The skin above the incision is gently pinched while the eyes are closed to determine the maximum amount of skin that can safely be removed without pulling up on the upper eyelid margin or down on the brow. To avoid a stark outcome, the actual amount of skin that is removed is always much less.
Upper eyelid skin is removed using a scalpel and fine scissors and forceps (the laser is not used, as the final scar may be compromised).
Only if the underlying orbicularis muscle is overdeveloped or stretched are its fibers trimmed conservatively.
If orbital fat is clearly bulging, a structural layer known as the orbital septum is opened. One or both fat pads are thinned conservatively to avoid hollowing.
If fat is not bulging, the orbital septum is left intact and no fat is removed from the middle pocket. In our practice, "tissue-sparing upper blepharoplasty" has become the rule rather than the exception.
The upper eyelid's opening muscle (levator muscle complex) located below the fat is identified and avoided during surgery. Bleeding is meticulously controlled with electrical and thermal cautery.
The skin incision is closed using a combination of interrupted and continuous (baseball) non-dissolving fine stitches.
