Chapter 110: Blepharoplasty

Five of the nine options will be used. Options: Answer is given in Fig. 110.2. v. i. ii. iii. iv. E. Müller’s muscle A. Levator palpebrae superioris F. Inferior oblique muscle C. Inferior rectus muscle Fig. 110.2 Anatomy of the eyelid.

2. Correctly identify the anatomic components of the eyelid and extraocular region on the diagram (Fig. 110.3). Six of the nine options will be used. Answer is in Fig. 110.4.

The orbicularis oculi is a sphincter muscle surrounding the eye aperture. It has three portions: orbital, preseptal, and pretarsal which relate to the underlying structures, respectively. The functions of each are different. For example, the orbital part is under voluntary control and causes tight closure of the eye and medial brow depression. It is the outermost part and lies superficial to the corrugators and procerus. It is innervated by the frontal and zygomatic branches of the facial nerve (CN VII). The preseptal part is involved in both voluntary and involuntary actions including blinking. The pretarsal part is involuntary and also assists with blinking. Both parts are primarily innervated by the zygomatic branch of the facial nerve. The superior and inferior recti are both extraocular muscles involved in the movement of the globe, causing elevation and depression, respectively. They are innervated by the oculomotor nerve (CN III) and work in conjunction with the other extraocular muscles to coordinate eye movement.1,2

4. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002;110(3):873–884, discussion 897–911

5. Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed. St Louis, MO: Quality Medical Publishing;

The capsulopalpebral fascia is the lower eyelid equivalent of the levator muscle. It originates from the inferior oblique muscle fascia and inserts on the septum below the tarsus. In contrast to the levator muscle, it has only a subtle action on the lower eyelid, resulting in a couple of millimeters of migration only (Fig. 110.5). Lockwood’s ligament is a hammock-like structure that supports the globe; it is part of the tarsoligamentous complex shown in Fig. 110.5. The tarsoligamentous complex is a connective tissue framework supporting the eyelids and globe. It also includes the upper and lower tarsal plates and the medial and lateral canthal ligament complexes. The orbital septum is an extension of orbital periosteum that extends from the orbital rim to the eyelid retractors. The arcus marginalis is the fibrous attachment of the eyelid to the inferior orbital rim and represents the origin of the septum from the periosteum. It is released during some lower eyelid blepharoplasty techniques, but it does not cause downward migration of the eyelid.1–3

Müller’s muscle is a component of the upper eyelid. It is a small muscle responsible for 2 to 3 mm of eyelid elevation. It originates from the levator palpebrae superioris and is essentially the deep continuation of this muscle where it inserts on the superior edge of the tarsus. It has sympathetic innervation and, when denervated, results in a subtle ptosis on the affected side.1 This clinical appearance is classically seen as a triad of features due to loss of sympathetic function known as Horner’s syndrome. This includes upper eyelid ptosis, meiosis (pupillary constriction), and anhidrosis (loss of sweating on the affected side). Causes include tumor compression of the nerves, cerebrovascular injury, and spinal cord injury.2

Orbital fat is physiologically different from normal body fat and is minimally affected by diet. In addition, the fat cells are smaller, the fat is more saturated, and it is less metabolically active and has less lipoprotein lipase. There are also subtle differences in fat type within the orbit; for example, the medial compartment fat of the upper eyelid is more vascular than the others and has more pallor, smaller lobules, and more fibrous tissue. Fat content of the periocular region is important, as it affects the appearance of the eyes. The Eisler fat pad is a small pocket of fat above the lateral canthus, which is a good landmark for canthoplasty and canthopexy procedures.1–3 Whitnall’s ligament Lockwood’s ligament Capsulopalpebral fascia Arcuate expansion Fig. 110.5 The capsulopalpebral fascia is shown as it originates from the inferior fascia and inserts on the inferior portion of the tarsus and orbital septum.

