Blepharoplasty: 5 Essential Technical Insights
Blepharoplasty is a popular cosmetic surgical procedure for periorbital rejuvenation, especially in aging individuals. It is considered more effective than nonsurgical methods, but it comes with challenges such as a steep learning curve, extended recovery time, and potential for appearance-altering complications.
Successful outcomes depend on understanding facial topography, patient and technique selection, and adopting a conservative approach. Modern blepharoplasty focuses on preserving tissue and enhancing volume rather than aggressive removal, as older techniques led to a hollowed appearance that emphasized aging.
In this blog, periorbital surgical anatomy, preoperative planning, and various blepharoplasty approaches and techniques will be discussed.
See below the figure illustrating the layered anatomy of the upper and lower eyelids and periorbital area. (Taken from Alghoul, 2018)
1. Surface Topography
Ideally, the periorbital area should have an anterior projection relative to the globe. Conversely, an inverse ratio leads to less aesthetically attractive eyes, which is observed in patients with prominent eyes, negative vector, and deflated cheeks and brows. A negative vector implies that the globe projects farther than the malar eminence, often associated with a lack of forward cheek projection and reduced soft tissue volume in the cheek area.
The upper eyelid can be divided into two distinct spaces: the upper eyelid fold, between the brow and upper lid crease, and the pretarsal space, which spans from the crease to the lash line. The ratio between these spaces (fold:pretarsal ratio) and their volume difference play a crucial role in determining upper eyelid aesthetics. This ratio varies from the center to the sides and differs between males and females.
A study on attractive Caucasian female models revealed that the ideal fold:pretarsal ratio averages 1.87 medially and widens laterally, peaking at the lateral limbus, with an average of 2.98. These findings highlight the significance of lateral brow vertical height and fullness, along with some degree of pretarsal show in females.
In males, the prominence of the pretarsal area is not as crucial, and the height of the upper eyelid fold is more consistent across the width of the palpebral fissure. The upper eyelid sulcus, located between the upper lid crease and the superior orbital rim, gains uniform fullness from orbital fat, contributing to the overall volume of the upper lid fold. With aging, the fat content in the upper lid can change, leading to herniation of orbital fat, causing localized bulges that obscure the sulcus. Conversely, a loss of orbital fat volume deepens the sulcus, resulting in a shadowy, sunken area under the brow and a hollowed upper lid.
For aesthetically pleasing eyes, the palpebral fissure shape and dimensions should be maintained and sometimes corrected during blepharoplasty. Aesthetically pleasing eyes have an almond shape with a superior arc that peaks medially and a slightly upward inclination of the lateral canthal angle (positive canthal tilt). The lateral canthal angle should be sharp and crisp, with the lateral commissure closely opposed to the globe, while the medial canthal angle is slightly blunted and separated from the globe by the caruncle and plica semilunaris. Assessing the size and shape of the lateral scleral triangle before and after surgery helps evaluate the palpebral fissure shape and any lower lid malposition.
The lower eyelid crease is less defined than the upper eyelid crease but is also considered a sign of youth, reflecting normal lower eyelid animation. The lower eyelid can be divided topographically into the pretarsal area, preseptal area, and the eyelid cheek junction. The pretarsal segment naturally bulges with smiling and animation due to the normal function of the pretarsal orbicularis. Orbicularis hypertrophy in some patients can cause noticeable bulges in this area, especially during squinting and smiling. The preseptal segment of the lower eyelid contains the orbital septum and orbital fat, which, when anteriorly protruded, results in distinct and localized bulges. The eyelid cheek junction is defined by the tear trough, which accentuates the orbital fat protrusion above and the upper cheek volume depletion below, creating a peak and valley visual effect and a dark shadow in the lower eyelid. Volume deflation in the upper cheek results in a central inverted triangular area of volume loss, and an additional bulge, known as the malar mound, may occur in the lateral cheek due to the descent of the prezygomatic space.
Finally, the lateral orbital area is an essential aesthetic component often overlooked. It is formed by the convergence of the lateral brow and upper lateral cheek just lateral to the lateral canthus. Graduated fullness from the lateral brow to the upper lateral cheek complements blepharoplasty results and completes the periorbital rejuvenation process.
See below the figure for a comparison of surface topography of the periorbital area between a youthful face and an aging face. (Taken from Alghoul, 2018)
2. Surgical Anatomy
The eyelid is a complex structure with different segments.
The pretarsal segment extends from the lash line to the margin of the tarsal plate and consists of skin, pretarsal orbicularis muscle, tarsus, and conjunctiva. It plays a crucial role in eyelid function and support. In blepharoplasty, the pretarsal orbicularis and tarsoligamentous sling must be preserved for proper function.
The preseptal segment makes up the majority of the eyelid and is composed of skin, preseptal orbicularis muscle, orbital septum, and orbital fat. The preseptal orbicularis can be trimmed during blepharoplasty.
