contemplating both browlift and simultaneous upper blepharoplasty, it may be best to perform the browlift first and address the upper lids at a later procedure so as not to overresect skin. For experienced surgeons, my axiom is that “if you need a browlift, you also need a blepharoplasty.” In my early career, I performed several browlifts with fantastic results, but the untreated dermatochalasis of the upper lids severely detracted from the aesthetics of the case. Everything looks cleaner and more sculpted when the lids are addressed with the browlift.

As stated earlier, it is imperative that patients are educated in the preoperative consent phase about the exact and precise difference between browlift and blepharoplasty as well as what each procedure will and will not do.

Surgical Technique

Preoperative Marking

Upper Eyelid

Blepharoplasty is in reality a relatively simplistic procedure compared with a facelift or other major surgery. It is, however, a technique of great finesse. Removing too little skin will produce a substandard result and necessitate revision surgery and inconvenience to the surgeon and patient. Overresection can cause serious functional problems that can lead to a lifetime of discomfort and aesthetic problems and possible legal action. There is no honor lost by revision surgery, only inconvenience. As previously stated, my supreme word of advice to all blepharoplasty surgeons is to be conservative. You will never go wrong with the following pearl. I tell all of my blepharoplasty patients in the preoperative period (and in the consent) that a small percentage will need some touch-up surgery. If they do require revision, they are mentally prepared for it. If they do not, then I am a hero.

The key to many types of cosmetic surgery procedures is accurate marking of the surgical site and landmarks; with blepharoplasty, it is absolutely critical. I have taught and proctored upper blepharoplasty surgery to well over 1000 surgeons from every conceivable specialty. Without exception, the biggest challenge for novice blepharoplasty surgeons is learning how to properly mark the eyelids. Once the marking procedure is understood and mastered, the surgery is relatively straightforward. Understanding correct marking technique is understanding cosmetic blepharoplasty. There is no “cookbook” technique to mark the upper eyelid, as each lid (even on the same patient) is different. At the time of this writing, I have performed over 5000 blepharoplasty procedures, and I still feel that I learn something on every single case.

It is imperative to mark the eyelids with the brow relaxed in the upright position before any local anesthetic is injected. When the patient is reclined or supine, the brows and lids are not in a natural position, and the markings can be inaccurate. Some surgeons do mark the patient supine on the operating room table, but I personally mark in the upright position.

An important pearl to remember is that it requires a minimum of approximately 20 mm of upper-lid skin for normal lid closure and function. Regardless of what technique is used to mark the lids, the “20-mm rule” must always be observed. It must be understood that this is not a repeatable measurement in every single patient, but a great limit to observe. In patients with a large orbit and high brow position, even more than 20 mm of skin may be needed for eyelid closure.

To increase adherence of the ink, the eyelids are wiped with alcohol before marking to degrease the skin. These marks must remain visible through surgical scrub, local anesthesia, and manipulation. Some marking pens fall short, and I have found retractable ultra–fine point Sharpie markers to be the best for ink longevity on the skin. If a robust ink is not used, the markings can wipe off with prep, and the surgeon will be at a loss for accuracy.

There are numerous ways to accurately mark the upper lids for blepharoplasty planning. Several techniques that have worked well for the author will be presented. When marking the lids, the brow is elevated with the fingers to stretch the lid skin, which facilitates drawing. The first step is to decide where to locate the upper-lid crease. Most male patients (non-Asian) have an upper-lid crease of about 8 mm above the lashes, and most female patients (non-Asian) have an upper-lid crease of 10–12 mm above the lashes. Generally, the lid crease is marked using the patient’s existing upper-lid crease. Female patients desire a high lid crease to create a significant lid shelf on which to apply eye shadow. A high crease in males can be feminizing. The position of the upper-lid crease can be discussed preoperatively. I prefer 10–12 mm for female patients and 8–10 mm for male patients. There are always exceptions. Some patients have an exceptionally high or low crease, which can be raised or lowered. The same situation exists when the crease height is not symmetric.

I first elevate the brow with my finger to lift any skin redundancy and almost mark the patient’s existing upper-lid crease. Most patients have discernible creases and look normal with their existing creases. In rare cases, no crease is present, and I arbitrarily use a default of 8–10 mm in male patients and 10–12 mm in female patients. A fine-tip surgical marker is used to draw a line from the lateral canthus to the lacrimal punctum. As many patients flinch and blink during marking, I prefer to make dots across the crease and connect them at the end of the marking procedure. The crease in many patients is arcuate, peaking in the center and tapering 4–5 mm at each terminus. Other patients have relatively straight-line creases, which are replicated with the markings. In these patients, exaggerating an arch can cause an artificial look. Some patients have levator dehiscence or simply do not have a discernable crease. In these patients, the average markings previously described are used per gender and race. It is sometimes difficult to find the actual crease, as some patients have multiple creases. I find it easiest to elevate the brow to stretch the lid skin, then slowly relax the upper-lid skin and observe the redundancy, which will reveal the actual crease ( Fig. 5.29 ). Elevating the brow and asking the patient to slowly look up and down can also help identify the crease. A skin marker is used to make a line on the crease from the lacrimal punctum to the lateral canthus ( Fig. 5.30 ).