The upper eyelid has two postseptal fat compartments: middle and medial (the lacrimal gland occupies the lateral compartment. These are separated by the trochlea of the superior rectus muscle which acts to abduct, depress, and internally rotate the globe. It is the only extraocular muscle to be innervated by the fourth cranial nerve (trochlear nerve). In contrast, the lower eyelid has three fat compartments, and the lateral and central compartments are separated by the inferior oblique muscle. This abducts and elevates the globe and is innervated by the oculomotor nerve CN III. The fat compartments are relevant to blepharoplasty, as they can be manipulated during the procedure. In some cases, the fat within the compartments can cause excessive bulkiness to the eyelids and is therefore removed or cauterized during blepharoplasty. In the lower eyelid, redraping of the fat may also be undertaken to smooth off the eyelid cheek junction.1–3

There is individual variation in the measurements of the eyelids and brow. However, in most individuals, there are some standard measurements usually quoted during forward gaze1 • Palpebral fissure: 12 to 14 mm vertically, 28 to 30 mm horizontally • Visible pretarsal skin: 3 to 6 mm • Lash line to supratarsal crease: 8 to 10 mm • Lateral canthus: 1 to 2 mm above medial canthus (i.e., positive canthal tilt) • In the midpupillary line: Anterior hairline to brow: 5 to 6 cm Brow to orbital rim: 1 cm Brow to supratarsal crease: 12 to 16 mm Brow to midpupil: 2.5 cm1–5

The Asian eyelid is distinctly different from other races. The key differences are descent of the preaponeurotic fat and absence of the supratarsal fold (or short supratarsal crease). This gives the upper eyelid a fuller and less well-defined appearance. In addition, the tarsus is also shorter (Fig. 110.6).1 Absence of the eyelashes is termed madarosis. It is associated with multiple conditions ranging from skin conditions such as eczema, through autoimmune diseases such as lupus and scleroderma, to malignancies such as sebaceous gland and squamous cell carcinomas. It is not specifically related to a particular racial group.2 Neutral vector line Positive vector line Negative vector line A B C Fig. 110.6 A–C On sagittal view, a line between the most anterior projection of the globe and the malar eminence. A positive vector exists when the most anterior projection of the malar eminence is anterior to the most anterior projection of the globe.

Blepharochalasis is a condition with thin, excessive upper and lower eyelid skin caused by repeated bouts of painless edema. It most often occurs before the age of 20 years and is refractory to antihistamines and steroids.1 Dermatochalasis refers to an excess of upper eyelid skin and is a common indication for upper eyelid blepharoplasty. Steatoblepharon is a condition where fat protrudes through a lax septum. Again, this can be an indication for blepharoplasty. Blepharoptosis is drooping of the upper eyelid that may be caused by muscle weakness, nerve injury, or traumatic disruption of the levator mechanism. This condition may be an indication for specialized lid repair, depending on cause and its degree of resulting dysfunction.2 Pseudoblepharoptosis is an appearance of ptosis with a normal lid position, commonly due to a ptotic brow and excess brow skin. Brow lift may be indicated in such cases.

Understanding the concept of positive and negative vectors in blepharoplasty is critical in decision-making for surgery. This term refers to the relationship of the lower eyelid to the orbital rim, as seen on lateral view. It considers the anterior projection of the globe compared with the most anteriorly projecting portion of the lateral orbital rim. A prominent eye is described as having a negative vector, where the anterior portion of the globe is anterior to the orbital rim. In this case, a lower eyelid blepharoplasty risks development of downward “clothes lining” of the lower eyelid below the inferior limbus (i.e., the lower lid becomes too tight and slides under the globe, leading to a low eyelid with scleral show and ectropion). A deep-set eye has a positive vector, and in mild cases this does not represent a problem for a standard lower lid blepharoplasty, because tightening the lower lid will tend to act as a snug hammock for the globe. In more severe cases, patients will need lower and deeper lateral canthal anchoring, however, because a standard canthal position would cause upward “clothes lining” of the lower lid with narrowing of the eye fissure and a reduction in the size of the lateral scleral angle.1 Eye prominence and vector assessment can be formally measured using a Hertel exophthalmometer. With this tool, a normal globe prominence should be 16 to 18 mm. A prominent eye would be 19 mm or more, and a deep-set eye would be 15 mm or less.1 The Bell’s phenomenon is a natural protective reflex and refers to upward movement of the globe during eye closure. Where this is absent the patient is at increased risk of dry-eye symptoms with postoperative lagophthalmos. Schirmer’s test assesses the lacrimal function and, if positive, indicates that dry eye is present preoperatively. It can be performed with or without local anesthetic depending on whether reflex secretion is to be assessed or not. Blepharoplasty should be avoided in these patients. It is vital to test for compensated brow ptosis before blepharoplasty, as this needs to be addressed before blepharoplasty, otherwise it is likely that the problem will not be corrected and may even be exacerbated. In addition, excess skin may be removed, and once brow correction is achieved, there may be insufficient eyelid skin leading to lagophthalmos.1–3

