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Volume 11 • Issue C2
BLEPHAROPLASTY
Ricardo A. Meade, MD
Cosmetic
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Reconstruction Topics
Editor Emeritus
F. E. Barton, Jr, MD
Breast Reconstruction
Cleft Lip and Palate
Craniofacial
Eyelid Reconstruction
Facial Fractures
Hand: Congenital
Hand: Extensor Tendons
Hand: Flexor Tendons
Hand: Peripheral Nerves
Hand: Soft Tissue
Hand: Wrist, Joints, Rheumatoid Arthritis
Head and Neck Reconstruction
Lip, Cheek, Scalp, and Hair Restoration
Lower Extremity Reconstruction
Nasal Reconstruction
Surgery of the Ear
Trunk Reconstruction
Vascular Anomalies
Wounds and Wound Healing
Contributing Editors
W. P. Adams, Jr, MD
S. M. Bidic, MD
G. Broughton II, MD, PhD
S. Brown, PhD
J. L. Burns, MD
J. J. Cheng, MD
A. A. Gosman, MD
J. R. Griffin, MD
K. A. Gutowski, MD
R. Y. Ha, MD
R. E. Hoxworth, MD
K. Itani, MD
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R. K. Khosla, MD
J. E. Leedy, MD
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A. H. Lipschitz, MD
J. H. Liu, MD
R. A. Meade, MD
J. K. Potter, MD, DDS
S. M. Rozen, MD
M. Saint-Cyr, MD
M. Schaverien, MRCS
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Cosmetic Topics
Blepharoplasty
Body Contouring: Excisional Surgery
Body Contouring: Noninvasive, Liposuction, Fat Grafts
Breast Augmentation
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BLEPHAROPLASTY
Ricardo A. Meade, MD
Dallas Plastic Surgery Institute, Private Practice
University of Texas Southwestern Medical Center at Dallas
Dallas, Texas
INTRODUCTION
Eyelid rejuvenation is a complex subject within
aesthetic facial surgery. With this in mind, we must
maintain a global perspective of the aging face.
Successful rejuvenation requires an individualized
approach with a clear understanding of the
underlying conceptual framework that delineates
the anatomic problems identified by preoperative
assessment. The main areas of potential focus
include the following: 1) resuspension of descended
periorbital structures; 2) restoration of volume loss;
3) support of the lateral canthus; 4) establishing
a smooth lower eyelid-cheek junction; and 5)
resurfacing or removing lower and upper eyelid
skin excess.
HISTORY
An excellent discussion of the history of eyelid
surgery can be found in articles by Dupuis and
Rees1 and Stephenson2 and in a textbook by
Wolfort and Kanter.3 A description of eyelid
surgery can be found in the 2000-year-old Indian
document, the Susruta. During the 10th and 11th
centuries, Arabian surgeons treated dermatochalasis
with a crescent-shaped cautery to burn the eyelid
and correct drooping.4 Johnson,5 in 1678, described
the works of Ambroise Paré who excised excess
upper eyelid skin and emphasized the importance
of avoiding over-resection.
The first illustrations of excess eyelid folds
in the medical literature were published in a
textbook by the Viennese surgeon Georg Joseph
Beer in 1792.6 von Graefe7 was the first to use
the term blepharoplasty to describe eyelid surgery.
Mackenzie,8 Alibert,9 Graf,10 and Dupuytren11
described resecting only the excess skin of the
eyelid. Sichel,12 in his 1844 review, distinguished
between paralytic ptosis, atonic ptosis, and fatty
ptosis. He was the first to describe herniated
intraorbital fat. Fuchs,13 in 1896, described a patient
with recurrent swelling of the upper eyelid that led
to wrinkles, a condition he termed blepharochalasis.
Cosmetic repair of baggy eyelids was
popularized by Miller14 in 1908 in the first
textbook devoted to cosmetic surgery. In it were
photographs illustrating lower eyelid incisions for
the removal of wrinkled skin. Bourguet,15 in 1928,
was the first to note the separate fat compartments
in the eyelids and described a transconjunctival
approach to correction of lower lid fat bulging.
Around the same time, Madame Noel’s16 technique
involving a subciliary incision became the standard
approach to the lower eyelid. Castañares,17 in
1951, described modern blepharoplasty and
detailed the pathological anatomy of the orbital fat
compartments. The technique used by the author
separated the skin of the lower eyelid from the
orbicularis muscle. In 1952, Fox18 first applied
the term dermatochalasis to the eyelid with
redundant skin.
The skin-muscle flap was popularized by
Rees and Dupuis19 and others in the 1970s. The
transconjunctival approach to correction of orbital
fat was popularized by Zarem and Resnick20 in
SRPS • Volume 11 • Issue C2 • 2010
1992. In 1996, laser resurfacing and chemical
peeling were proposed for the treatment of lower
eyelid dermatochalasis.21
Researchers’ attention turned to the
rejuvenation of the lower eyelid-cheek junction,
specifically tear trough deformity. Loeb22–24 initially
reported reposition of lower eyelid medial and
central compartment fat for the correction of deep
nasojugal grooves. The technique was modified by
Hamra25,26 who then popularized it as the septal
reset. The benefits of septal reset for tear trough
deformity were further elucidated by Barton et al.27
zygomaticofrontal nerve coursed through the
infraorbital foramen and the zygomaticofacial
foramen, respectively. The nerves coursed superficial
to the periosteum, beneath and then within the
epimysium of the orbicularis muscle, and then
distributed to the skin; 99.4% of infraorbital nerve
branches were medial to the lateral canthus. The
zygomaticofacialis nerve terminal branches were
found lateral to the lateral canthus. The authors
concluded that the skin-muscle flap infringes
less than the skin flap on these terminal branches
during lower blepharoplasty.
ANATOMY
For more in-depth descriptions of the anatomy
associated with blepharoplasty, the reader is
referred to descriptive articles, textbooks, and
atlases by Zide and Jelks,28–30 McCord et al.,31 and
Baker et al.32
The palpebral fissure, which is the aperture
between the upper and lower eyelid margins,
measures 12 to 14 mm vertically and 28 to 30 mm
horizontally. The upper eyelid normally rests up
to 2 mm below the limbus, with the lower eyelid
margin at the level of the lower limbus.33 The
arterial distribution of the eyelids is illustrated in a
2007 article from Turkey.34 Nineteen cadaver heads
were injected, and schematization showed the
marginal and peripheral arterial arcades and their
feeding vessels.
Orbicularis Oculi
The orbicularis oculi is the sphincter of the
eyelid. This broad, thin, oval muscle is adherent
to the overlying skin and consists of three parts:
a peripheral orbital portion spreading over the
forehead and cheek, a palpebral portion that
constitutes the voluntary muscle of the eyelids,
and a small lacrimal portion associated with the
medial palpebral ligament. The orbital portion
attaches to the medial canthal tendon, the nasal
part of the frontal bone, and along the inferomedial
orbital margin. Laterally, the orbital portion of the
orbicularis oculi continues around the orbit without
interruption at the lateral canthus.32
The palpebral portion of orbicularis oculi
spreads concentrically in the subcutaneous tissue
of the upper and lower eyelids. The palpebral
orbicularis oculi has pretarsal and preseptal
segments. Mild eyelid closure is primarily through
contraction of the pretarsal and preseptal portions
of the orbicularis oculi. Tight closure is the result
of contraction of the orbital portion of
the muscle.37,38
Medially, the preseptal orbicularis oculi has
two heads. The anterior head becomes the anterior
crus of the medial canthal tendon and inserts into
the frontal process of the maxilla. The posterior
head inserts into the posterior lacrimal crest
(Horner muscle).32 Laterally, fibers of the preseptal
palpebral portion of orbicularis oculi interdigitate
superficial to the lateral palpebral ligament to form
the lateral palpebral raphe.31,38
The orbicularis oculi is anchored by welldefined ligamentous attachments. Muzaffar
Skin
The skin of the eyelid is the thinnest in the body.
Subcutaneous fat is sparse. Edema fluid can rapidly
engorge the loose subcutaneous space and defines
the juncture with the surrounding subcutaneous
fibroadipose tissue, which is denser.32
Age-related changes in the sun-exposed area
of the periorbita include decreased type I collagen
synthesis and increased dermal collagenase activity.
With time, these metabolic alterations lead to
thinning, folding, and wrinkling of the
eyelid skin.35
Hwang et al.36 discussed the loss of skin
sensation or numbness after lower blepharoplasty.
They dissected 14 fresh cadaver heads and
found that the infraorbital nerve and the
2
SRPS • Volume 11 • Issue C2 • 2010
et al.39 provided a detailed description of the
attachments. Medially, the orbicularis oculi has
a direct attachment to the inferior orbital rim
from the region of the anterior lacrimal crest to
approximately the level of the medial limbus.
Laterally, the attachment is indirect and is provided
by the orbital retaining ligament (ORL) (Fig.
