Preoperative Considerations in Blepharoplasty
Cecilia Tran, M.D.
April 22, 2004

Today we will review blepharoplasty procedures and how they have evolved over history to become so frequent today. We will review the pertinent anatomy of the eye and surrounding face. We will discuss all of the factors involved in evaluating these patients preoperatively, including the patient’s own expectations, their past medical history, ophthalmologic exam, surgical evaluation, and other facial concerns.

This was a humorous illustration found in nineteenth century text where the author proposed that excess eyelid skin could be removed by tightening these screws attached to the eyelids. The history of blepharoplasty dates back to the first century AD when Allus Cornelius Sellus, a first century Roman, described an excision of skin to relax the eyelid. As early as the 10 th century, Arabian surgeons had devised ways to excise excess skin folds in the upper eyelids that impaired vision. The term blepharoplasty dates back to 1817 when Von Graefe described a technique for repairing deformities caused by resection of cancer in the eyelids. In 1844, Sichel provided the first accurate description of herniated orbital fat. In 1907, Dr. Conrad Miller wrote the first book on cosmetic surgery entitled Cosmetic Surgery in the Correction of Facial Imperfection. His diagrams of incisions for eyelid surgery are still similar to those used today. In 1951, Dr. Castanares described the fat compartment of the upper and lower eyelids in detail and now, in 2004, blepharoplasty has become the most popular cosmetic surgical procedure in America.

The American Society of Facial Plastics and Reconstructive Surgeons reports that blepharoplasty averages 11% of their cases. The American Society of Plastic Surgery reports that more than 230,000 Americans underwent cosmetic eyelid surgery in 2002. For those over the age of 35, blepharoplasty was the most popular cosmetic surgical procedure. It surpassed liposuction, breast augmentation, rhinoplasty, and facelifts. For those between the ages of 31 to 50, blepharoplasty was performed four times more frequently than facelifts; and for those between the ages of 51 to 64, blepharoplasty was performed twice as frequently as facelifts.

In the year 2000, there was a wide age distribution for those who underwent blepharoplasty. Only 3% were in the age group between 19 to 34, 33% were between the ages of 35 to 50, almost half were between the ages of 51 to 64, and 16% were over the age of 65. This procedure has become so popular because the eyes serve such important aesthetic and functional roles. Besides their obvious role in vision and perception, they help express a person’s emotions and moods and, for people such as Grace Kelly, the eyes are a major aesthetic facial unit.

Today we will define blepharoplasty as an operation in which redundant tissues including skin, muscle, or fat are excised from the eyelid. The goal is to eliminate and correct any laxity and redundancy of the skin, to remove any pseudoherniated fat, and to correct abnormal eyelid position. A blepharoplasty can be performed for either functional or aesthetic purposes. Functional blepharoplasty restores normalcy to an eyelid that has been altered by infection, degeneration, or neoplasm. It can also seek to improve vision. Cosmetic surgery attempts to improve the appearance of redundant tissue and restore a youthful image.

This diagram reviews external eyelid anatomy. This is the medial canthus, lateral canthus, upper eyelid crease, lower eyelid margin, and the nasojugal fold.

The eye is almond shaped, and the average palpebral opening is about 10 mm in height and 30 mm in width. The upper lid fold in Caucasians is approximately 8 to 11 mm, and this upper crease corresponds to the superior edge of the tarsus and the inferior edge of the insertion at the levator aponeurosis. In the Asian eyelid, the crease is much lower due to a more inferior fusion of the orbital septum with the levator aponeurosis. On this diagram, you can see the lower lid crease is about 5 to 6 mm, the distance from the lateral canthus to the orbital rim is about 5 mm, and the lateral canthus is slightly more superior than the medial canthus by about 2 to 4 mm.

We will now review the anatomy of the eyelid by dividing the lid into tissue planes. Working posteriorly there is skin, orbicularis, orbital septum, preaponeurotic fat, levator aponeurosis, tarsus, and conjunctiva. The skin of the upper lid is extremely thin. Its average thickness is 0.13 inches, which is the depth of a split-thickness skin graft. The skin becomes thicker and more sebaceous laterally. The lid skin is well vascularized, and healing usually occurs quickly with good scar formation. Beneath the skin and subcutaneous tissues lies the orbicularis oculi. This muscle acts to close the eyes, protect the eyes, and pump fluid into the lacrimal sacs. It may become hypertrophied and redundant, causing an excess fullness to the upper or lower lid. These three bands of striated muscle encircle the orbit just beneath the skin. The muscle is divided into the outer orbital portion and the inner palpebral portion. This inner palpebral portion has two parts, the preseptal part that overlies the orbital septum and the preseptal part that overlies the tarsal plate. Lateral and medial segments of the orbicularis participate with the tarsal plates in forming the canthal tendons. The orbicularis muscle is innervated by the zygomatic branch of the facial nerve. The orbital septum, which lies deep to the orbicularis, is a key landmark. The septum is a thin sheet of fibrous tissue that hangs like a curtain across the eyelid. It arises from the periosteum of the superior orbital rim at the arcus marginalis. It provides the skeletal framework of the eyelids and keeps the fat in its posterior position. When the septum becomes weak, this may cause protrusion of the orbital fat. All of the important interorbital structures of surgical concern during blepharoplasty lie posterior to the orbital septum. The orbital fat provides a cushion to the inter-orbital structures, both for stabilization and frictionless movement. This orbital fat does not seem to be related to other fat in the human body because the quantity remains relatively constant regardless of weight change and also the orbital fat is a static structure in that once it is removed it does not seem to regenerate. The upper lid has two fat compartments, and laterally the fat may be associated with the lacrimal gland. The lower lid is believed to have three fat compartments, a small medial, a small temporal, and a fairly large central compartment. The inferior oblique muscle separates the medial fat compartment from the central fat compartment, so clinically it is susceptible to injury during blepharoplasty. A few recent studies have disputed Dr. Castanares's strict compartment theory. One study found ectopic or accessory upper eyelid fat pads in about 21% of patients. In all of these patients, this third fat pad was situated lateral to the two compartments described by Dr. Castanares behind the orbital septum.