Lateral upper-lid fullness is most likely caused by ptosis of the lacrimal gland. The upper eyelid has only two (central and medial) postseptal fat pads, and the lacrimal gland fills the lateral aspect. Awareness of the location of the lacrimal gland is vital when performing eyelid surgery, since damage to this structure can lead to a dry-eye condition. Although not commonly required, lacrimal glandulopexy is preferable to resection of some of the gland from a functional standpoint. Caution should always be taken when considering removing anything other than skin and orbicularis from the upper eyelid. For example, postseptal fat removal from the upper eyelid can lead to a sunken, aged appearance that can be difficult to later correct.1,2 Conversely, if fullness is in the lower eyelids, then careful removal or cautery of some postseptal fat may be indicated to decrease fullness, although again this should be done with caution. Fat transfer is not commonly performed in the eyelids, though it may be used to improve a tear-trough deformity at the eyelid–cheek junction. Septal redraping is another lower lid technique that may be useful to improve the tear-trough deformity. This releases the tight band created by the septum as it joins the maxilla and allows the fat to be used to soften the interface between the two facial zones—eyelid and cheek.3,4

15 mm of upper eyelid excursion. The superior and inferior oblique muscles are extraocular muscles involved in movement of the globe assisting with abduction and adduction, respectively. The superior rectus is one of the other extraocular muscles that causes elevation of the globe. Orbicularis oculi is a sphincter muscle located beneath the skin of the periorbital area that serves to close the eye and assists with the lacrimal gland system function, thereby having a protective role for the globe.1–3

Markings for upper eyelid blepharoplasty are key to get right in order to achieve the optimal outcome. These must be performed with the patient upright to take account of gravity on the brow position. The patient will need to close and open their eyes repeatedly during the marking procedure, as the markings need to be done with eyes closed, but the skin excess and scar placement is best guided with them open. The lower line is marked first and is placed close to the supratarsal crease usually around 10 mm from the lash line. Following this, skin excess can be assessed using non-toothed forceps. The excess, which can be safely taken without causing lagophthalmos, is noted and the upper line can then be drawn. This mark cannot be set at a specific numerical value as it will differ according to skin excess and eye shape characteristics. The skin pattern created will not normally be a symmetrical ellipse but will involve extension laterally by canting upward from the lower line to the upper line, thereby removing more tissue laterally and keeping the scar within a rhytid in the crow’s foot area (Fig. 110.7). The planned excision should not pass medially to the medial canthus but should pass laterally beyond the lateral canthus in order to remove adequate lateral tissue and blend the scar discretely.1–3

This man needs attention to multiple layers of the lower eyelid with reduction of skin, muscle, and fat. A lower lid blepharoplasty in his case would be best achieved through a subciliary skin approach allowing composite muscle Fig. 110.7 Blepharoplasty markings. and skin removal with fat redraping and or removal. This procedure should help tighten the lax muscle which will likely have a weak septum beneath it and allow redraping of the overlying soft tissues to smooth the lid–cheek junction. Most surgeons would also resuspend the lower eyelid following this with either a lateral suspension suture through the orbicularis oculi flap into periosteum at the lateral orbit or with a lateral canthopexy. No description of his lower eyelid laxity preoperatively was mentioned, and it is crucial that this is assessed. One would expect from the age of the patient and the description that there was lower lid laxity and so resuspension would be indicated. A pinch blepharoplasty is a procedure indicated in patients with good lower eyelid support, either naturally or following facelift who just have a small volume of excess lower eyelid skin with or without muscle and but no other significant eyelid concerns. In the right patient, this can be a rewarding procedure as the downtime is low, the risk of ectropion and postoperative swelling is low, and the scar is very subtle. In this case, however, it would not address the key problems listed for this patient. Transconjunctival blepharoplasty can be a discrete way to reshape the lower eyelid without creating a skin scar. However, it does not allow adjustment of skin excess, which this patient has.1–6