1).39 This structure is the same as the orbitomalar
ligament described by Kikkawa et al.40
The ORL extends from the periosteum
just outside the orbital rim to the fascia on the
undersurface of the orbicularis oculi. At its
lateral extent (and in the region of the lateral
canthus), the ORL merges with the lateral
orbital thickening (LOT). The LOT represents a
triangular condensation of the superficial and deep
orbicularis oculi that extends across the frontal
process of the zygoma onto the deep temporalis
fascia. In the study presented by Muzaffar et al.,39
the dimensions of the LOT varied greatly with
age (Fig. 2). The ORL is predictably continuous
with the LOT below the lateral canthal tendon;
specifically, the ORL, LOT, and lateral palpebral
raphe form a single anatomic unit in that region
(Fig. 3).39 Release of the ORL and LOT, therefore,
allows untethered redraping of all the structures.
Age-associated changes in the orbicularis
oculi are caused by muscle relaxation and increasing
laxity and attenuation of the orbicularis oculi
ligamentous attachments. The changes ultimately
result in progressive eyelid ptosis. Combined with
ptosis of the malar soft tissues, with which they
are frequently associated, the changes result in a
characteristic deformity at the point where the
inferior muscle border becomes visible, forming a
malar crescent or festoon over the malar eminence
and creating a clinical appearance of periorbital
soft-tissue widening.41
Septum
The orbital septum consists of dense fibroelastic
tissue and forms the anterior border of the orbital
contents. The septum represents a continuation of
the orbital periosteum. The junction is termed the
arcus marginalis. Putterman and Urist42 noted that
the orbital septum inserts 10 to 15 mm above the
superior tarsal border of the upper eyelid to join
the levator aponeurosis. On the lower eyelid, the
orbital septum joins the capsulopalpebral fascia 5
mm below the tarsal border.42 The measurements,
however, are subject to debate, as discussed
by Zide.28
Figure 1. Cadaveric dissection within the prezygomatic space. The upper border is indicated by the blue line. Medially, the
orbicularis oculi (OO) originates directly from the orbital rim above the origin of the levator labii superioris (LLS). More centrally,
the orbicularis has an indirect attachment to the orbital rim by means of the orbicularis retaining ligament (ORL), which courses
directly on the orbital side of the zygomatico-facial nerve (ZFN). At the lateral orbital rim, the ligament merges into the lateral
orbital thickening. Sub-orbicularis oculi fat (SOOF) lines the undersurface of the prezygomatic orbicularis (pars orbitalis). Zmaj.,
zygomaticus major muscle; Zmin., zygomaticus minor muscle. (Reprinted with permission from Muzaffar et al.39)
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SRPS • Volume 11 • Issue C2 • 2010
not occur. Camirand44 proposed that the cause of
herniated fat and enophthalmia of aging is likely
to be a combination of the descended Lockwood
suspensory ligament, the relaxed muscle tone of
the orbicularis oculi and extrinsic muscles, and the
weight of the globe pushing on the orbital fat as
the patient lies on the operating table.
Figure 2. Dimensions of the orbicularis retaining ligament.
The larger light blue outline is the ligament of the youngest
specimen. The dark blue triangle defines the diminished
attachment in the older specimens. (Reprinted with
permission from Muzaffar et al.39)
Figure 3. Superficial fascia, or superficial
musculoaponeurotic system, is a continuous unit
composed of the temporoparietal fascia (TPF) and the
orbicularis muscle fascia. It attaches to the skeleton along
the orbital rim, by the lateral orbital thickening (LOT) in
continuity with the orbicularis retaining ligament (ORL); to
the lateral orbital tubercle by means of fibrous connections
of the orbicularis fascia with the tarsal plates (TP); and from
there to the deep head of the lateral canthal tendon (LCT).
(Reprinted with permission from Muzaffar et al.39)
Camirand and colleagues43,44 reported that the
orbital septum does not offer much support and
cannot maintain the fat within the orbit even at a
very young age. After an orbital floor exploration or
traumatic laceration, suturing of the orbital septum
is seldom performed, yet herniated fat pads do
4
Fat
Postseptal (Intraorbital) Fat
The postseptal, or intraorbital, fat lies on the
eyelid proper. Bourguet15 recognized two distinct
adipose compartments in the upper eyelid, divided
by the superior oblique. The medial fat pad is
lighter in color and firmer in consistency than the
central fat pad. The medial fat pad is associated
with the infratrochlear nerve and the terminal
branch of the ophthalmic artery. Bourguet,15 and
later Castañares,17 also identified three distinct
fat compartments in the lower eyelid, but the
observation was subsequently challenged by
Berry45 and Beard,46 who noted only two discrete
compartments. Hugo and Stone47 injected dye
into individual fat pockets in the lower eyelids
of cadavers and found that the dye diffused
throughout the entire eyelid, indicating a lack of
true compartmentalization. On the other hand, in
vivo dye injection studies conducted by Barker48
showed that the dye remained within
the compartments.
Preseptal (Extraorbital) Fat
The preseptal, or extraorbital, fat accumulates
outside the orbital rim on the inferior lateral brow
and upper malar areas. Owsley49 described “a thick
cushion of fatty tissue beneath the orbicularis
muscle that overlies the lateral orbital rim
extending outward toward the end of the brow. The
lateral fat pad is superficial to the orbital septum,
where it may overlie the lateral extension of the
central fat pad.” May et al.50 reviewed the value
of resecting the fat, which they termed the retroorbicularis oculi fat, in decreasing heaviness of the
lateral brow and upper eyelid.
Aiache and Ramirez51 described a counterpart
in the lower eyelid and called it the suborbicularis
oculi fat. In their words, “The suborbicularis oculi
SRPS • Volume 11 • Issue C2 • 2010
fat represents the position of the fat pad in relation
to the orbicularis oculi muscle and is analogous
to the retro-orbicularis oculi fat designated to
the fat pad located in the brow area.” The authors
suggested that “malar bags” are the result of
ptosis of the suborbicularis oculi fat. Hwang et
al.52 delineated the retro-orbicularis oculi fat
and suborbicularis oculi fat pads histologically
and by precise anatomic location relative to the
midpupillary line.
Eyelid Retractors
Upper Eyelid
The levator palpebrae muscle originates from the
lesser wing of the sphenoid and extends anteriorly
along the superior orbit.33 Approximately 14 to 20
mm above the superior border of the tarsus, the
levator forms a condensation of fascia known as
Whitnall ligament.53 It functions as a fulcrum to
translate a posterior vector into a superior vector.
Anterior to that structure, the levator forms a
bilamellar aponeurosis that joins with the septum
to insert into the tarsus. A lateral horn divides the
lacrimal gland into the palpebral and orbital lobes
and contributes to the lateral retinaculum. A medial
horn inserts into the lacrimal crest.54 The posterior
lamella contains Mueller muscle.55
Lower Eyelid
The equivalent retractor in the lower eyelid is
formed by the capsulopalpebral fascia. It originates
as a fibroelastic tissue from the inferior oblique
muscle as two sheets. Anteriorly, the sheets
fuse to form Lockwood ligament. Anterior to
Lockwood ligament is the capsulopalpebral fascia.
Approximately 5 mm below the inferior tarsus,
the septum and the capsulopalpebral fascia fuse to
insert into the tarsus. Some smooth-muscle fibers
are present in the condensation (the inferior tarsus
muscle). Other capsulopalpebral fibers extend
through the orbicularis oculi toward the skin and
contribute to the lower eyelid crease (Fig. 1).32,39,56
Lateral Canthus
Jelks and Jelks30 stated that “the lateral canthus
defines the geometric pattern of the lateral aspect
of the eyelids” and is more appropriately termed
a lateral retinaculum. The complex structure
anchors the lateral soft tissues to the bony orbit.
The retinaculum consists of the following: 1)
lateral horn of the levator palpebrae superioris,
2) preseptal and pretarsal orbicularis oculi, 3)
Lockwood ligament, and 4) check ligament of
lateral rectus muscle.30,57 The dimensions were
described by Gioia et al.58 Muzaffar et al.39 and
Flowers et al.59 described the relationship between
the lateral canthal tendon with the LOT and ORL,
also known as orbitomalar ligament as labeled by
Kikkawa et al.40
Medial Canthus
The medial canthal tendon inserts into the bony
orbit in a tripartite manner: anterior and posterior
horizontal elements and a vertical element.
McCord et al.31 defined the medial canthal
retinaculum as the deep head of the pretarsal
orbicularis, the orbital septum, the medial end of
Lockwood ligament, the medial horn of the levator
aponeurosis, the check ligaments of the medial
rectus muscle, and Whitnall ligament.
PERIORBITAL AESTHETIC GOALS
Clearly defined goals of brow and orbital aesthetics
are the basis of successful results in surgical
rejuvenation of the upper portion of the face.
The goals vary significantly with sex, age, fashion,
race, culture, and personal preference. The globe
by itself is entirely expressionless and depends on
the surrounding soft-tissue complex to convey the
myriad human emotions.