The orbital orbicularis covers the eyelid-brow and eyelid-cheek junctions and is separated from the preseptal orbicularis by the orbicularis retaining ligament. The orbital fat is located deep to the orbital septum and is divided into different compartments. Understanding these structures is essential for performing various eyelid procedures like canthopexy and fat grafting.
The orbicularis retaining ligament is a septum that separates the eyelids from the cheek and brow and contributes to nasojugual and palpebromalar grooves. It consists of two segments - the tear trough ligament, located medially and ending at the medial scleral limbus, and the orbicularis retaining ligament, which is a bilamellar septum extending laterally and fusing with the lateral orbital thickening. It is important to distinguish it from the arcus marginalis, another fibrous thickening at the orbital rim. Lateral canthal fixation involves three structures attaching at different levels on the lateral orbital rim: the lateral palpebral raphe, superficial lateral canthal tendon, and the deeper lateral canthal tendon that originates from the upper and lower tarsal plates and inserts on Whitnall's tubercle.
3. Preoperative Evaluation
The preoperative evaluation for blepharoplasty aims to identify medical history and anatomical factors that may increase the risk of complications. This includes assessing poorly controlled hypertension, bleeding disorders, and the use of certain medications and herbal supplements that can lead to bruising and bleeding.
Prior cosmetic and reconstructive periorbital procedures should be documented. Patients' history of dry eye symptoms and risk factors should be carefully evaluated, as blepharoplasties can affect eyelid closure mechanics and worsen dry eye symptoms. A Schirmer test may be performed to assess tear production.
The presence of Bell's phenomenon (upward rolling of the globe when attempting to open a closed eye) is noted, while the absence of it may guide a more conservative approach. History of recent ocular or corneal surgery, such as LASIK, should be considered, and it's recommended to wait for 6 months after LASIK before performing eyelid surgery to allow normal corneal sensitivity to be restored.
Specific cosmetic complaints of the patient are verified while looking in the mirror, and standardized preoperative photographs are taken in different views to analyze periorbital topography and signs of aging. The surgical plan is then customized based on the patient's goals and desired outcome, taking into account the presenting features.
In the evaluation of the upper eyelid for blepharoplasty, three key features are assessed: the presence of a well-defined and visible crease, the degree of pretarsal show (the amount of upper eyelid skin visible above the eyelashes), and the height, volume, and contour of the upper eyelid fold.
The marginal reflex distance-1 (MRD-1), which measures the distance between the corneal light reflex and the upper eyelid margin, is checked to rule out any concurrent blepharoptosis (droopy eyelid) that may need to be addressed during the blepharoplasty.
In Caucasian females, the crease usually has a gentle arch and is about 8 to 10 mm in height from the lash line at the midpupil. It should be visible from the inner to outer corners of the eye. The desired amount of pretarsal show may vary among patients, and past photographs can be helpful in determining the ideal level for each individual. Caution is necessary for patients who already have full visibility of their crease and pretarsal space, as a standard upper blepharoplasty may lead to excessive pretarsal show, which can be undesirable.
The youthful upper eyelid fold typically exhibits a smooth surface with a gradual increase in height and volume from the inner to outer corners, blending with the lateral orbital area. In non-Asian males, the crease tends to be straighter, and the upper eyelid fold has a more uniform height and volume, with less emphasis on the visibility of the pretarsal space. Contour irregularities in the upper eyelid fold can arise from excess skin, bulging orbital fat, or a prolapsed lacrimal gland. Fat grafting may also be considered to create a smooth, full, and convex upper eyelid fold when needed. Additionally, a temporal brow lift can be a complementary procedure to upper blepharoplasty in some cases.
The evaluation of the lower eyelid for blepharoplasty includes assessing the position of the lower eyelid, looking for features like scleral show or bowing of the lateral lower lid that may indicate a risk of postoperative retraction.
The presence of a negative vector, where the lower lid travels at an upslope to cover the globe, increases the risk of retraction and should be considered. The Hertel exophthalmometer can measure corneal projection relative to the lateral orbital rim, which helps identify patients with prominent eyes who may be at higher risk for postoperative lower lid malposition.
Lower eyelid laxity and tone are examined using the "distraction" and "snap back" tests. Abnormal results in these tests may indicate increased lower lid laxity and decreased muscle tone. Any lower eyelid malposition should be evaluated, investigated, and documented before surgery.
The unacceptable cosmetic appearance of the lower eyelids can result from various factors like dark shadows due to skin pigmentation and contour irregularity from the tear trough depression and bulging orbital fat, orbicularis oculi muscle laxity or hypertrophy, skin excess, and volume loss at the eyelid-cheek interface.
The surgical plan should be customized based on the patient's specific anatomy and the risk of postoperative complications. The extent and severity of each abnormality should be carefully assessed to determine the best approach for addressing the anterior lamella (the outer layer of the eyelid).
4. Surgical Techniques
Upper Blepharoplasty: “Open Sky” Technique
Over time, upper blepharoplasty has transitioned from being a procedure focused on removing excess tissue to a more balanced and volume-preserving approach.
