Upper Blepharoplasty

Introduction

The primary physical function of the upper eyelids is protection of the eyes but, together with the eyebrows and forehead, they form an expressive aesthetic unit, with significant social function.

Anatomy and Aging

Ideally, the upper eyelid resting position is 1 to 2 mm below the superior border of the corneal limbus and has 12 to 15 mm of lid excursion. Insertion of the levator aponeurosis forms the upper eyelid crease, which in whites usually ranges 8 to 12 mm above the margin (men at the lower end, women at the higher end). The fusion of the levator aponeurosis, orbicularis oculi fascia, and orbital septum forms a pretarsal condensation of fascia that divides the eyelid into tarsal and orbital portions ( Fig. 6.2 ). The aponeurosis takes a higher course medially and is at risk of injury when exposing the medial fat pad during open blepharoplasty.

Traditionally, there are two periorbital fat pads in the upper lid, medial and lateral, although some have reported a third distinct central pad. The medial fat pad is pale yellow and histologically different from the other periorbital fat, with more nerves and vessels within it.

With aging, the soft fullness of youth disappears (see Fig. 6.1 ). Excess eyelid skin and forehead lines develop, the temples hollow with fat atrophy, and the horizontal palpebral aperture narrows. Dehiscence of the levator aponeurosis can lead to involutional ptosis and, paradoxically, the medial fat pad volume appears to increase (or at least become more visible). Lambros believes that this is the legacy of deflation rather than gravitational descent.