Blepharoplasty

Author Credentials 

Myriam Loyo Li, MD
Assistant Professor
Division of Facial Plastic & Reconstructive Surgery
Department of Otolaryngology- Head & Neck Surgery
Oregon Health & Science University
Phone 503 494 5678
Fax 503 494 4631
loyo@ohsu.edu

 

Lauren B. Moneta, MD
Fellow, Facial Plastic & Reconstructive Surgery
New York Head & Neck Institute
New York, NY
Phone: 212 434 4500
laurenbmoneta@gmail.com 

Module Summary

Blepharoplasty is the surgery used to correct defects of the eyelids and aesthetically to improve the appearance of this area. The anatomy of the upper and lower eyelid and the surrounding brow and midface. This outline describes embryology, anatomy, pathophysiology, patient evaluation and treatment options. Emphasis is placed on surgical techniques for upper and lower eyelid blepharoplasty and possible complications. 

Module Learning Objectives 
  1. Describe the anatomy of the upper and lower eyelids.
  2. Explain the pathogenesis of lid dermatochalasis and fat prolapse.
  3. Review pre-operative evaluation and functional considerations.
  4. Summarize the indications for cosmetic and functional blepharoplasty.
  5. Recognize complications of blepharoplasty and understand management strategies.

 

Anatomy

Learning Objectives 
  • Explain relevant anatomy that will affect upper and lower lid blepharoplasty
    • Describe what constitutes the anterior and posterior lamella
      • Anterior: skin, orbicularis muscle
      • Posterior: tarsal plate, conjunctiva
      • Separated by orbital septum
    • Recognize eyelid layers and understand orbital septum attachments 
      • Upper lid
        • Layers, superficial to deep 
          • Inferior: Skin, muscle, tarsus, conjunctiva
          • Superior: skin, muscle, orbital septum, preaponeurotic fat pads (nasal and central) or lacrimal gland laterally, levator aponeurosis, Müller’s muscle, conjunctiva
        • Fat compartments 
          • Nasal, central
        • Describe how orbital septum fusion interacts with tarsus to create eyelid crease in Asian vs. non-Asian eyelid
          • Upper crease formed by insertion of levator fibers into pre-tarsal dermis
      • Lower lid
        • Layers, superficial to deep
          • Superior: skin muscle, tarsus, conjunctiva
          • Inferior: skin, muscle, orbital septum, fat pads, lower lid retractors, conjunctiva
        • Fat compartments and what divides compartments
          • Medial, central and lateral fat pads
          • Medial and central pads are separated by the inferior oblique muscle
          • The middle and lateral pads are separated by arcuate expasion
    • Orbital ligaments and aponeurosis
      • Whitnall’s and Lockwood’s
      • Levator aponeurosis
      • Arcus marginalis
      • Medial and latheral canthal ligament
        • Attachments
        • Function
    • Describe orbital rim and midface relation to the globe
  • Lymphovascular Supply
    • Arterial supply
      • Lacrimal and palpebral arteries 
      • Tarsal arcade 
    • Venous drainage
      • Upper eyelid
        • Superior palpebral, supratrochlear, supraorbital veins
      • Lower eyelid
        • Inferior palpebral, angular and infraorbital veins
      • Lymphatic drainage
        • Vertical incisions in the lower eyelid may lead to chronic lymphedema
  • Innervation
    • Motor including which cranial nerves assist with eye closure and opening
      • Cranial nerve VII: 
        • Main upper eyelid protraction is via orbicularis oculi
        • Secondary protraction via corrugator supercilii, procerus
      • Cranial nerve III:
        •  innervates levator palpebrae superioris and is the major upper eyelid retractor
      • Sympathetic fibers
        • Innervate Müller’s muscle and contribute to upper lid retraction
        • Inferior tarsal muscle innervation contributing to lower lid retraction
    • Sensory
      • Cranial nerve:
        • Ophthalmic division (V1):
          •  supraorbital, supratrochlear, lacrimal branches supply upper lid
          • Infratrochlear branch supplies medial upper and lower lids
        • Maxillary division (V2):
          • Infraorbital and zygomaticofacial branches supply the lower lid
    • Muscles
      • Orbicularis oculi
        • Orbital, pre-septal and pre-tarsal components
      • Levator palpebrae superioris
        • Upper lid retraction
      • Mller’s
    • Lacrimal system and tear production
      • Gland located in lateral upper lid deep to orbital septum
      • Lacrimal canaliculi at medial aspect of eyelid
References 
  1. Codere F, Tucker NA, Renaldi B. The anatomy of Whitnall ligmament. Opthalmology. 1995; 102(12): 2016-2019.
  2. Stasior GO, Lemke BN, Wallow H, Dortzbach RK. Levator aponeurosis elastic fiber network. Opthal Plast Reconstr Surg. 1993; 9(1): 1-10.
  3. Jeong S, Lemke B N, Dortzbach R K, Park Y G, Kang H K. The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. Arch Ophthalmol. 1999;117(7):907–912.

