Chapter 13:
Upper eyelid blepharoplasty

• Other names: Eyelid lift, cosmetic eye surgery

• Primary goal: Removal of excess skin, fat, and/or orbicularis muscle to restore the upper eyelids to a more youthful apearance

• Secondary goals: Uplift of drooping eyelashes, increase in peripheral vision, restoration of the eyelid crease

• Special anatomy: None

• Anesthesia: No special requirements. Most commonly performed under local anesthesia with oral sedation in an office operating room.

• Operative technique: (for step-by-step photos.)

A marking pen is used to outline the amount of excess skin to be removed. The initial incision is made along the normal eyelid crease (about 7-10 mm above the lashes) across the entire lid and extending slight upward and outward into the lateral canthus. The second incision is made a variable distance above the first, depending on the amount of skin that needs to be removed. Only if the orbicularis muscle is unusually thickened is a tiny strip trimmed.

The orbital septum is opened, thus exposing the fat pockets overlying the levator aponeurosis (tendon of the eyelid opening muscle). The first or "middle" pocket is inspected and trimmed as indicated using a process of dissection, clamping, excision, and cauterization. The second or "nasal" fat pocket requires a slightly deeper dissection. A graded removal of any excess is performed is a similar fashion. Fat removal is intentionally conservative to avoid a hollowed look after surgery as well as in later age when the body may absorb facial fat. In some cases, no fat is removed.

The skin edges are closed using sutures to reform, reposition, and/or deepen the eyelid crease.

• Variations:

"Tissue-sparing upper blepharoplasty" provides a means to avoid an artificially high crease as well as eyelid hollowing. No orbicularis muscle is thinned, the orbital septum is left essentially intact, and little or no orbital fat is removed.

For more on tissue-sparing: Narrated Video or QuickNote

"Laser-assisted blepharoplasty", in which the actions of the traditional scalpel and scissors are undertaken with the use of a laser, has received widespread attention in recent years. While some advocates have claimed quicker operating time due to decreased bleeding (primarily an advantage to the surgeon), objective studies have not demonstrated less bruising or a more rapid recovery. Many surgeons feel that the skin scars after healing from laser-assisted blepharoplasty are slightly more irregular and take longer to strengthen than those made with a scalpel ("cold steel"). Other approaches to incising and excising skin and deeper eyelid tissues have been and are currently used, including electrocautery, heat cautery, heated scalpels, and radiofrequency ( RF ) energy. While such approaches may each have some proponents, none have demonstrated convincing advantages over the stainless steel scalpel and scissors.

In selected patients, a modification known as "deep fixation" may be used to deepen the eyelid crease, achieve a more stable platform of skin on which to apply cosmetics, strengthen support for drooping eyelashes, and prevent later scar "migration" out and above the hidden area of the normal crease. At the time of skin closure, the cut skin edges are lightly attached to the underlying levator aponeurosis (tendon) using either permanent or removable sutures.

A tissue adhesive (Dermabond) resembling super-glue may be used to help close the upper eyelid incision, but usually at least a few sutures are placed for reinforcement. This method is seldom employed.

If the lacrimal gland (tear gland) has dropped down from its normal position just inside the orbital rim of bone, it may create a bulge that mimics eyelid fat at the lateral (towards the temple) side of the upper eyelid. If severe, the gland may require resuspension with sutures.

If only the nasal fat pocket is bulging and there is no excess upper eyelid skin, fat removal may be undertaken through a transconjunctival incision (i.e., from the inside surface of the eyelid) without creating an external scar.

• Advantages: Upper eyelid blepharoplasty is a relatively safe and proven operation. Because the eyes are the focal point on the face, the procedure may achieve anything from a subtle to dramatic improvement in a person's appearance, depending of the starting point and patient preferences. For this and such reasons as its relatively modest cost and much quicker recovery, many people choose blepharoplasty over full face lift. A reasonable expectation is that you will obtain about an 75-90% improvement.

• Limitations: If the presence of a weakened or already droopy eyebrow, added brow stabilization may be indicated to prevent further descent; browpexy can be performed through the same eyelid incision. "Crow's feet" (wrinkles at the lateral canthus) are only minimally improved. If true ptosis (a droopiness of the eyelid due to a defective levator muscle or aponeurosis), blepharoplasty alone will not remedy the problem. Because every patient possesses some pre-existing anatomical limitations and because no wound ever heals perfectly, some slight asymmetry after upper blepharoplasty is the rule rather than the exception.

• Care and recovery: Discussed fully in Section Four below

• Risks and complications: See Chapter 28: Blepharoplasty Risks-Complications

• Comments:

As the most popular operation in cosmetic eyelid surgery, nearly every chapter in this Guide refers fully or in good part to upper eyelid blepharoplasty. While some cosmetic surgeons seem to emphasize brow and forehead lifting to the virtual exclusion of upper eyelid surgery, one procedure does not replace the other.

Some patients worry that a properly performed upper blepharoplasty will cause the eyebrow to drop to a lower position. Based on a review of thousands of photos from our practice, in our experience this is not the case. As with any operation, however, if surgery is performed in an overly aggressive manner or without respect for pre-existing limitations, adjacent structures will indeed be affected.

"Functional blepharoplasty" or blepharoplasty undertaken with the primary purpose of increasing the field of vision narrowed by overhanging skin, entails the removal of eyelid skin only. While vision may be improved, the results compared to a full blepharoplasty may, in fact, be disappointing to a patient who was hoping to coax his or her insurance company into paying for what is, for the most part, a cosmetic operation.