Farkas and Kolar,60 Flowers,61 and Wolfort et
al.62 reviewed the aesthetic goals of blepharoplasty.
Certain numerical guidelines are helpful in
planning the surgery. At the midpupillary line, the
anterior hairline to brow distance should measure
5 to 6 cm. The distances from brow to orbital rim,
brow to supratarsal crease, and brow to midpupil
should be 1, 1.6, and 2.5 cm, respectively.63 Canthal
tilt averages 4.1 mm (+4 degrees) in women and 2.1
mm (+3 degrees) in men.64 Visible pretarsal skin
should measure 3 to 6 mm,65 whereas lash line to
eyelid fold ranges from 8 to 10 mm.66 The upper
eyelid should cover 2 to 3 mm of the iris, and the
lower eyelid forms a lazy-S and should just meet
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SRPS • Volume 11 • Issue C2 • 2010
its inferior aspect.30 The intercanthal distance is
ideally one-fifth of the facial width at eye level and
represents one eye-width.67
The cornerstone of successful eyelid surgery
is comprehensive but judicious resection of
redundant skin, fat, and muscle while preserving
or restoring symmetry and function. Goals for the
upper eyelid include the restoration of sharp, crisp
tarsal folds and pretarsal show with deepening of
the orbitopalpebral sulcus. The lower eyelids must
appear smooth and soft. Distortion of eyelid shape
and position must be avoided. The lateral canthal
angles should be maintained as sharp and distinct.
PREOPERATIVE EVALUATION
Astute preoperative evaluation requires thorough
general medical and ophthalmic histories, physical
examination, and photographic documentation of
the appearance and function of the globe, eyelids,
and adnexal structures. With proper evaluation,
many of the unfavorable postoperative outcomes
can be anticipated and avoided. For preoperative
evaluation considerations, please review the
maintenance of certification continuing medical
education article on blepharoplasty by Trussler
and Rohrich.68
Jelks and Jelks69 detailed the steps of
preoperative evaluation of a patient before
blepharoplasty. In decreasing order of importance,
they are as follows:
•• detailed ocular history
•• assessment of the ocular and periocular anatomy
•• Schirmer test
•• tear film breakup time
•• assessment of Bell phenomenon
The history should include subjective
assessment of vision, use of corrective lenses and/
or contact lenses, symptoms of dry eye, facial
nerve disorders, hypertension, bleeding disorders,
endocrine disorders, cataracts, glaucoma, diabetes,
corneal or previous eyelid surgery, psychiatric
disorders, trauma, and medications. The physical
examination should document any existing skin
lesions and dermatological conditions.69 The status
of the extraocular muscles should be documented.
The bony topography and asymmetries should
6
be noted. Malar hypoplasia should be recognized
preoperatively. Jelks and Jelks69 described the
relationship, as seen on lateral view, among the
anteriormost projection of the globe, the lower
eyelid margin, and the malar eminence. A “negative
vector” is one that angles posteriorly and indicates
an absence of support for the lower eyelid. Because
patients with negative vectors frequently exhibit
scleral show, appropriate modifications of lower
eyelid surgery are indicated in such cases.30
The upper eyelid examination should
document asymmetries, ptosis, levator function,
skin and fat excesses, and eyelid retraction.
Examination of the upper eyelid is performed with
the brow in its normal resting position and in an
elevated position simulating browpexy.
The lower eyelid is assessed for scleral show,
eyelid position, eyelid tone and support, entropion
and ectropion, malar bags, nasojugal folds, and skin,
muscle, and fat excess.70 The snap back test consists
of pulling the eyelid down as far as it will go and
watching its return to normal position when
released. Hinderer71 summarized the standard tests
for lower eyelid laxity.
Unfortunately, the eyelid snap back and
distraction tests are unreliable predictors of
postoperative eyelid malposition. Codner et al.72
suggested pulling the incised lower eyelid laterally
to determine intraoperatively the degree of laxity.
The distance the lower eyelid stretches from the
lateral commissure to the orbital rim represents
the amount of redundancy and dictates treatment:
<3 mm overlap of the lateral orbital rim generally
is managed with a suture canthopexy, but more
severe redundancy usually requires canthoplasty. A
prominent globe is also a high-risk indicator for
postoperative eyelid malposition.72
Other preoperative evaluations should include
the visual acuity in each eye, with and without
correction, and a basic funduscopic examination. A
Schirmer test can aid in screening patients prone to
dry eye conditions postoperatively. The presence of
Bell phenomenon should be noted.
PITFALLS
Jelks and Jelks69 presented a review of the problems
SRPS • Volume 11 • Issue C2 • 2010
that can occur in association with palpebral and
periorbital surgery.
Ptosis, Pseudoptosis, and Eyelid Retraction
Depression of the eyelid margin to a position lower
than normal (with relation to the limbus in central
gaze) is a sign of possible ptosis. An elevated
position of the supratarsal crease suggests levator
dehiscence. Jones et al.73 presented a discussion
of the anatomy and pathology of eyelid ptosis.
Possible causes of ptosis include trauma, chronic
progressive external ophthalmoplegia, Horner
syndrome, myasthenia gravis, and upper eyelid
tumors.31 Pseudoptosis occurs when excess skin is
present and hooding depresses the upper eyelid.
Pseudoptosis can be differentiated from true ptosis
by elevating the excess skin. Eyelid retraction is
indicated by elevation of the eyelid margin above
the limbus. The most common cause of eyelid
retraction is thyroid infiltrative ophthalmopathy.74
Ptosis, pseudoptosis, and eyelid retraction must
be accurately diagnosed preoperatively so that the
appropriate levator surgery can be performed.
Malar Hypoplasia and Prominent Globe
Jelks and Jelks30,69 analyzed the influence of the
anatomic relationships of the orbital region on the
outcome of lower blepharoplasty and suggested
adding a lateral canthoplasty in the patient with a
negative vector. With age, the orbital rim moves
posteriorly, relative to the anterior cornea, and the
negative vector becomes more pronounced.75 To
ensure stability of the surgical result, McCord et
al.76 recommended redraping of the inferior arc
of the orbicularis oculi and lateral canthoplasty
as adjuncts to blepharoplasty in the aging face.
Patients who have scores of ≥19 mm on Hertel
exophthalmometry are at increased risk of
“clotheslining” when the lower eyelid is tightened,
in which case both orbicularis oculi arc redraping
and lateral canthoplasty require supra-placement
of fixation.
Dry Eyes
Rees and Jelks77 and Jelks and McCord78 reviewed
dry eye syndrome. Symptoms of itching, foreign
body sensation, burning, mucoid secretions,
frequent blinking, and conjunctival infection
suggest dry eyes. The diagnosis is made clinically
when mucous filaments are seen on a dull,
gray-appearing cornea, by corneal staining with
fluorescein testing, and by a positive result to a
Schirmer test. The Schirmer I test measures both
basic and reflex secretions, whereas the Schirmer
II test measures basic secretion by using a topical
anesthetic to block reflex tearing.
Per Rees and Jelks,77 a strip of #41 filter paper,
5 × 35 mm, is folded 5 mm at one end. The folded
end is placed on the lateral one-third of the lower
eyelid conjunctiva, and the patient is requested to
fix the gaze on an object above the direct line of
vision for 5 minutes. Less than 10 mm of wetting
(of the paper) is considered hyposecretion. The
normal range is between 10 and 30 mm.
McKinney and Zubowski79 found the
Schirmer test to be an unreliable predictor of
possible dry eye complications after blepharoplasty.
The authors reported that the best predictor of dry
eye was an abnormal preoperative ocular history or
abnormal orbital and periorbital anatomy.
In a 10-year update of their 1989 study,
McKinney and Byun80 confirmed their original
impression and noted that they did even less
preoperative tear film testing at the time of the
second writing in 1999. They preferred to rely
on the history and the anatomy as predictors of
postoperative dryness, particularly the presence of
scleral show, lagophthalmos, or a loose lower eyelid
that is not adherent to the globe in its outer third.
Rees and LaTrenta81 noted that 65% of
patients with postoperative dry eye syndrome
had normal preoperative Schirmer test findings,
and proposed five clinical variables that indicate
morphologically prone eyes, as follows:
•• relative or real proptosis
•• exophthalmos
•• hypotonia of the lower eyelids
•• maxillary hypoplasia
•• inferior scleral show
These anatomic characteristics were found
to be statistically significant predictors of dry eye
syndrome, more meaningful than measured low
tear film. Patients who exhibit one or more of these
criteria should be treated with caution. The patients
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SRPS • Volume 11 • Issue C2 • 2010
can still undergo blepharoplasty as long as adequate
ocular protection is provided and the procedure is
altered to include a variety of
reconstructive measures.
Lee et al.82 discussed changes in the cornea
after keratorefractive surgery and the effect of
the changes in patients seeking blepharoplasty
surgery. The authors recommended a 6-month
wait after laser vision correction before performing
blepharoplasty surgery. The patient might develop
dysfunctional tear syndrome after laser
vision correction.
