Blepharoplasty plays a vital role in facial rejuvenation, with direct aesthetic relation to the brow and the cheek. Upper and lower eyelid blepharoplasty are indicated for the treatment of excess skin and/or orbital fat. Preoperative evaluation should include a thorough medical and ophthalmic history, along with a detailed cutaneous and eye examination. Symptoms of preexisting dry eye should be elicited preoperatively, as they directly correlate with postoperative complications. Physical examination should take into account brow position, eyelid ptosis, lower eyelid position, and cheek projection. Blepharoplasty can be performed by many operative approaches. This review highlights the standard skin-only upper blepharoplasty and lower eyelid conservative fat excision or repositioning.
Ophthalmic plastic surgery primarily deals with disorders of the eyelid, lacrimal apparatus, orbit and periocular cosmetic surgery. In the past, the average ophthalmic plastic surgeon focused mainly on the functional disciplines, with few surgeons showing any interest in cosmetic surgery. This trend is gradually changing, and today, most ophthalmic plastic surgeons perform cosmetic surgeries and many specialize in this area of practice.
The eye is an important component of facial aesthetics, and blepharoplasty can play a vital positive role in facial harmony and the perception of aging. Blepharoplasty is one of the most commonly performed facial cosmetic procedures. Symptoms such as tired-looking eyes, excess skin, droopy eyelids, or circles around the eyes may benefit from blepharoplasty. It can also be combined with other facial and skin rejuvenation procedures such as brow or mid-face lift, lasers or chemical skin resurfacing. This article aims to give an overview of upper and lower eyelid blepharoplasty techniques.
Preoperative patient evaluation for blepharoplasty should document medical and ophthalmologic history such as chronic systemic diseases and medications. Ophthalmologic history should be obtained, including 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 evaluation of the periorbital area should take into account 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 loss of elasticity and support in the skin. This can create a fold of excess upper eyelid skin, which can impair the function of the eye, including supero-lateral visual field obstruction [Figure 1, top left and right]. Evaluation of pre-septal and eyebrow fat pads is important in redefining the superior sulcus. Assessment of patient’s old photographs aids the surgeon in restoring the youthful look. Upper eyelid ptosis should also be noted, since it can be corrected simultaneously.
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.
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 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.