Abstract

Blepharoplasty plays an important role in skin rejuvenation, with direct beauty relation to the brow and the cheek. Upper and lower eyelid blepharoplasty are suggested for the medical treatment of excess skin and/or orbital fat. Preoperative appraisal should include a complete medical and ophthalmic history, additionally a detailed cutaneous and eye checkup. Signs of preexisting dry eye should be evoked preoperatively, as they directly interact with postoperative complications. Physical examination should include brow position, eyelid ptosis, lower eyelid position, and cheek projection. Blepharoplasty can be completed by many operative solutions. This review focus on the standard skin-only upper blepharoplasty and lower eyelid conservative fat excision or repositioning.

INTRODUCTION

Ophthalmic plastic surgery generally negotiates with disorders of the eyelid, lacrimal apparatus, orbit and periocular cosmetic surgery. In the past, the normal ophthalmic plastic surgeon focused generally on the functional disciplines, with few surgeons displaying any interest in cosmetic surgery. This trend is eventually improving, and today, most ophthalmic plastic surgeons operate cosmetic surgeries and many are experts in this area of technique.

The eye is a critical piece of facial appearances, and blepharoplasty can play an essential positive role in facial overall look and the viewpoint of elderly. Blepharoplasty is one of the most commonly performed facial cosmetic treatments. Signs such as tired-looking eyes, excess skin, droopy eyelids, or circles around the eyes can enhance via blepharoplasty. [1] It can also be integrated with other facial and skin rejuvenation methods such as brow or mid-face lift, lasers or chemical skin resurfacing. [2] This article attempts to deliver an introduction of upper and lower eyelid blepharoplasty techniques.


PREOPERATIVE EVALUATION

Preoperative patient analysis for blepharoplasty should document medical and ophthalmologic history such as chronic systemic diseases and treatments. Ophthalmologic history should be obtained, involving vision, corrective lenses, trauma, glaucoma, allergic reactions, excess tearing, and dry eyes. No cosmetic surgery of the periorbital region should be performed for a minimum of six months following corneal refractory surgery. Schirmer’s test should be considered if there is history of dry eye.

In addition to complete eye examination, the estimate of the periorbital area should take into consideration skin quality and quantity, underlying three-dimensional soft-tissue contours, and the bony skeletal support.

Assessment of the upper eyelid

Upper eyelid dermatochalasis is the lack of elasticity and protection in the skin. This can provide a fold of excess upper eyelid skin, which can impair the function of the eye, consisting of supero-lateral visual area obstruction [Figure 1, top left and right] Evaluation of pre-septal and eyebrow fat pads is important in redefining the great sulcus. Analysis of patient’s old photographs assists the surgeon in repairing the younger look. Top eyelid ptosis should also be kept in mind, since it can be improved at the same time.

Blepharoplasty
Figure 1
Typical aging changes in the eyelid. Overhanging upper eyelid skin (top left and right), with prominent orbital rim hollow and lower eyelid fat prolapse (top right). Lower eyelid fat prolapse becomes less prominent in downgaze (bottom left) and more prominent in upgaze (bottom right)


Assessment of the lower eyelid

Lower eyelids should be assessed for skin excess and fat herniation, which typically presents as medial, central, and lateral fat pads. Lower eyelid fat becomes more prominent in upgaze and less prominent in downgaze [Figure 1, bottom left and right]. Downward displacement of the lateral canthus can result from disinsertion, laxity, or the presence of a prominent eye [Figure 1, top right]. Lower lid distraction test can determine the degree of laxity and guide lower eyelid canthal repositioning. The posterior displacement of the orbital rim in relation to the anterior cornea and lower lid margin, a negative vector, should be noted preoperatively. Prominent or deep-set eyes should be documented with exophthalmometry. Malar anatomy needs to be evaluated for periorbital hollows.

Assessment of the eyebrow

Brow ptosis is assessed by evaluating the position of the eyebrow in relation to the superior orbital rim. Asymmetry in the upper and lower eyelids and brow position is common and should be recognized and addressed individually.

ANESTHESIA

Blepharoplasty may be performed under either local or general anesthesia depending upon the surgical plan, patient and surgeon preference, and need for concomitant operations. A simple upper or lower eyelid blepharoplasty where only skin or fat is excised can be performed under local anesthesia. Other more invasive procedures, such as lower blepharoplasty combined with fat repositioning, mid-face lift, or endoscopic browlift may need intravenous sedation, or general anesthesia.

UPPER EYELID BLEPHAROPLASTY

Preoperative marking

Preoperative markings should be made with the patient sitting upright in neutral gaze with the brow properly positioned. The eyelid crease is situated above the ciliary margin approximately 8 to 9 mm in women and 7 to 8 mm in men. The lower limit of excision should be along the eyelid crease, and the lateral extent of the marking should be limited by an imaginary line joining the lateral end of the brow to the lateral canthus [Figure 2, top right]. The extent of excision should be at least 10 mm from the inferior border of the brow, making a pattern of skin excision as shown in the Figure 2. A skin pinch test can confirm the preoperative markings. A minimum of 20mm of vertical lid height should be preserved for normal eye closure. The location of fat should be determined and marked preoperatively.

Blepharoplasty
Figure 2
Upper eyelid blepharoplasty. Measurement is performed to leave minimum 20 mm vertical lid height (top left). Skin marking for upper eyelid blepharoplasty (top right). Subcutaneous injection of local anesthetic agent (bottom left). Skin incision with radiofrequency fine monopolar empire tip (bottom right)

Surgical technique

The upper lids should be injected superficially, with 2% lidocaine with 1:100,000 epinephrine using a 27 to 30-gauge needle [Figure 2, bottom left]. Skin incision can be made either with a No 15 Bard Parker blade or the Empire tip of radiofrequency monopolar cautery [Figure 2, bottom right]. Conservative fat excision can be performed as part of upper lid blepharoplasty [Figure 3, top right]. There are two fat compartments, medial and central that can be accessed through small incisions in the septum, teased out, and resected using radiofrequency monopolar tip. Of the medial and central fat, only the fat that comes easily into the wound is excised. It is important not to aggressively pull fat from the orbit.

Figure 3
Skin undermining and excision with radiofrequency monopolar tip (top left). Fat pad excision after incising the orbital septum (top right). Periosteal anchoring suture which helps in restoring brow fat pad fullness (bottom left). Skin closure with 6-0 Prolene™ continuous suture (bottom right)

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