Lower Eyelid Laxity and Ectropion
The most common complication of lower
blepharoplasty is distortion of the eyelid.
Preoperative eyelid laxity and ectropion must be
identified, shown to the patient, and accounted
for in the surgical treatment plan. Failure to do so
can lead to a typical deformity with marked scleral
show worsening laterally, rounding of the lateral
canthus, and a narrowed intercanthal distance.83
Carraway and Mellow70 suggested other conditions
that cause lower eyelid malposition:
•• large globe
•• hypoplastic malar eminences
•• paralysis of the orbicularis oculi
•• adhesion of the orbital septum
•• hematoma
•• lax eyelid margin
•• proptosis
•• excessive skin, fat, or muscle removal
•• scar contracture
Postoperative malposition of the lower eyelid
can be prevented by preoperatively checking for
horizontal tension of the eyelid with a snap back
or distraction test and identifying any scleral show.
The tests were summarized by Hinderer.71
UPPER BLEPHAROPLASTY
Incisions
By the 1930s, the basic blepharoplasty incisions
had been described and standardized. The incision
is placed 9 to 12 mm above the ciliary margin at
the level of the upper edge of the tarsus. Baker et
al.,66 Ellenbogen and Swara,84 Gradinger,85 and
8
Flowers65 emphasized the need for precise planning
of the lower aspect of the incision. The superior
aspect of the incision is determined by marking the
level of overhanging skin after grasping the upper
eyelid skin with Adson forceps.
An alternative way to estimate the upper
skin excess was proposed by Silver,86 who marks
only the eyelid crease and then redrapes the upper
eyelid skin downward and removes the excess.
Stambaugh87 compared both techniques and found
no significant difference between them regarding
the amount of skin that is excised. Flowers65 noted
that the minimum distance from brow to fold is 12
mm, which is the minimum amount of skin that
must be preserved. Modifications of the medial and
lateral aspects of the incision for dealing with skin
redundancy at either end include medial Z-plasty,88
lateral Z-plasty,89 lateral W-plasty,90 and
lateral Y-V-plasty.91
Most authors use a scalpel to create the initial
skin incision. Tebbetts92 used a needlepoint Bovie
on blended cutting current for skin and muscle
resection. He reported that cautery helps to obtain
hemostasis and minimize tissue morbidity.
Mittelman and Apfelberg93 compared
the CO2 laser with conventional techniques
of blepharoplasty in 10 patients and found
no difference in postoperative pain, swelling,
ecchymosis, quality of scars, or long-term results.
Intraoperative findings did suggest improved
hemostasis, however. David and Sanders,94 in a
similar study of 13 patients, found no difference
in final cosmetic appearance but did observe less
ecchymosis and edema with laser surgery. Trelles
et al.95 questioned the methodology of the study
by David and Sanders and cited his own favorable
experience in 560 cases of blepharoplasty with the
CO2 laser. Januszkiewicz and Nahai96 removed
the medial fat pad in the upper eyelid through
a transconjunctival incision followed by CO2
laser resurfacing to address the skin excess in
selected patients. Guerra et al.97 reported use of
the transconjunctival approach in 42 patients for
the treatment of pseudoherniated upper medial
fat with little or no excess skin. Halvorson et al.98
reported their 10-year experience in marking for
SRPS • Volume 11 • Issue C2 • 2010
upper blepharoplasty using a simple method to
achieve expectations after surgery.
Muscle Excision
Opinions vary regarding the amount of muscle to
resect during upper blepharoplasty, if any. Baker99
excised a strip of orbicularis oculi 5 to 8 mm long
from immediately above the supratarsal fold in all
cases. Tebbetts92 reported that a generous muscle
resection, excising only 2 to 3 mm less than the
skin resection, is necessary to avoid the excess
orbicularis oculi from obscuring the supratarsal fold
and to allow a natural fixation. Flowers65,88 removed
a maximum of 2 to 3 mm of muscle and cautioned
that tenting up the muscle during the excision can
lead to inadvertent transection of the septum and
levator aponeurosis.
Fat Excision
The septum should be opened cautiously, placing
pressure on the globe to identify the fat and
septum. The incision is made somewhat high to
avoid the insertion of the septum and aponeurosis
inferiorly. Flowers65 angled the incision upward,
considering that the union between the septum
and aponeurosis is higher in the central portion
of the eyelid than laterally. Tebbetts92 indicated
several landmarks to look for during fat resection
and recommends resecting only the fat that bulges
anterior to the plane of the orbital rim without
retraction or globe pressure. The dissection should
be anterior to the septal plane to avoid injuring the
neurovascular structures or extraocular muscles.
Over-resection of fat will lead to an undesirable
“hollowed out” look.
Kranendonk and Obagi100 reported the details
of their fat transfer techniques as an enhancement
of volume restoration using autologous fat
transplantation. An argument against surgery of the
eyelids was suggested because of the cosmetically
unacceptable results that the authors often observed
after those operations. Hamra101 provided a strong
argument opposing relying on fillers for facial
rejuvenation, considering that surgery is the gold
standard against which to compare results. He
reported the long-term follow-up of patients who
had undergone surgical anatomic correction and
presented follow-up photographs that span
many years.
Supratarsal Fold and Fixation
When the levator contracts and pulls the eyelid up,
the dermal attachments of the levator aponeurosis
produce a fold in the skin of the upper eyelid at the
level of the superior tarsus (Fig. 2).39 Traditional
methods for reconstituting the crease after
blepharoplasty involve precise surgical planning
of the lower incision and strip orbicularis
oculi excision.
Fernandez,102 Sheen,103 and Flowers104
proposed fixation of the pretarsal orbicularis
oculi or dermis—an anchoring technique—to
create a more precise upper eyelid crease. Several
blepharoplasty surgeons, including McCord et
al.,31 Hinderer,71 and Siegel,105 also have reported
incorporating some type of anchoring sutures into
their blepharoplasties (Fig. 3).39 The aims are to
excise less skin, recreate a more youthful upper
eyelid, and achieve longer lasting results than if no
fixation were used.
Flowers104 stated that a major problem with
traditional blepharoplasty is that the supratarsal
fold with its connections to the levator mechanism
usually is excised, leaving a less-distinct fold than
preoperatively. He cited photographs presented
in an article by Baker99 to support the need for
tarsal fixation. Baker, however, reviewed his
blepharoplasty cases and did not find long-term
improvement in the crease with the anchor
technique. Spira106 analyzed his own cases
and likewise could not confirm any benefit of
supratarsal fixation.
Asian Eyelid
The Asian upper eyelid is characterized by an
absent palpebral crease, a medial epicanthal fold
hooding the caruncle, upward tilt of the lateral
canthus, and a narrow palpebral aperture.107,108 The
levator muscle inserts into the superior tarsal edge,
but no fibrous extensions continue through the
orbital septum to the pretarsal orbicularis oculi. The
lack of attachment frequently allows the pre-levator
fat to prolapse inferiorly, making the eyelid
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SRPS • Volume 11 • Issue C2 • 2010
appear puffy.102
In 1954, Sayoc109 described an operative
procedure designed to produce a more Western
appearance to the Asian upper eyelid. Twenty
years later, Sayoc108 reviewed his and other authors’
experience with the procedure.102,108−111
Several surgeons102,108−115 have reported their
individual modifications of the blepharoplasty
operation for use in Asian eyelids. Most of the
procedures involve at least some of the original
elements proposed by Sayoc,109 including
the following:
•• supratarsal incision
•• excision of a 2-mm strip of orbicularis oculi over the entire length of the eyelid
•• removal of excessive pre-levator fat
•• anchoring the lower muscle and/or skin flap to the insertion of the
levator aponeurosis at the upper tarsal edge to construct the absent fibrous attachment
Combined with levator excursion, these maneuvers
help create an upper palpebral fold.
Baek et al.116 proposed a single-stitch, nonincision technique to create an aesthetically
pleasing supratarsal fold in Asian eyelids, with
minimal morbidity. Their 762 patients were
followed for up to 5 years, by which time the fold
had disappeared in 2.9%. The authors concluded
that the procedure is indicated in young patients
whose upper eyelids have thin, non-redundant skin
and no excessive fat.
Bang117 described the double-eyelid
operation without supratarsal fixation for creating
a supratarsal fold in Asian patients. Watanabe118
noted that the Asian upper eyelid grooves differ in
position and shape from those of Europeans. He
devised a method for determining the amount of
excess skin to remove from the upper eyelid.
Yoon and Park119 reported their experience
with 241 young Asian patients who underwent
blepharoplasty to create supratarsal folds. The
authors described their systematic approach
and selective tissue removal based on increasing
degrees of skin thickness and eyelid puffiness, from
resection of peri-incisional tissue only to pretarsal
10
tissue, orbital fat, and upper retromuscular fatty
tissue in the more severe cases.
