Upper Eyelid Blepharoplasty

Blepharoplasty is currently defined as excision of excessive eyelid skin, with or without orbital fat, for either functional or cosmetic indications. ^[1] Upper lid blepharoplasty may be performed in a traditional fashion, using stainless steel instruments, or may be modified with radiosurgery incisional techniques or laser incisional techniques. ^[2] In addition to standard suture techniques, tissue adhesives have also been used for skin closure.

The eyes and periorbital area are commonly the focal point during human conversation and communication. Changes in the eyelid appearance that are caused by aging may convey an inappropriate message of tiredness, sadness, and absence of vigor, which may diminish the aesthetic appearance of the face. In some cases, the dermatochalasis (excess eyelid skin) or steatoblepharon (pseudoherniation of orbital fat) is significant enough to cause a pseudoptosis. These patients have symptoms related to the obscuration of superior visual fields.

Sex, race, and age influence the relationships of the landmarks of periorbital anatomy. The structures around the eyes differ significantly among people of different sexes and races. These unique anatomic relationships are an important framework when surgical alterations of the periorbita are designed.

The cephalometric dimensions of the periorbital region are different in men and in women. In the female, the brow and lid crease are higher and more arched, and the lid fold is less prominent. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. In white women, the crease is usually 8-11 mm above the lid margin; in white men, it is usually 6-9 mm above the eyelid margin.

In contrast to white anatomy, the Asian eyelid has more fullness of the upper eyelid, narrower palpebral fissures, medial epicanthal folds, and a lid crease closer to the eyelid margin. The lid crease in the Asian population can be absent, nasally tapered, or flat but typically lies lower and is flatter than the typical white patient. This is because the orbital septum attaches to the levator aponeurosis at or slightly above the superior tarsal border or over the anterior surface of the tarsus.

Cosmetic surgeons must evaluate the periorbital aesthetic relationships before performing blepharoplasty surgery. Additionally, a basic ophthalmology examination, including testing visual acuity and testing for dry eyes, should be performed.

Blepharoplasty may be performed as an isolated procedure or in combination with ptosis repair, or rejuvenation of the upper and lower face. In particular, the aging process affects the position of the forehead, brows, and cheek complex. These all contribute to the position and appearance of the eyelids.

Actinic and degenerative changes of the facial skeletal and soft tissues lead to loss of elasticity of the skin, fat atrophy or redistribution, downward descent of the facial units, and rhytides. These features are all evaluated in the assessment of the upper eyelid and in the planning for surgical procedures to alter the periorbital tissue.

Cosmetic eyelid surgery has been described for over a century. Aulus Cornelius Celsus discussed skin excision in the upper eyelid in his De re Medica, published in 1478. In 1818, von Graefe used the term blepharoplasty (from the Greek blepharon, meaning eyelid, and plastos, meaning formed) to describe a case of eyelid reconstruction. In 1817, Beers wrote and described the first illustration of eyelid deformity caused by fat herniation and a mechanical ptosis due to excess skin. Some authors called this finding ptosis adiposa. Fox introduced the term blepharochalasis to describe the apparent excess of eyelid skin associated with aging changes.

Aesthetically, the eyes are an important facial unit, as well as a sensitive projector of facial aging. Patients may experience tired eyes, sad eyes, or extra tissue around the eyes. Dermatochalasis, fat herniation or protrusion, brow ptosis, and eyelid ptosis secondary to disinsertion or dehiscence of the levator aponeurosis all contribute to a patient's perception for the need of an upper eyelid blepharoplasty. ^[3]

This article discusses aging changes in the upper eyelid secondary to dermatochalasis and describes surgical techniques to modify these changes. Traditional upper lid blepharoplasty techniques, indications for surgery, psychological considerations in candidates for cosmetic surgery, and complications are also discussed.

Frequency

Blepharoplasty continues to be the most common invasive cosmetic surgical procedure of the face. According to The Aesthetic Society, an estimated 104,214 blepharoplasties were performed in the United States in 2022, compared with 108,284 in 2021 and 77,022 in 2019 (prior to the coronavirus disease 2019 [COVID-19] pandemic). ^[4]

Blepharoplasty is performed more often in women than in men. Women continue to request the procedure at a younger age than males. Cosmetic blepharoplasty is most commonly performed in the fifth decade of life.

Aging changes in the eyelid are caused by a combination of degenerative and pathological processes (sun damage) that alter the skin and periorbital structures. Dermatochalasis results from aging changes in the skin and adnexal structures in the eyelid and brow. With age, the orbital septum, which is a distensible anatomical layer of the eyelid, weakens. New evidence suggests the orbicularis retains its morphology and function with age and may not be a contributing factor to dermatochalasis. ^[5]

The action of gravity on the fat and contents of the orbit produces a downward and anterior displacement of the orbital fat due to a loss of the septal and muscle support of the fat pads. Dehiscence or weakness of the levator aponeurosis may also cause an involutional ptosis associated with dermatochalasis. In the skin, the elastic fibers, collagen fibers, and ground substance demonstrate changes secondary to sun damage and degenerative processes (see Pathophysiology). The resultant loss of elasticity in the skin creates broadened surface areas of epidermis necessary to cover the protruding fat. This contributes to the redundant tissues of the upper lid.