Pathogenesis

Learning Objectives 
  • Summarize factors contributing to upper eyelid dermatochalasis and fat prolapse 
    • Collagen loss in skin
    • Weakening of the orbital septum
    • Weakening of the levator aponeurosis
    • Orbital bone loss and volume change
    • Aging
    • Genetic pre-disposition, family history
    • Increased body mass index
    • Males > females
    • Lighter skin
    • Smoking
  • Recognize and define specific deformities that contribute to need for blepharoplasty
    • Lateral hooding:
      • Dermatochalsis 
      • Weakening of the orbital septum
      • Steatoblepharon
      • If severe may lead to compromise of peripheral vision
    • Identify blepharoptosis
      • Abnormally low upper eyelid margin (covering >1-2mm of superior cornea)
    • Brow ptosis
      • Brow rests just above orbital rim in women
      • Brow rests at orbital rim in men
      • Brow should be about 1.5cm superior to upper eyelid skin crease
      • Can contribute to dermatochalasis
    • Midface aging
      • Hollowing due to volume loss and soft tissue atrophy in the aging face
      • Bone loss 
      • Tear trough triad: Fat herniation, prominent orbital rim depression, malar rim retrusion resulting in a negative vector

 

References 
  1. Stutman RL, Codner MA. Tear trough deformity: review of anatomy and treatment options.  Aesthetic Surgery Journal, 2012; 32 (4): 426-440
  2. Barton FE, Ha R, Awada M.  Fat extrusion and septal reset in patients with the Tear Trough Triad: A critical appraisal. Plastic and Reconstructive Surgery, 2004; 113(7): 2115-2121
  3. Lelli GJ, StClair R, Zoumalan C. Double Convexity Deformity. In: Schmidt-Erfurth U, Kohnen T, editors Encyclopedia of Ophthalmology. Berlin, Springer; 2018. 
  4. McCord CD, Kpodzo DS, Nahai F. Malar mounds and festoons: review of current management. Aesthetic Surgery Journal, 2014; 34(2): 235-248

 

Genetics

Learning Objectives 
  • Family history
  • Cite risk factors for dermatochalasis and steatoblepharon
    • Sun exposure
    • Aging
    • Smoking
    • Family History
    • Inflammatory disease affecting the eyelids (i.e. thyroid orbitopathy)
  • Note that there is increased risk of blepharoptosis in contact lens wearers

 

References 
  1. Kitazawa T. Hard contact lens wear and the risk of acquired blepharoptosis: A case-control study. Eplasty, 2013; 13e30. Published 2013 Jun 19. 

Patient Evaluation

Learning Objectives 
  • Medical and ophthalmic history
    • History of prior corneal surgery 
  • Explain cosmetic vs functional motivations for surgical intervention
  • Anesthesia considerations
    • local or general anesthesia depending upon the surgical plan, patient and surgeon preference, and need for concomitant operations
  • Palpebral fissure evaluation
    • Distance between the upper and lower eyelid in the vertical alignment with central pupil
    • Calculated by MRD-1 + MRD-2
  • Marginal reflex distance (MRD)
    • MRD-1
      • Distance of from the center of the pupillary light reflex to the upper eyelid margin while eye is in primary gaze
      • Normal: 4-5mm
    • MRD-2
      • Distance from the center of the pupillary light reflex to the lower eyelid margin while eye is in primary gaze
      • Normal: 5mm
  • Describe the brow – eyelid relationship
  • Evaluation of the upper eyelid crease height
    • Height females: 8-10mm
    • Height males: 6-8mm
  • Evaluate lid margin at natural gaze
    • Upper: relationship to upper limbus margin 
      • Evaluate with a relaxed brow at natural gaze
      • Diagnose blepharoptosis 
    • Lower: relationship to inferior limbus; degree of expected scleral show
      • Evaluate lower eyelid position and strength
      • Test distraction and snap 
  • Explain how relationship of the anterior most projection of the globe relates to malar eminence and its implications
    • Understand the difference between a positive and negative vector as a risk factor to postoperative eyelid retraction and postoperative eye dryness
    • When to consider lateral canthoplasty or lid-tightening procedures
  • Describe ideal relationship between medial and lateral canthus
  • Cite relative contraindications to blepharoplasty
    • Recent orbital surgery
    • Recent corneal refractive surgery
    • Dry eyes
    • Psychiatric disease
    • Acute angle glaucoma
    • Some auto-immune diseases
    • Infections – active or latent
    • History of hypertrophic or keloid scarring
    • Bleeding disorder
    • Unrealistic patient expectations or goals