anterior lid distraction, but satisfactory skin volume following a previous lower eyelid blepharoplasty. Which one This woman requires lower eyelid tightening, which can be achieved with either a lateral canthopexy or a canthoplasty. In her case, given the degree of laxity, a canthoplasty is probably preferable. This would likely be performed with a lateral tarsal strip which involves denuding some of the lateral lower eyelid (overlying the canthal tendon) of skin and conjunctiva, dividing the lateral canthus, and re-securing the canthus deep in the lateral orbit with sutures passed through the inner layer of periosteum or drilled through bone. The skin and conjunctiva are removed because this part of the lid becomes buried as the lid is tightened and effectively shortened. A canthopexy is a useful and less invasive procedure where the lateral canthal tendon is not divided, but instead just resuspended deep and often higher in the lateral orbit. This can be performed using a double- ended polypropylene suture passing both needles from the lower canthal tendon through the lateral inner orbit periosteum and securing them via an upper blepharoplasty access incision. For less tightening, a Kuhnt- Szymanowski procedure would be appropriate. This involves a pentagonal excision of the lower eyelid including some tarsus and is therefore ideally indicated where there is a true tarsal excess as opposed to a lower lid laxity alone. The Loeb procedure is a technique used to improve the lower eyelid–cheek junction and involves sliding the medial postseptal fat out of its compartment into the tear trough before it is sutured to the angular muscles.1–4

Tarsal fixation techniques are used to help create a high supratarsal fold. These may be suture or no suture techniques. An example of a suture technique is the anchor blepharoplasty approach described by Flowers,1,2 which uses a permanent suture passing from the skin to the tarsus and levator. Baker et al3 described a different approach without sutures that involved resection of a section of the orbicularis oculi and allowing the skin to scar to the septum. These techniques are particularly useful in the Asian eyelid, which has an absent or short supratarsal crease. They may also be useful in other scenarios including secondary blepharoplasty, men with brow ptosis, and patients with low preoperative eyelid folds. The Asian eyelid tends to have a shorter tarsus and descent of the aponeurotic fat; so, tarsal shortening and fat transfer would not be indicated. Lid tightening is indicated in lax lower eyelids, but this is not a characteristic of the young Asian eyelid. Septal reset is used to improve a tear-trough deformity, which is not typically present in the Asian eyelid, either.

Patients who undergo blepharoplasty with removal of postseptal fat have a very small but appreciable risk of developing retrobulbar hematoma.1 This is a clinical emergency that without appropriate treatment within 1 to 2 hours can result in permanent blindness. The patient above has key signs and symptoms of this condition: proptosis, altered vision and pain, and bruising around the eye. The pathophysiology is similar to that of compartment syndrome where there is an expanding volume (continued bleeding/swelling) held within a fixed space (the bony orbit). should be placed with the head up (approximately 30 degrees) to help venous drainage and reduce swelling. Other measures also directed at relieving intraorbital pressure can be medical (such as steroids, mannitol, and acetazolamide) or surgical (such as release of the lateral canthus to decompress the globe). Mannitol and acetazolamide both act to shrink the vitreous humor, thereby reducing intraocular pressure. Mannitol is an osmotic agent that should be given intravenously in boluses of 12.5 g over 3 to 5 minutes. Acetazolamide is a carbonic anhydride inhibitor also administered intravenously (not topically) in 500 mg doses. Lateral cantholysis is required and the patient should be transferred to the operating room so that release can be performed and the hematoma fully evacuated. The risk of blindness after blepharoplasty remains exceedingly low, but given the significance of losing vision, it must still be discussed with patients preoperatively.1,2