Zubiri120 illustrated differences between
European and Asian eyelids and noted three
variants of the supratarsal fold as it relates to the
epicanthus. Correction of the epicanthal fold by
some form of Z-plasty frequently is necessary108
to complete the conversion of Asian eyelids to
a European look. Zubiri120 and Hin121 discussed
potential complications of blepharoplasty in
Asian patients and detailed methods for
secondary revision.
The epicanthal fold does not need to be
modified in most cases and probably should not
be unless it constitutes a severe deformity. del
Campo107 used a Z-plasty technique, whereas
Flowers65 preferred a V-W-plasty for correction
(Fig. 4).103 Wu122 reported a simple and useful
technique in epicanthoplasty with minimal scar
as a modification of the technique presented
by Fukuta.
Figure 4. Illustration shows basic anatomy of eyelid in
cross-section. The levator expansion perforates the orbital
septum and the orbicularis to insert into the skin at the
level of the superior edge of the tarsus. The attachments
determine the level of the palpebral fold. (Reprinted with
permission from Sheen.103)
SRPS • Volume 11 • Issue C2 • 2010
Kim et al.123 reported their variation of
improving Asian upper lateral eyelid hooding
by an infrabrow excision in a select group
of patients. Li and Ma124 shared their V-Y
epicanthoplasty technique in conjunction with
double blepharoplasty.
The Asian lower eyelid is also different.
The subcutaneous tissue has only sparse fibers of
capsulopalpebral fascia, making the lower eyelid
crease minimal and poorly defined. Compared with
European lower eyelids, in Asian eyelids, the orbital
septum fuses with the capsulopalpebral fascia at a
higher level, and the lower eyelid retractor does not
attach to skin).125
The concept of a glide zone and its
biomechanics on the blinking Asian upper eyelid
was reviewed by Chen.126 The anatomy and the role
of the upper eyelid crease and preaponeurotic space
and fat in Asian and Caucasian eyelid anatomy
were reviewed as applies to aesthetic blepharoplasty.
Chen described the necessary third layer that
should be entirely preserved to allow for frictionfree sliding of the upper eyelid blink.
Lateral Fullness
Excessive fullness in the lateral aspect of the
upper eyelid can occur secondary to brow ptosis,
prominent supraorbital rims, prominent lacrimal
gland, or subcutaneous fat.
Lassus127 described ostectomy of the superior
orbital rim in cosmetic blepharoplasty to decrease
lateral fullness secondary to prominent and
downward-slanting bony rims. Ortiz Monasterio128
described remodeling of the orbital rim with a burr
through a coronal approach.
An enlarged or herniated lacrimal gland can
also produce fullness of the lateral portion of the
eyelid. The lacrimal gland accounts for lateral eyelid
fullness in 10% to 15% of patients.129,130 Horton
et al.131 resuspended the gland to the lateral rim.
Beer and Kompatscher132 used the lateral third
of Whitnall ligament to resuspend the gland to
the orbital rim with sutures. Excision of one lobe
of the gland is discouraged because it can lead to
keratoconjunctivitis sicca.
Subcutaneous fat deposits superficial to the
orbital septum (retro-orbicularis oculi fat) can
produce excessive bulk laterally that can extend
beyond the canthal region. Owsley49 suggested
removal through the upper blepharoplasty
incision when indicated. May et al.50 reported
their experience with 63 cases. All patients had
transient lateral brow numbness but no paralysis
of the orbicularis oculi. The superior orbital nerve
courses near the medial border of the fat and must
be protected. To obtain a natural, sculpted eyelid,
the fibrofatty layer must be carefully resected with
meticulous hemostasis and painstaking feathering
of the edges.50
Gulyás133 reported a technique using
imbrication of the orbicularis oculi and grafting
of 1 ml of fat in the crease to accent fullness and
thus add to the convex appearance for a more
youthful appearance.
LOWER BLEPHAROPLASTY
Skin Flaps
In 1951, Castañares17 reported that the skin flap
method was most popular among American
surgeons. The intraorbital space is approached
through a subciliary incision, and the skin is
elevated off the orbicularis oculi to the level of the
infraorbital rim. Hinderer71 trimmed hypertrophic
orbicularis oculi fibers and removed fat after
separating the orbicularis oculi fibers and opening
the septum.
Casson and Siebert134 described their
technique for skin-flap blepharoplasty with
muscle split for easier identification of the fat
pads. In patients with malar mounds or cheek
pads, a subcutaneous dissection can be continued
onto the cheek. Doing so, however, severs the
attachments of the cheek skin to the orbital rim,
with the subsequent possibility of the heavier cheek
skin placing traction on the eyelid skin, risking
ectropion. Furnas135 addressed this concern by
limiting the subcutaneous flap to the lateral aspect
to the dissection and suspending the orbicularis
oculi and dermis.
The skin-flap-only approach is recommended
for the removal of wrinkling and redundant
skin when good orbicularis oculi tone is present.
Drawbacks of the approach are the potential
for devascularization of the flap and possible
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SRPS • Volume 11 • Issue C2 • 2010
impairment of the lymphatic drainage.
Skin-Muscle Flaps
The skin-muscle flap technique of lower
blepharoplasty was reported by Beare136 in 1967 as
the McIndoe-Beare technique. In its technical details,
the procedure is similar to other blepharoplasties
described by contemporary authors. A 2-mm
incision is made below the ciliary margin, and the
dissection proceeds through the orbicularis oculi,
exposing the orbital septum down to the level
of the orbital rim. The periorbital fat is removed
through perforating incisions in the orbital septum.
After the skin-muscle resection is redraped, a
2-mm-wide strip of orbicularis oculi along the free
upper edge of the skin flap usually is resected so
that the muscle will not overlap in the pretarsal
area). Aston137 recommended a submuscular
dissection from lateral to medial because it is
quicker and easier to accomplish than is the
classic dissection.
The skin-muscle flap is considered to be less
effective in patients with marked skin redundancy.
Rees and Tabbal,138 however, stated that the skinmuscle flap approach is indicated in more than
90% of patients, even young adults with baggy
eyelids. Spira139 compared patients who had skin
flap only on one side and skin-muscle flap on
the other and found little if any difference in
postoperative appearance between the two groups.
Putterman140 reported that the cause of baggy
eyes is the separation of the capsulopalpebral
fascia from the orbital septum that allows fat to
bulge into the lower eyelid. See also the discussion
of Putterman’s article by Codner.141 Goldberg et
al.142 presented a study of 114 patients who were
interested in lower blepharoplasty for fat pads.
The histories and photographs were evaluated for
the cause of the condition. The authors found that
cheek descent and hollow tear trough were the
most prevalent anatomic bases for lower eyelid
bags. Other anatomic bases were prolapse of the
orbital fat, skin laxity, eyelid fluid, orbicularis
oculi prominence, and triangular malar mound.
The authors concluded that surgery is designed
according to skin elasticity, extent of prolapse,
and midface descent, but no single anatomic
12
basis was identified. The discussion presented by
Codner141 raised two points of clarification: first,
the tear trough is a specific anatomic structure
that manifests as a concavity overlying the narrow
triangle formed by the origins of the orbicularis
oculi, levator labii superioris, and levator labii
alaeque nasi muscles. Second, the malar bag is
made up of fat and fluid that accumulates between
the orbitomalar and zygomatic cutaneous ligaments
at the inferior border of the orbicularis oculi.
The skin-muscle flap approach maintains the
normal skin vascularity and skin-orbicularis oculi
interface. It successfully corrects sagging from
either cutaneous or muscular causes. Because the
dissection proceeds along a relatively avascular
plane, it results in less postoperative ecchymosis,
subcutaneous scarring, and irregularity of the skin
surface.143 Associated complications include the
possibility of denervation of the orbicularis oculi
and paralytic ectropion.
DiFrancesco et al.144 presented a report of
18 eyes in nine patients. Electromyography and
video of blink and squint were evaluated before,
4 weeks after, and 12 weeks after subciliary
blepharoplasty. The results of that study showed
that lower eyelid malposition or disfunction of the
lower eyelid orbicularis oculi after blepharoplasty
could not be explained by denervation of the
zygomatic branch of the facial nerve. The most
critical recommendation for this surgery presented
by the authors is to properly perform a lower
eyelid canthal anchoring maneuver. Despite the
findings, some controversy exists. Lowe et al.145
reported their findings on dissection of 16 cadaver
heads. The authors located multiple motor nerves
to the lower eyelid without a single dominant
branch identified. Byrd146 suggested that the
terminal branches of the lateral innervation of
the orbicularis oculi are probably divided with a
subciliary transmuscular incision, which contributes
to a loss of tone in the pretarsal strip and thus
scleral show, necessitating canthoplasty. McCord
et al.147 stated that the inner canthal muscle is
innervated by the buccal branch of the facial nerve
and that the extra-canthal orbicularis oculi is
innervated by the zygomatic branch of the facial
nerve. The statement suggested that a subciliary
SRPS • Volume 11 • Issue C2 • 2010
incision is not the cause of clinical lower eyelid
denervation. The authors noted a parasitization of
sensory nerves, both infratrochlear and infraorbital,
by the buccal branch to augment its innervation
and field of effect.