 

References 
  1. Inoue K, Shiokawa M, WAkakura M, Tomita G.  Deepening of the upper eyelid sulcus caused by 5 types of prostaglandin analogs. Journal of Glaucoma 2013; 22(8): 626-631.
  2. Putterman AM. Margin reflex distance (MRD) 1, 2 and 3. Ophthalmic Plast Reconstr Surg. 2012 Jul-Aug;28(4):308-11.

 

Measurement of Functional Status

Learning Objectives 
  • Snap and distraction test
    • Test of lower lid laxity
    • Evaluate how far away from the globe the eyelid moved (>10mm is concerning
    • Evaluate how long it takes to return to anatomic position
  • Be able to evaluate and assess the levator function
    • Recognize signs of levator detachment from tarsus resulting in ptosis
      • High crease suggests involutional or aponeurotic ptosis
      • May result in visual field obstruction
      • Brow elevation and frontalis contraction 
      • Measure MRD-1 (normal 4-5mm)
  • Pupil reaction
  • Goldman Visual field testing – evaluated visual field with and without eyelids and/or brow taped to evaluate the degree of improvement in visual field
  • Basic visual acuity examination
  • Slit-lamp testing
  • Schirmer testing
    • Consider testing patients with history of dry eye
    • Helps determine if tear production is adequate
  • Pupil reaction
References 
  1. Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, Marcet MM, Mawn LA., Functional Indicators for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology, Ophthalmology, 118 (2011), p. 2510-2517.
  2. Jacobs LC, Liu F, et al. Intrinsic and extrinsic risk factors for sagging eyelids. JAMA Dermatology, 2014; 150 (8): 836-43.

 

Imaging

Learning Objectives 
  • Rarely indicated 
  • Used in evaluation when there is concern for underlying pathology contributing to changes in orbital appearance and function 
  • Consider orbitopathy in the differential diagnosis in cases of exophthalmos

 

Treatment

Learning Objectives 
  • Medical therapies
    • Eyelid taping
    • Topical antibiotics, topical steroids only temporary for dermatochalasis patients with infection or inflammatory reactions respectively; not permanent treatment
    • Underlying medical conditions may contribute to dermatochalasis and should be managed primarily

 

  • Surgical therapies of the upper eyelid
    • Fundamental steps for approaching the upper eyelid
      • Pre-operative marking 
        • Inferior marking @ level of the lid crease
          • Men: central aspect 6-8mm superior to lid margin
          • Women: central aspect 8-10mm superior to lid margin
        • Superior marking
          • Use pinch testing to help identify superior edge of excision
          • Leave 20mm skin from lid margin to eyelid-brow junction
            • Generally 10-15mm skin should be left between superior planned excision and eyelid-brow junction
            • During pinch testing upper lashes should just begin to evert
    • Fundamental steps of the upper lid blepharoplasty
      • After marking infiltrate with anesthetic/epinephrine in subcutaneous plane
      • Corneal protection
      • Precise skin excision
      • Controversies regarding orbicularis oculi excision (pro: more defined supratarsal crease; con: possible eye dryness and impaired blink)
      • Consider fat pad resection or repositioning
      • Evaluate lacrimal gland ptosis
    • Describe the differences between ptosis repair surgery and upper eyelid blepharoplasty
      • This distinction is very important to prevent doing the incorrect surgery 

 

