Cosmetic Blepharoplasty and Browplasty

Upper Eyelid

Anatomy of the upper eyelid is discussed in Chapter 12.1 . The eyelid crease is an important anatomical and aesthetic landmark. The skin and muscle between the crease and the brow form the eyelid skin fold. If upper lid fat recedes or the levator aponeurosis becomes stretched or disinserted, the crease assumes a higher position. In the Asian eyelid, the crease (if present) is lower because of the low insertion of the orbital septum into the levator aponeurosis with consequent descent of the preaponeurotic fat pockets.

When the eyelid opens, the lid crease skin is pulled upward and backward by the aponeurosis as it retracts under the fat pads ( Fig. 12.15.2 ). The eyelid skin fold then bulges slightly as the fat pushes the skin forward. During downgaze, tension in the aponeurosis becomes lax, resulting in a weakened or absent lid crease.

Lower Eyelid

The lower eyelid has a similar but simpler anatomy and is reviewed in Chapter 12.1 . Integrity of the medial and lateral canthal tendons is very important to maintain a proper lid position, especially in the aging face. However, the bony configuration of the midface also plays a key role. Because the lower eyelid is less mobile than the upper, less redundancy of the skin and orbicularis muscle occurs. The major aging changes include sagging of skin, deepening of wrinkles and of the medial tears trough, descent of the lateral canthus from loss of bony support, and atrophy of the lower eyelid fat pockets.

History and Psychological Evaluation

When evaluating patients who seek cosmetic improvement of the periorbital area, the surgeon should understand the patients' motives for undergoing surgery and the decision-making process they have undertaken. Asking patients what they expect the surgery will change for them can sometimes reveal unexpected motives or unrealistic expectations. The psychological screening should include a medical and surgical history with specific questions about previous cosmetic surgery. Outcomes of previous surgeries might give a clue to unrealistic expectations, especially if the objective results of these previous surgeries are not in harmony with the patient's perception. Previous mental illness should alert the surgeon—a psychiatric consultation is sometimes useful.

In assessing expectations, the surgeon can help by carefully discussing the surgery and explaining the improvements to be expected. It is important to detail the cosmetic defects that cannot be changed by surgery and establish a realistic plan for facial rejuvenation.

The patient is asked to consider carefully the decision to undergo surgery and, if one is sought, should be encouraged to obtain a second opinion. Establishing a relationship of trust is of paramount importance. If in any doubt, even for unclear objective reasons, a conservative attitude is recommended.

Physical Examination

The position and shape of the different periorbital structures are evaluated along with the quality of the skin. In the forehead area the level and shape of the hairline, the quality of skin of the forehead, and the position and shape of the brows are evaluated with specific attention to detecting brow asymmetry. The muscular layer is judged by looking at the frown lines in the forehead and glabellar area and by asking the patient to relax the forehead. The bony orbit is then evaluated, especially laterally at the orbital rim, where some prominence can mimic lacrimal gland prolapse. This is a good time to evaluate the position of the globe in relation to the bony orbit, because this is an important determinant of the type of lid fold to aim for. A fuller orbit with a large eye leads to a convex upper eyelid above the crease, whereas a large orbit with a small eye results in a more concave upper lid above the crease. A prominent globe with recessed zygoma often leads to lower lid malposition.

For the eyelids, precise measurements of the eyelid vertical and horizontal apertures should be recorded, noting the high point of the upper lid both from the lower lid and from the midpupil. The general shape of the palpebral fissure is noted. The position of the lid crease and upper eyelid skin fold should be documented. The amount of fat to be removed in all fat pad areas is estimated, and any prolapse of the lacrimal glands is noted. In the lower lids the fat pads are carefully assessed, with any areas of prolapse noted. The inferior periorbital area over the upper cheek is evaluated in a similar fashion. The quality of the skin is important, and cicatricial changes from dermatological conditions or chronic sun exposure can make the lid more susceptible to malposition after surgery. The cheek is examined for the presence of festoons, noting whether they consist of only skin and orbicularis muscle or also of suborbicularis fascia and/or orbital fat. The lower lid is assessed with the distraction test by pulling the central lower lid margin away from the eye. A distance of more than 6 mm is considered abnormal and may require a lift tightening. The position of the lateral canthus is noted and normally is 1–2 mm higher than the medial canthus. As an aging phenomenon, the lateral canthus is often lower. Laxity of the canthal tendons is noted and if present is manually tightened with the finger before estimating the amount of skin to be removed. The nasojugal area should be examined to detect tear trough deformities, which may need correction instead of fat pad removal.

The use of a flow sheet to outline systematically the physical findings is an excellent way to plan present and future surgery. Surgical planning must take into account the patient's desires, what he or she is willing to undergo, and what the surgeon thinks is reasonable and safe. Fig. 12.15.4 gives an overview of the patient consultation evaluation for blepharoplasty and correction of any brow malposition. A good set of photographs should carefully document the changes noted and must be kept as part of the patient's medical record.

Upper Lid Blepharoplasty

Before upper eyelid blepharoplasty is begun, the brow should be repositioned as needed, especially lateral brow droop. A proposed skin incision is marked in the existing eyelid crease, or if there is no visible crease, the line is marked about 8–10 mm above the lash line, taking into account the racial background of the patient. The crease marking usually goes from a point above the superior punctum to—but not beyond—the lateral orbital rim. Skin excess is evaluated by placing one arm of a forceps on the crease incision line and pinching the redundant skin within the opposite arm so that in downgaze the skin is tight without lagophthalmos. In general, 20–24 mm of skin should be left between the brow and the lid margin to prevent postoperative lagophthalmos. The long-taught rule that the eyes should not close on the operating table has certainly become obsolete. Excessive skin removal medially may result in hood formation. If disproportionate tissue is still present in this region after surgery, a glabellar lift can be considered. An optional small triangular flap of skin can be added to the usual skin pattern medially to minimize folding of the skin at the time of closure in patients with excess of skin medially ( Fig. 12.15.5 ).

The lid is placed under downward traction, and a Bard–Parker No. 15 blade is used to incise the skin. The skin flap is removed with a blade or scissors, leaving the orbicularis muscle intact at this stage.

Gentle pressure on the globe will prolapse the orbital fat pockets that bulge behind the orbicularis muscle and orbital septum. The fat is exposed by a small buttonhole that is made centrally through the orbicularis and the septum above its insertion on the aponeurosis. The septum is opened laterally and medially from this buttonhole ( Fig. 12.15.6 ). Each fat pad capsule is opened. The fat is gently prolapsed and transected. The section line is cauterized with a bipolar cautery (see Fig. 12.15.6 ).

The orbicularis muscle is thinned, but some surgeons prefer to remove it completely along with the overlying skin. The aponeurosis is exposed above the tarsal border. Invagination of the skin by fixing the skin edge to the aponeurosis at the time of closure ensures a good position of the crease in fuller lids but is not always necessary. The orbicularis can be tacked down to the aponeurosis immediately under the upper skin edge using two or three 6–0 plain sutures. This defines the position of the eyelid crease and controls the position of the fat pad in the lid ( Fig. 12.15.7 ). The skin is closed with a running 6–0 nylon or 6–0 plain gut suture. The area beyond the lateral canthal angle is closed with interrupted sutures to obtain an edge-to-edge closure without folds ( Fig. 12.15.8 ).