Codner et al.148 reported a 10-year experience
with use of a transcutaneous incision and routine
canthal support anchor in 264 patients. The authors
achieved a very acceptable complication rate
requiring reoperation for eyelid position in 3.5%,
hematoma in 0.4%, blepharitis in 3.8%, and minor
surgical revisions in 11.7%.
Separate Skin and Muscle Flaps
Klatsky and Manson,149 Massiha,150 and Hinderer71
advocated separate skin and muscle flaps for lower
blepharoplasty. After the skin flap is elevated off
the orbicularis oculi, the pretarsal orbicularis oculi
is left intact. Massiha150 noted that the advantages
of this protocol are that it leaves the orbicularis
oculi-tarsus relationship intact and the pretarsal
orbicularis oculi innervated. Skin and muscle can
also be removed independently.
Transconjunctival
In 1928, Bourguet15 described the transconjunctival
approach to lower blepharoplasty. Almost 50
years later, Tomlinson and Hovey151 reviewed the
procedure and Schwartz and Randall152 compared
the preseptal and retroseptal approaches.
Schwartz and Randall152 stated that the
preseptal approach affords better identification
and control of the separated fat loculation. Baylis
et al.153 and Zarem and Resnick,20,154 on the other
hand, supported a retroseptal approach. The
retroseptal approach has the theoretic advantage of
leaving the septum intact, which could decrease the
incidence of eyelid retraction.
Although the transconjunctival blepharoplasty
is limited in its ability to resect skin in the pure
sense, Zarem and Resnick154 proposed that the skin
excess is often more apparent than real and that the
skin is necessary to recontour the lower eyelid after
the fat is excised. In approximately 50% of patients,
the authors used additional subciliary incision and
skin flap with skin resection in conjunction with a
transconjunctival lower blepharoplasty.155
Zarem and Resnick155 presented an update of
his experience and concluded that transconjunctival
lower blepharoplasty is superior to other techniques
in that it is possible to completely resect the
fat, avoid retracted lower eyelids and dry eye
postoperatively, and achieve long-lasting correction.
Jelks156 combined a transconjunctival
blepharoplasty with a trichloroacetic acid peel for
further skin tightening. The author introduced
the concept of “no-tack” in lower blepharoplasty,
which consists of transconjunctival fat removal,
conservative pinch skin excision, and lateral
canthopexy. The orbicularis oculi (or middle
lamella) remains undisturbed. Good results have
been achieved with the technique, as reviewed by
Rohrich et al.157 Stark et al.158 reported realigning
the intraorbital fat via a buccal mucosa incision in
addition to an endoscopic midface-lift.
McKinney et al.159 combined transconjunctival
resection of fat with full-strength Baker phenol
chemical peeling to tighten the skin. Dinner
et al.160 removed skin after a transconjunctival
blepharoplasty while leaving the middle lamellar
structures intact. The CO2 laser has also been
used to tighten the skin in conjunction with
transconjunctival blepharoplasty.161
The main disadvantages of transconjunctival
blepharoplasty are limited exposure and potentially
inadequate fat removal, particularly from the lateral
compartment.154 Baker et al.32 reported removing
slightly more fat during a transconjunctival
blepharoplasty than they would during
transcutaneous blepharoplasty to obtain the same
result in fat contouring. Possible complications
with that approach include damage to the inferior
oblique muscle and persistent chemosis.
A review from the Manhattan Eye, Ear,
and Throat Hospital162 documented six patients
who were referred with diplopia status posttransconjunctival lower blepharoplasty. The
cause of diplopia was injury to the inferior
rectus, inferior oblique, or lateral rectus muscle
from intramuscular hemorrhage and edema,
cicatricial changes within the muscle, or accidental
incorporation of the extraocular muscle in the
closure of the orbital septum. Two patients required
muscle surgery for correction, and the other four
13
SRPS • Volume 11 • Issue C2 • 2010
improved spontaneously after 6 to 8 months of
observation. The authors recommended making
the transconjunctival incision on the palpebral
conjunctival surface, not deep in the interior fornix
or on the bulbar conjunctiva.
An article by Sadove163 on transconjunctival
septal suture repair for lower blepharoplasty
argued in favor of muscle-preserving procedures.
Comments indicated that tightening of the septum
alone is not a panacea for rejuvenation of the
lower eyelid; more is required for a comprehensive
youthful result.
Orbicularis Oculi Hypertrophy
Sheen164 suggested that pretarsal orbicularis oculi
hypertrophy is characteristic of a youthful eyelid,
and suspended the upper 8 mm of the skin-muscle
flap to the tarsal plate to produce a lower eyelid
fold. Rees and Tabbal,138 however, warned of the
dangers of extrusion of permanent sutures and
ectropion with that type of technique. Fodor165
recreated the youthful bulge by leaving the pretarsal
orbicularis oculi intact and overlapping the cut
edge of the skin on the skin-muscle flap.
Castañares,166 Loeb,167 and Bernardi et al.168
advocated resection of variable portions of the
hypertrophied orbicularis oculi to reduce muscle
bulge, which they considered unsightly. Connell
and Marten169 split the muscle vertically at the
lateral canthus to lessen postoperative crow’s feet
from a hyperactive orbicularis oculi. Care must be
taken during the dissection to avoid injury to the
frontotemporal branch of the facial nerve.
de Assis Montenegro Cido Carvalho et
170
al. described their technique of resection of
the lateral third of the orbicularis oculi in 105
patients during face-lift dissection. A superficial
musculoaponeurotic system graft was placed to
avoid depression. The authors reported achieving
excellent results without increasing complications.
Orbicularis Oculi Suspension
Furnas171 offered an excellent review of the
anatomy, physiology, and surgical alteration of the
orbicularis oculi. Pretarsal hypertrophy, muscle
laxity, festoons, and crow’s feet are problems related
14
to the orbicularis oculi and dictate modification
of the blepharoplasty technique. Festoons of
hypotonic muscle are diagnosed by the “squinch
test,” in which the patient tightly contracts the
orbicularis oculi and the fold disappears. Muscle
suspension is indicated for correction in such cases.
To improve the appearance of the lateral
canthal area and reduce crow’s feet, Aston172
splayed the muscle and sutured it to the
temporal fascia under tension. In cases of large
skin folds and a thick muscle and in cases with
perceived hyperactivity of the orbicularis oculi,
the muscle ring can be divided and the ends
suspended separately.
Complementing these techniques, as an
alternative to laser resurfacing, Gruber et al.173
reported their dermabrasion technique as an
effective, economic alternative for periocular
rhytides confined to the lateral canthal region in 25
patients with no pigmentary changes.
Mladick174 preferred routine lateral suspension
of the orbicularis oculi to the orbital periosteum.
He suggested that the method reduces the risk
of scleral show and rounding of the eyelid and
produces better contact of the eyelid with
the globe.
Surgeons often suspend the orbicularis oculi
after dissection in the suborbicularis plane or
in the periosteal plane in an attempt to lift the
malar fat pad, decrease the periorbital aperture, or
both. Hamra,41 Hester et al.,175 and Moelleken176
described their respective techniques for suspension
of the orbicularis oculi to the lateral orbit or
temporal area.
Orbital Septum
The orbital septum is the fascial barrier that keeps
the intraorbital fat from protruding anteriorly.
Castañares17 and Beare136 concluded that it is not
necessary to suture and reconstruct the septum
during blepharoplasty to prevent subsequent
reherniation of fat. Tipton177 empirically confirmed
that philosophy in a series of 33 consecutive
blepharoplasties. The author sutured the septum
on one side but not the other. At a follow-up visit
2½ years later, it was impossible to detect any
significant differences between the two sides.
SRPS • Volume 11 • Issue C2 • 2010
To lessen the risk of reherniation of the
lower eyelid fat, Huang178 and Sensöz et al.179
plicated the orbital septum whereas de la Plaza and
Arroyo,180 Mendelson,181 and Camirand182 sutured
the capsulopalpebral fascia to the periosteum of
the lower eyelid. Stark et al.183 suggested a pullout
suture technique to facilitate fixation.
A comparative study of 26 patients who had
undergone capsulopalpebral fascia hernia repair in
one lower eyelid and standard blepharoplasty in the
other showed no discernible differences in aesthetic
outcomes at 6 weeks and 6 months postoperatively.