  • Surgical therapies of the lower eyelid
    • Significance surgeon preference in choosing approach
    • Subcilliary approach (aka. Skin-muscle flap approach)
      • Some authors suggest this may be indicated if significant skin resection is indicated
      • After marking anesthetic with epinephrine is infiltrated
      • Incision should be made at least 1mm inferior to lash line
      • Dissect skin flap inferiorly superficial to muscle until inferior to tarsus
      • Fat pads exposed via preseptal orbicularis and septal incision
      • Fat pads are approached individually and resected or repositioned as indicated
      • Orbicularis re-suspended
      • Skin excised and closed
    • Transconjunctival approach
      • Indicated if no plan for skin excision or if a separate skin-pinch excision only is planned
      • Mark fat pads and tear troughs prior to infiltration of anesthetic
      • Place corneal shield
      • Evert lower eyelid
      • Excise through conjunctival 4-5 mm inferior to the tarsus
      • Suspend conjunctiva superiorly with silk suture 
      • Dissection carried to orbital rim and suborbicularis oculi fat plane is entered by releasing orbicularis muscle from the rim
      • Fat pads individually approached, resected or repositioned as indicated
    • Explain indications for prophylactic lateral canthal anchoring
      • Canthoplasty vs. Canthopexy

 

  • Concomitant surgery
    • Summarize the implications of combination of blepharoplasty with other procedures including browlift, midface rejuvenation, fat transfer, and rhytidectomy 

 

  • Surgical Complications
    • Describe possible surgical complications and the associated technical errors that may lead to these complications in upper and lower blepharoplasty
    • Retrobulbar hematoma
    • Scleral hematoma
    • Corneal injury
    • Lagopthalmos 
    • Dry eye
    • Conjunctivitis/chemosis
    • Incision complications: suture granuloma, webbing of medial incision, infection
    • Diplopia
    • Lower eyelid malposition including entropion and ectropion 
    • Hallowed appearance
    • Dissatisfaction
    • Vision loss and blindness
References 
  1. Lieberman DM, Quatala VC. Upper lid blepharoplasty: a current perspective. Clinics Plastic Surgery, 2013; 40: 157-165
  2. Fedok FG, Carniol PJ: Upper Blepharoplasty. In: Fedok FG, Carniol PJ (eds.): Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery: Minimally Invasive and Office- Based Procedures, Thieme, New York, 2013, Chapter 22
  3. Jacobs LC, Liu F, et al. Intrinsic and extrinsic risk factors for sagging eyelids. JAMA Dermatology, 2014; 150 (8): 836-43.
  4. Steinsapir KD, Rootman D, Wulc A, Hwang C. Cosmetic microdroplet botulinum toxin A Forehead Lift: A New Treatment Paradigm, Ophthalmic Plastic Reconstructive Surgery, 2015; 31(4): 263-268.
  5. Jacono AA, Moskowitz B. Transconjunctival versus transcutaneous approach in upper and lower blepharoplasty. Facial Plast Surg. 2001;17:21–8
  6. Fedok FG, Perkins SW: Transconjunctival blepharoplasty. Facial Plast Surg 1996 Apr;12(2):185-95.
  7. Fedok FG: The transconjunctival approach in the trauma setting: Avoidance of complications. Am J Otolaryngol 17 (1):16-21, 1996. 

 

Case Studies

  1. 50- year-old male presents with ectropion 2 weeks after orbital floor and zygoma repair with transconjunctival approach
  • Recognize patient risk factors: age, lower eyelid snap and distractions, and orbital vector
  • Evaluate the eyelid anatomy looking at posterior shortening and incisions healing and lateral canthal tendon position and strength
  • Discuss eye protection to prevent corneal injury
  • Discuss conservative management with soft tissue massage and steroid injection and  surgical repair of lower eyelid ectropion including canthopexy, tarsal strip, release of adhesions, spacer grafts, and skin grafting
  1. 40- year-old female with dermatochalasis who comes in complaining of decreased visual field slowly over the past 10 years. She wants to know the cause of her problem and if medical insurance could cover surgical repair
  • Differential diagnosis to include eyelid ptosis, brow ptosis, thyroid disease and myasthenia gravis
  • Document the degree of visual field obstruction with photography and visual field test
  • Counsel on upper eyelid blepharoplasty (PARQ)

Review

Review Questions 
  1. What constitutes the anterior and posterior lamella of the eyelid?
  2. What muscle separates the medial and central fat compartments in the inferior eyelid?
  3. What is the name of the most commonly used perimetry test to document visual field obstruction from dermatochalasis?
  4. What are possible complications of upper eyelid surgery?
  5. List two different surgical approaches to lower eyelid rejuvenation. 
  6. What are possible complications with lower eyelid surgery?