The "open sky" technique, as described by McCord, involves excising a myocutaneous segment of skin, orbicularis oculi muscle, and orbital septum to expose the preaponeurotic and nasal fat pads during upper blepharoplasty. Intraoperative skin markings are made, and the lateral extent of skin excision is determined by assessing skin redundancy while manually elevating and depressing the tail of the brow. The upper limit of excision is marked on the upper lid fold, and the incisions are connected with a gentle curve that tapers nasally to avoid excessive skin removal in that area.
During the procedure, skin infiltration with a local anesthetic is performed, and precise incisions are made. The orbital septum is incised to access and manage the preaponeurotic and nasal fat pads. The preaponeurotic fat is either trimmed or redistributed along the length of the sulcus. The nasal fat pad can be excised or blended with the central fat pad as needed. The skin-muscle flap is then excised at the level of the crease, taking care to prevent disruption of the levator aponeurosis attachment to the tarsal plate. Closure involves approximating the skin and muscle in one or two layers. Supratarsal fixation can be performed to stabilize the crease by reattaching the pretarsal orbicularis to the levator aponeurosis using absorbable sutures.
See below the figure for the Open-sky technique showing the upper incision, dissection through the orbicularis oculi muscle (OO) and septum (S) exposing the preaponeurotic fat pad (PF). (Taken from Alghoul, 2018)
There are two popular surgical approaches for lower eyelid rejuvenation: the transconjunctival and skin-muscle flap blepharoplasties.
The main difference between the two is that the transconjunctival approach does not involve cutting the orbicularis oculi muscle and allows the orbital septum to remain intact. It primarily focuses on skin-only excision when needed. On the other hand, the skin-muscle flap technique involves mobilizing and tightening the orbicularis oculi muscle through suspension, similar to a SMAS facelift. The term "transcutaneous" can refer to various modifications of the skin-muscle technique but may not always include orbicularis suspension.
Skin-Muscle Flap Lower Blepharoplasty
The skin-muscle flap blepharoplasty is a surgical technique used for lower eyelid rejuvenation. It involves making a stair-step incision in the skin just below the lash line, extending laterally beyond the outer corner of the eye. Dissection is performed through the orbicularis oculi muscle to reach the inferior orbital rim, where the tear trough ligament and orbicularis retaining ligaments are released. This allows mobilization of the orbicularis muscle and its overlying subcutaneous fat, which is then redraped and lifted laterally, where excess tissue is trimmed. The procedure provides excellent exposure for fat redraping and tightening of the lower eyelid, especially in patients with orbicularis oculi laxity.
However, it is considered an aggressive approach with a higher risk of postoperative lower eyelid retraction and requires skillful lateral canthal anchoring. In inexperienced hands, it can be unforgiving, particularly in patients at high risk of postoperative retraction.
See below the figure for skin muscle flap lower blepharoplasty. (Taken from Alghoul, 2018)
Transconjunctival Lower Blepharoplasty
A transconjunctival incision provides access to the orbital fat through a posterior approach without disturbing the orbicularis muscle and septum. The incision is made in the conjunctiva about 5 to 6 mm below the tarsus to avoid the fusion zone between the capsulopalpebral fascia and the orbital septum. This allows direct posterior access to the orbital fat in a postseptal plane. A subperiosteal dissection is performed, taking care not to damage the infraorbital neurovascular bundle. The tear trough and orbicularis retaining ligaments are not directly severed, but rather elevated from their periosteal origin, with an emphasis on "arcus marginalis release".
Some surgeons prefer a preseptal dissection for better access to release various structures. After fat redraping, lateral canthal tightening can be performed if needed. The conjunctival incision can be closed or left to heal by secondary intention. Skin excision techniques, such as "pinch" blepharoplasty or skin-only flaps, can be used when indicated.
5. Outcomes & Complications
Standardized outcome measures for blepharoplasty are lacking, and most studies focus on reporting complications and revision rates.
Postoperative complications may include hematoma, asymmetry, lower eyelid malposition, dry eyes, ectropion, webbing, and chemosis. The most serious complication is blindness, which can result from globe injury, retrobulbar hematoma, or fat grafting. Reported complications are generally low but may not accurately reflect common practice. Lower eyelid retraction is a significant concern and can be addressed through proper lateral canthal tightening techniques and customizing the procedure to each patient's anatomy. Chemosis, bulbar conjunctival swelling, can occur postoperatively and may require treatment with lubrication, antibiotics, steroids, and vasoconstrictive agents. Dry eye syndrome can also occur, particularly in patients with preexisting risk factors, and management includes conservative surgical approaches, continued lubrication, and treatment of inflammation.
Blepharoplasty: Anatomy, Planning, Techniques, and Safety (2018)
Upper Eyelid Blepharoplasty: Evaluation, Treatment, and Complication Minimization (2017)
Lower Eyelid Blepharoplasty: A Procedure in Evolution (2010)
Blepharoplasty: An Overview (2009)
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