However, the capsulopalpebral fascia technique is
associated with less discomfort and pain during
the operation, less postoperative bleeding and
hematoma, and a reduced incidence of hollowing
and sunken eye appearance.184 At 11.3 years of
follow-up, the fat-preserving capsulopalpebral
fascia repair presented by de la Plaza and
Arroyo180 for palpebral bags was associated with
a lower recurrence rate than was blepharoplasty
by lipectomy in the same 26-patient cohort. The
average time for recurrence was 6.5 years in the
second group.185
van der Lei et al.186 reported 296 bipolar
coagulation assisted-orbital septoblepharoplasties
of the upper eyelid. The authors considered the
procedure to be an effective method to coagulate
the septum for shrinkage to reposition the
prolapsed fat pads. They reported no short-term (9
weeks−2 years) fat necrosis and no complications
occurring in association with their controlled burn
of the septum. A similar study187 compared the use
of CO2 laser and Colorado needle tip cautery of the
septum for non-resective shrinkage; no difference
between the two was identified.
Persing et al.188 presented a report of the
“shade” procedure. It is a variant of previously
described fascial barriers to fat herniation with
which augmentation of the infraorbital rim is
achieved by septum and capsular palpebral fascia
release from the lower eyelid, securing the fascia
and released septum to an intramuscular pocket
at the inferior orbital rim. With this procedure,
canthopexy is necessary. The procedure is indicated
for patients with lower eyelid fat herniation,
particularly in cases in which the infraorbital rim is
significantly depressed. McCord et al.189 reported
their use of Enduragen grafts for 129 eyelids. The
complication rate associated with the material was
very low. Reid et al.190 reported a septal extension,
confirming that the septum orbitale does continue
onto the tarsal plate.
Nasojugal Groove and Orbital Aperture
Loeb24 discussed the origin and management of
palpebral depressions. He described using free
fat grafts and sliding the fat from the retroseptal
area over the arcus marginalis. Hamra25 further
championed the fat-sliding technique to soften the
lower eyelid depressions and make the palpebral
aperture smaller. He later modified his technique
to include anterior reset of the septum.41 Barton
et al.27 confirmed the benefits of anterior fat
repositioning and septal reset and reported a low
incidence of complications with appropriate patient
selection. Goldberg and colleagues191,192 attested to
the usefulness of fat repositioning with
lower blepharoplasty.
Patipa193 listed the following causes of lower
eyelid retraction after blepharoplasty:
1. inadequate skin (anterior
lamellar insufficiency)
2. middle lamellar inflammation and subsequent scarring between the orbital septum and
capsulopalpebral fascia
3. lateral canthal tendon laxity
or disinsertion
4. midfacial descent
Fat pad manipulation or resection causes
inflammation that can act as a scaffold for
fibrosis between the overlying orbital septum and
capsulopalpebral fascia, resulting in lower
eyelid retraction.193
As mentioned above, several authors use
malar cheek lift and orbicularis oculi suspension to
reduce the orbital aperture.41,175,176,194 By elevating
the malar fat pad and interrupting the arcus
marginalis, the surgeon narrows the palpebral angle
and creates a more youthful appearance. Malar
cheek lifts performed through the lower eyelid have
been associated with a higher risk of lower eyelid
ectropion and malposition.175,193−196
15
SRPS • Volume 11 • Issue C2 • 2010
Goldberg197 wrote an editorial about three
targeted periorbital hollow areas in which to
inject filler and thus restore volume in lieu of any
surgical options. He noted an alternative concept in
aging (deflation) and concluded that gravitational
changes might play less of a role in aging changes
than traditionally thought. Hamra101 disagreed
and reminded the reader of the value of “real
plastic surgery” for a long-lasting, comprehensive,
harmonious rejuvenating result. Odunze et al.198
reported that the lateral canthal complex descends
relatively more quickly than in Caucasian women
because of more dramatic attenuation.
Laxity of the Lower Eyelid
Preexisting laxity of the tarsal margin combined
with slight over-resection of skin can lead to scleral
show postoperatively and, if severe enough, to
frank ectropion. Neuhaus199 studied the anatomic
etiology of horizontal lower eyelid laxity leading to
senile (involutional) ectropion in 20 patients and
noted significant attenuation of the lateral canthal
tendon. That view was shared by several other
authors.83,200,201 Neuhaus199 recommended surgery
to correct the horizontally lax canthal tendon
rather than full-thickness or tarsal resection of
normal eyelid structures in the palpebral fissure.
The following intraoperative measures help
prevent post-blepharoplasty scleral show
and ectropion:
•• temporary external support of the eyelid margin
•• wedge resection to shorten
the eyelid202−206
•• suspension or tightening of the
lower eyelid using skin or muscle components to create a
suspensory sling207,208
•• tarsal suspension to the periosteum
or soft tissue of the lateral
orbital rim209−214
•• lateral canthoplasty215,216
Lisman et al.217 reviewed the evolution
of tarsal suspension techniques for lower
blepharoplasty and described a modification that
approximates the edge of the tarsal plate to the
lateral orbital rim periosteum.
16
Jordan and Anderson218 reported their
experience with a tarsal suspension operation
during which the lateral border of the tarsus is
sutured to the periosteum just superior to the
insertion of the lateral canthal tendon inside the
orbital rim. Techniques that rely on cantholysis
and resuspension of the tarsus have been said to
be appropriate for patients with horizontal eyelid
lengthening, but Flowers83 observed that many
of the tarsal flap techniques and wedge resections
shorten the aperture and give patients the
appearance of having small, beady eyes.
Weber et al.219 illustrated several refinements
of the tarsal strip operation. Fagien220 noted that
tarsal strip procedures have been misapplied to a
number of eyelid types and conditions regardless
of horizontal eyelid length, canthal position,
orbital rim, and malar complex relationship, globe
size, or degree of exophthalmos. McCord et
al.221 reviewed the principles involved in canthal
support and illustrated the application of different
techniques for canthal anchoring depending on the
preoperative examination. Modifications are made
based on presence of lower eyelid laxity and eye
position (Figs. 5–9).
According to Fagien,220 many suture
canthoplasty and retinacular suspension procedures
have been described and have been very useful in
patients for whom there is less need to actually
shorten the eyelid, especially in aesthetic surgery.
Fagien advocated lateral retinacular suspension
according to the method presented by Jelks et al.,222
with which a double-armed suture is used to hitch
the lateral canthal tendon to the periosteum of the
upper lateral orbital rim (Fig. 10).220
The trans-canthal canthopexy used by
Hamra41 is technically straightforward and only
slightly more lateral than that used by Jelks et
al.222 Flowers83 recommended routine suspension
of the lateral canthal tendon at the time of
lower blepharoplasty and opted for a drill-hole
canthopexy to achieve lower eyelid support. The
author reported his finding of the “tarsal strap”
as a new anatomic finding. The strap anchors the
tarsus to the periosteum of the inferolateral orbit.59
Stampos223 reported the use of Lockwood ligament
to suspend the orbicularis oculi laterally.
SRPS • Volume 11 • Issue C2 • 2010
Figure 6. Illustrations show upward clotheslining in
patients with deep-set eyes (Hertel measurement, <15
mm). The position of fixation of canthal anchoring needs
to move inferiorly to prevent upward clotheslining and
narrowing of the lateral scleral triangle. It should also be
placed internally, inside the lateral orbital rim, to maintain
lid position against the globe. (Reprinted with permission
from McCord et al.221)
Figure 5. Upper illustrations, standard canthal anchoring
with lysis (canthoplasty) and without lysis (canthopexy) in
a patient with standard eye position as measured by the
Hertel exophthalmometer. The canthal anchoring is placed
at the inferior edge of the pupil. Lower illustrations, drawing
illustrates proper placement of the canthal anchoring
suture through the lower and upper lateral canthal tendon.
The canthal anchoring is placed at the inferior edge of the
pupil. (Reprinted with permission from McCord et al.221)
COMPLICATIONS
Chemosis
Chemosis is the most common nonsurgical
complication occurring in association with
blepharoplasty. It is edema of the conjunctiva and
very often occurs after eyelid or facial surgery.
Clinically, it presents as visible swelling of the
conjunctiva and has several levels of severity.
Weinfeld et al.224 reported an incidence of chemosis
of 11.5% among 312 primary blepharoplasties.
The authors presented a classification system:
type 1, acute mild chemosis with complete eyelid
Figure 7. Illustration shows downward clotheslining
of the lower lid in patients with prominent eyes (Hertel
measurement, >18 mm). In such cases, fixation for canthal
anchoring needs to be supraplaced above the inferior
pupillary edge to prevent downward clotheslining of the
eyelid. (Reprinted with permission from McCord et al.221)
17
SRPS • Volume 11 • Issue C2 • 2010
Figure 10. Illustration shows lateral retinacular suspension
canthoplasty. (Reprinted with permission from Fagien.220)
Figure 8. In patients with lax lower eyelids, the lid needs
to be shortened by lysis canthoplasty before performing
canthal fixation. This helps keep the eyelid tight against the
glove, preventing ectropion. (Reprinted with permission from
McCord et al.221)
Figure 9. Upper left, illustration shows position of drill
hole on orbital rim. In many cases, the ideal position is
higher or lower. The proper position of the drill hole can be
determined by positioning the canthus against the lateral
rim until the desired eye fissure shape is obtained. Upper
right, passage of suture and fixation to deep temporal
fascia. Lower illustration, axial view shows proper vector of
inward slant of drill hole. (Reprinted with permission from
McCord et al.221)
18
closure; type 2, chemosis-induced lagophthalmos;
type 3, subchronic lasting longer than 3 weeks;
and type 4, associated with eyelid malposition.