It is not unusual for patients to have more skin excess on one lid than the other, so it is not uncommon for the upper incision marking to vary. The actual eyelid crease, however, must be exact on both lids . Even a difference of 1.5 mm can be noticeable to the patient and a cause of unhappiness. A caliper is a necessary instrument, and the eyelid crease must be exact on both lids as measured from the lid margin to the center of the crease. Several methods of upper lid marking are discussed here, but they all have the common denominator of an exact crease marked accurately on both lids. This is ground zero for the marking procedure, which will become the accuracy of both incision and excision to follow.

“Pinch” Technique of Skin Marking

The next step is to mark the upper extent of the blepharoplasty incision. There are numerous ways to accurately perform this task. One of the most common ways to safely and accurately mark the upper incision is what I call the “skin-pinch” technique. This technique consists of four steps:

• Step 1: Mark the patient’s natural crease (or the surgeon’s desired crease).

• Step 2: Pinch the skin until the lashes just begin to evert, and make several marks across the lid.

• Step 3: Connect the upper and lower lines with a superolateral vertical marking to address lateral skin hooding.

• Step 4: Pinch the upper and lower lines to confirm that the proposed amount of excised skin will allow normal lid closure. Generally, the limit has been reached when the upper lid lashes begin to evert. Novice surgeons should err on the conservative side.

The first step is to mark the patient’s creases, as shown in Fig. 5.30 . For the second step, forceps are used to pinch the upper-lid skin until the lashes slightly evert. Then, a mark is made in the medial, central, and lateral portion of the lid ( Fig. 5.31 ). I personally use a dental cotton plier as my forceps instrument.

The upper and lower markings provide the basic outline for the upper and lower limb of the proposed incision. The third step is to join the upper and lower markings with a vertical line angled outward and upward at a 15–20-degree angle. This geometry allows for removal of slightly more skin on the lateral lid to compensate for excess skin hooding that is usually present ( Fig. 5.32 ). I do not extend this past the bony orbital rim.

The fourth and final step in this technique (or any other marking technique, for that matter), is to pinch the upper and lower markings together with forceps to ensure that the lid will close normally. Slight eversion of the upper lid lashes when pinching is the limit of proposed skin excision ( Fig. 5.33 ).

“Figure Gaze” Technique of Skin Marking

This technique is accurate but is not replicable on all patients. With this technique, the patient stands 18–24 inches away from the surgeon and stares at a fixed object such as the surgeon’s index finger. Marks are then made at the overlap of the skin above the crease ( Fig. 5.34 ). When the patient closes their eye, these markings will correspond with the upper extent of the proposed eyelid excision ( Fig. 5.35 ). In most patients, this is a very accurate way to mark the upper limb of the incision. The next step is to locate and mark the patient’s normal eyelid crease (assuming it conforms to the surgeon’s desired height) (see Fig. 5.35 ). The final step is to mark the lateral most part of the incision with the superiolateral upsweep. I do not extend this past the bony orbital rim.

After the first eye is marked, a caliper is used to measure the crease height, which is then confirmed on the contralateral lid ( Fig. 5.36 ). Although most patients have symmetric creases, some do not, and it is important to make both creases the same height. The same lateral extension is also made (see Fig. 5.36 ), and the skin pinch test is performed to ensure that the eye will still close with the proposed amount of skin excision (see Fig. 5.36 ).

Several fine points require discussion regardless of the technique used for upper blepharoplasty skin marking. Although some textbooks show the discussed lateral extension to extend out into the crow’s feet region, I never do this. The skin texture changes from the thin crinkly eyelid skin to the thicker facial skin at the crow’s foot region. A noticeable scar can occur if the lateral incision is extended out into skin lateral to the orbital rim. I personally stop the lateral extension at the orbital, rim as shown by the dotted line ( Fig. 5.37 ). Additionally, the distance from the upper lid margin to the marked crease should be the same. This is generally 3–5 mm from the upper lid margin to the marked crease (see Fig. 5.37 ).

Final Thoughts on Skin Marking

Whatever technique the surgeon uses to mark upper lid skin excision, it is always important to keep in mind that at least 20 mm of upper lid skin will remain after the excision for normal lid closure and function and that the upper creases are always bilaterally symmetrical. An additional check can be performed by reclining the patient during the aforementioned “pinch” technique to confirm full eyelid closure.

Be aware that in patients who have a hollow superior sulcus, this technique may tent the skin over the hollow and provide false reassurance that enough skin will be left behind. Remember that additional skin will be needed to dive in to the concavity of the upper eyelid. The same consideration should be made in patients with puffy eyelids who will undergo extensive fat removal. If there is ever a doubt, the surgeon should err on the conservative side, particularly in the medial and central eyelid, where excessive skin removal is more likely to cause lagophthalmos. If future revision is required, this is easily performed with local anesthesia and minimal recovery. Remember to measure twice, and cut once!

When marking the patient, it is important to have an acute angle at the medial canthal region to allow a smooth approximation at closure. It is also very important not to extend the medial portion of the incision onto the multicontoured concave regions on the lateral nose. Incisions over concave regions are notorious for poor scarring and can produce medial canthal webbing, which can be very difficult to improve ( Fig. 5.38 ).

The surgeon must remember that the amount of upper-lid skin removal is frequently different on each lid, but the crease position must always be the same ( Fig. 5.39 ).

Upper Blepharoplasty Surgical Techniques