Dermatochalasis is a process that occurs secondary to changes in collagen fibers, elastic fibers, and ground substances in the dermis and epidermis. The eyelid skin is divided microscopically, from superficial to deep, into the epidermis, the dermis, and the subcutaneous tissue. Aging and sun exposure are the primary factors that produce dermatochalasis by reducing the number of collagen and elastic fibers in the dermis. In addition, the epidermis becomes atrophic, the collagen content is reduced, and biochemical changes occur in the elastic fibers.

Upper eyelid blepharoplasty is performed for various functional or cosmetic indications. The upper eyelids protect the globe, distribute tears on the surface of the eye, and facilitate the drainage of tears through the lacrimal apparatus. If any of these functions is impaired or significant ptosis of the upper eyelid blocks vision, the physician must determine if a surgical procedure is indicated.

A literature review by Hollander et al indicated that beneficial results from upper eyelid blepharoplasty include a greater visual field and an enhanced quality of life in association with improved vision and a reduction in the number of headaches. Conflicting results were found with regard to the surgery’s impact on eye dryness and eyebrow height. ^[6]

Cosmetic upper lid blepharoplasty is an elective procedure performed to improve the appearance of the eyes. This procedure requires alteration of the relationships of the eyebrows, the sub-brow fat, upper lid dermatochalasis, or upper lid steatoblepharon. Often, the patient describes tired-looking or droopy eyes.

One of the most important issues that all facial plastic surgeons should consider is the psychological status of the cosmetic patient. The two most important issues to evaluate before the surgeon agrees to perform a cosmetic blepharoplasty procedure include the patient's motivation and expectation of the outcome. The best way to produce a satisfied patient is to have clearly defined and well-understood goals for the surgery. Patients who anticipate secondary gains such as improvement in personal relationships or professional status are not good candidates for cosmetic surgery. Patients who expect this type of result judge the success of the surgery by their own personal satisfaction rather than by restoration of aging changes.

For any physician involved in the care and surgery of the periorbital structures, thorough knowledge of the anatomy is vital in order to achieve the optimal results and to avoid potential complications. Superior to the level of the tarsus, the upper eyelid consists of several individual layers from anterior to posterior: skin, orbicularis muscle, orbital septum, preaponeurotic or orbital fat, eyelid retractors (levator palpebrae superioris and Müller muscle), and conjunctiva. At the level of the superior tarsus, the layers from anterior to posterior include skin, orbicularis muscle, fibers from the levator palpebrae, tarsus, and conjunctiva. Superficially, the skin of the upper eyelid is the thinnest throughout the body. The orbicularis muscle is divided into the pretarsal, preseptal, and orbital orbicularis, depending on the structure immediately posterior to it.

The orbital septum attaches between the bony orbital rim at the arcus marginalis and the levator aponeurosis several millimeters above the tarsus. The fat in the upper eyelid consists of medial and middle fat pads. The medial fat pad is located just medial to the medial horn of the levator aponeurosis in the upper eyelid and is considered orbital fat. It is often whiter than the preaponeurotic fat. The middle fat pad is considered preaponeurotic fat and is immediately anterior to the levator aponeurosis.

The superior levator muscle originates at the apex of the orbit and divides into an anterior aponeurotic layer innervated by cranial nerve III and the posterior superior tarsal muscle (Müller muscle) innervated by the cervical sympathetic system. The anterior aponeurosis attaches to the anterior tarsal surface with fibrotic bands that attach to the pretarsal muscle and skin, and the Müller muscle inserts on the superior tarsal border. Posteriorly, the tarsus is a plate of dense connective tissue that occupies the inferior aspect of the upper eyelid with several meibomian glands on the inferior border. The conjunctiva is attached to the tarsus and superior tarsal muscle.

In the eyelids of whites, the orbital septum inserts on the anterior surface of the levator aponeurosis 2-5 mm above the superior tarsal border. The preaponeurotic fat is located beneath the septum and is shaped by the position of the orbital septum. The eyelid crease is determined by the insertion of extensions of the levator aponeurosis to the skin. The contours of the eyelid fold are influenced by the position of the orbital septum. The eyelid crease and fold are important aesthetic landmarks and are a vital feature of the upper eyelid appearance.

In white women, the crease is usually 8-11 mm above the lid margin; in white men, it is usually 6-9 mm above the eyelid margin. In contrast, the Asian eyelid has more fullness of the upper eyelid, a lower lid crease, and narrower palpebral fissures. A medial epicanthal fold may also be present. The lower lid crease is due to the orbital septum inserting into the levator at or over the anterior surface of the tarsus. With this anatomic configuration, the lid fold overlaps and obscures the position of the eyelid crease.

Prior to surgery, the surgeon should discuss lid crease position with the patient to determine the patient's desires regarding the postoperative lid crease position. The location of the incision and the technique of closure are modified according to the desired confirmation of the eyelid crease. Some asymmetry in preoperative margin crease distance may result from disinsertion of the levator aponeurosis. This should be considered by the surgeon prior to surgical intervention. Blepharoplasty alone does not modify this asymmetry.

The globe position (hypoglobus, hyperglobus, enophthalmos) and globe protrusion should be evaluated prior to surgery. Asymmetry of globe position may alter the appearance of the superior sulcus, and blepharoplasty alone does not necessarily correct the full asymmetry.

Surgery of the Asian eyelid is unique and is not detailed in this article. However, it is important to take into account the varied shape of the upper eyelid tarsus in Asians before performing blepharoplasty. ^[7]

Patients who anticipate secondary gains, such as improvement in personal relationships or professional status, are not good candidates for cosmetic surgery. Patients who expect this type of result judge the success of the surgery by their own personal satisfaction rather than by restoration of aging changes.