They also presented a comprehensive review of
pharmacological, mechanical, and surgical therapies
for the management of chemosis. The authors
emphasized the importance of prevention by
minimizing triggering factors intraoperatively and
immediately postoperatively.
Hamawy et al.225 reviewed the prevention and
management of dry eyes after surgery by addressing
risk factors before surgery (Fig. 11).224 Cheng and
Lu226 reported an effective treatment procedure for
chemosis using a 27-gauge needle for perilimbal
manipulation of chemosis using local anesthesia.
The authors observed improvement in all cases at 2
months.
Visual Loss
Approximately 78 cases of visual loss after
blepharoplasty have been reported in the English
language medical literature.227−230 DeMere et
al.231 estimated the incidence of blindness after
blepharoplasty to be 0.04%. The common event
in most reported cases is intraorbital hemorrhage,
although the source remains controversial.
The widely accepted theory suggests that
orbital bleeding increases intraorbital and
intraocular pressure, compromising ocular
circulation.232 Ischemic optic neuropathy and
SRPS • Volume 11 • Issue C2 • 2010
Figure 11. Chemosis classification system. Type 1,
mild acute edema and inflammation with complete lid
closure; Type 2, severe acute edema with inflammation
that prohibits complete lid closure (chemosis-induced
lagophthalmos); Type 3, subchronic edema and
inflammation that persists longer than 3 weeks; and Type 4,
chemosis associated with lower lid malposition. (Reprinted
with permission from Weinfeld.224)
central retinal artery occlusion are thought to be
the most common final events in most cases of
blindness after blepharoplasty.232−234 Suttcliff et
al.235 examined the sources of hemorrhage in an
anatomic study. The transconjunctival CO2 laser
approach to lower blepharoplasty revealed left eye
blindness in a case report from France.236
Acute orbital hemorrhage is a medical
and surgical emergency that demands prompt
recognition and management. Severe, permanent
visual impairment is likely to occur if the
circulation to the globe is compromised for
>90 minutes.234 The clinical signs of retrobulbar
hemorrhage include rapid onset of pain and
proptosis, usually accompanied by eyelid
ecchymosis.233 Visual acuity usually is reduced
but can range from normal to no light perception.
An emergency ophthalmological consultation
should be obtained, and treatment must not be
delayed. Retrobulbar hemorrhage without visual
impairment is managed by opening of the incisions
with decompression and exploration to identify the
source of bleeding. Usually, a source is not found.237
Retrobulbar hemorrhage with visual impairment
requires the following:
•• surgical decompression of the
orbit by opening the skin incisions and releasing the septum orbitale and the lateral canthus238
•• reduction of intraocular pressure with an intravenous osmotic agent such as 20% mannitol, 1–2 mg/kg body weight, 12.5 g administered during 3 minutes and the remainder during 30 minutes
•• further control of intraocular pressure with 500 mg of acetazolamide (Diamox; Lederle Laboratories, Pearl River, NY) by intravenous injection and then
250 mg by mouth every 6 hours239
•• administration of 95% oxygen/5% CO2 mixture to dilate intraocular and intracerebral vessels
Anterior chamber paracentesis remains
controversial.231,240 Bone decompression is
recommended by several authors if the above
19
SRPS • Volume 11 • Issue C2 • 2010
measures fail and has been successful in four
cases reported by Sacks et al.241 Hepler et al.,242
Castillo,243 and Goldberg et al.244 reviewed the
management of acute intraorbital hemorrhage
accompanied by visual loss.
Corneal Injury
Corneal injury can be prevented by careful
attention to technique and the use of corneal
shields. Hepler et al.242 suggested that if corneal
injury is suspected, fluorescein staining should be
performed under high magnification to obtain a
diagnosis. Large or deep corneal wounds should be
referred to an ophthalmologist. Superficial injuries
are managed with topical antibiotics and patching
of the eye. Patients should be examined every 24
hours or whenever they complain of pain.
Bleeding
Meticulous hemostasis and avoidance of
pharmacological impediments to clotting
are imperative in preventing bleeding after
blepharoplasty. Lisman et al.245 outlined preventive
measures. Likely causes of hemorrhage include
traction on the posterior vessels during aggressive
fat resection, poorly controlled fat pad vessels
that retract into the orbit, and bleeding deep into
the orbit from the cut edges of the orbicularis
oculi.233,235,245,246
Careful examination is required to
differentiate a localized hematoma from a sightthreatening hemorrhage. Eyelid hematomas are
anterior to the septum, without ocular symptoms.
In the event of persistent bleeding or inability
to rule out postseptal hemorrhage, the wound
should be reexplored. Superficial hematomas might
require observation only. Evacuation, if necessary,
is performed in 7 to 9 days to allow time for
liquefaction of the hematoma.228,247
Diplopia
Temporary diplopia has been attributed to wound
reaction, edema, and hematoma.248 Permanent
strabismus results from structural damage to the
extraocular muscles or nerves. Lowry and Bartley227
stated that the inferior oblique muscle is most
frequently injured and the superior oblique muscle
20
the second most frequently injured. The mechanism
of injury has been postulated to be excessive use
of cautery or direct trauma during injection of the
local anesthetic.249,250 Secondary blepharoplasty
seems to be a risk factor for the development of
diplopia after surgery. Conservative management
and close observation are recommended until no
further improvement occurs. Refractory cases can
be referred for appropriate strabismus surgery.227
Ptosis
The most frequent cause of perioperative upper
eyelid ptosis is the failure to recognize the
condition preoperatively.251,252 Nevertheless, upper
eyelid ptosis can result from direct injury to the
levator aponeurosis during blepharoplasty. Baylis
et al.253 suggested that such injury occurs at the
inferior one-half of the skin-muscle excision, where
the levator merges with the septum. Any injury
that is recognized intraoperatively or immediately
postoperatively should be repaired immediately.
Lagophthalmos
Lagophthalmos often occurs to some degree during
the first week after blepharoplasty. Lagophthalmos
is well tolerated by patients who have normal
tear production and resolves with conservative
treatment such as lubrication, massage, eyelid
taping, and patching.227 Persistent lagophthalmos
can occur secondary to excessive skin resection
or incorporation of the orbital septum in the
incisional scar. If conservative treatment fails to
control ocular exposure, definitive surgical therapy
is required, releasing the retraction by recreating
the defect and applying a full-thickness
skin graft.254
Ectropion
Malposition of the lower eyelids is the
most common and possibly the most visible
complication of blepharoplasty. Carraway and
Mellow70 stated that the ultimate position of the
lower eyelid is determined by a balance of forces:
the tarsus and canthal ligament pulling up against
gravity; the pretarsal orbicularis oculi muscle fibers
acting to support the eyelid; and cicatricial forces
of skin, orbital septum, and capsulopalpebral fascia
SRPS • Volume 11 • Issue C2 • 2010
pulling inferiorly. According to the authors, the
possible causes of ectropion are as follows:
•• excessive skin, fat, or muscle removal
•• scar contracture
•• paralysis of the orbicularis oculi
•• adhesion of the orbital septum
•• hematoma
•• lax eyelid margin
•• proptosis
•• unilateral high myopia
Techniques for the prevention of simple senile
ectropion are described in the section, “Lower
Eyelid Laxity and Ectropion.”
McCord and Ellis255,256 and Jelks and Jelks257
proposed that mild cases of lower eyelid retraction
after blepharoplasty are the result of previously
unrecognized eyelid laxity and can be corrected
with lateral canthoplasty. Progressive degrees of
eyelid retraction must be addressed by additional
means, including vertical skin recruitment and
spacer grafts in the most severe deformities.256,257
McCord et al.258 described a special situation
requiring cantholysis to perform a criss-cross
anchoring technique of fixation of the upper and
lower canthus separately. It is indicated in the case
of primary blepharoplasty in which the patient has
significantly prominent eyes and supra-placement
of the lateral drill hole will not suffice, nor will
release of the capsular palpebral fascia for sufficient
superior displacement (>2 mm). Insertion of a
posterior lamellar spacer might be required.
Over-resection/Under-resection of Fat
Excessive intraorbital fat resection can result in
a hollowed out socket.25 Inadequate fat resection
most likely occurs in the upper and lower medial259
and lower lateral260 fat compartments. Maniglia et
al.261 reported a technique for surgical correction of
a sunken upper eyelid.
Asymmetry
By far the most common complication associated
with blepharoplasty is asymmetry of the results.262
Fortunately, this is generally addressed satisfactorily
with subsequent operations.
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