The upper and lower lids have analogous structures, but they are less well defined in the lower lid. The anterior lamella is composed of skin, orbicularis muscle, and the orbital septum. The posterior lamella is composed of the tarsus, capsulopalpebral fascia, which is analogous to levator, inferior tarsal muscle, and conjunctiva. Between these two lamella lies the orbital fat.

On the first preoperative visit patients should describe what they would like corrected and what level of expectation they have towards this aesthetic goal. Determining the reason why the patient is seeking surgery is very important. The ideal patient usually describes a desire to reverse an appearance that has been progressively deteriorating. They should be realistic about the expected results. They may be seeking surgery for self-improvement, or they would like to advance in a public-oriented career profession. They should not count on the surgery to provide secondary gain, such as improvement of personal relationships or professional status; and any patient with a psychiatric history should have proper consultation and clearance before scheduling surgery.

Cosmetically, patients may want to accentuate their eyes, improve their overall appearance, and instead of looking tired, they may want to restore a rested and youthful appearance. Functionally, the patient may complain of visual problems and eyestrain related to heavy upper eyelid tissue. The skin of the upper eyelids may rest across their eyelashes and block their vision, making them feel like they are looking through their lashes. Patients may report that they can improve their vision by elevating the flaps of skin with their fingertips. Female patients may report trouble putting on eye shadow, or their eyeliner becomes smeared across their upper lid. VA patients present to us with a variety of complaints.

This VA veteran is a 65-year-old truck driver who presented to the VA ENT clinic last month complaining of having small eyes and having bags under his eyes. He reports upper visual gaze restriction, worse when he reads or drives his truck. On exam, his brows are in good position, but he has bilateral marked hooding and festooning with pseudoherniation. This is another VA patient. He is a 63-year-old male who presented to our clinic several months ago. He complained of difficulty looking up and reading and of sweat accumulating under the skin of his lower eyelids.

After patients present for surgical evaluation, their past medical histories must be carefully examined. Contraindications to blepharoplasty are all medical conditions that would preclude elective surgery, such as severe heart or lung disease. Any medical problem that causes fluid retention should be controlled before surgery. Postop results might be affected by disorders such as dermatologic disorders or collagen vascular disorders. Attention should be paid to bleeding disorders or the recent use of anticoagulants, aspirin, or NSAIDs. Patients with previous facial palsy may have persistent weakness of the periorbital musculature, which may lead to inadequate corneal lubrication and recurrent periorbital edema. Chronic renal disease and diabetes may affect wound healing and increase the risk of infection. And there is always the possibility of thyroid disease manifesting as orbital disease. Graves disease can cause globe protrusion, eyelid retraction, and symptoms of dry eyes. Hypothyroidism may produce myxedema, which the patient and surgeon may misdiagnose as protruding orbital fat.

In addition to medical history, an ophthalmologic history is critical. Minimal evaluation includes visual acuity, ocular motility, and ocular tension by palpation. In patients who have had eye complaints, previous eye disease, or systemic disease suggesting retinal pathology, an ophthalmology consult is mandatory. These patients will need a complete examination including funduscopy, intraocular pressure, and width of palpebral fissures. Some facial plastic surgeons send all their patients to an ophthalmologist preoperatively. Questions should be asked of the patient to determine any chronic eyelid disorders. Does the patient wear glasses or contact lenses? Is the superior visual field decreased by the upper eyelids? Has the patient had previous eye surgery? This includes Lasik surgery. They should be asked about tearing, dryness, blinking, the presence of mucus discharge, red eye, eyelid edema, and itching or burning. Keratitis sicca or dry eye syndrome is characterized by the symptoms of tearing, burning, use of artificial tears, and stinging at night. Patients with full-blown dry eye syndrome are at danger during blepharoplasty because it could result in the upper lid temporarily failing to close and thus exposing the cornea to drying. Some surgeons advocate a preoperative screening Shermer’s test on everyone, while others have found the Shermer’s test to be less important than history in predicting the development of dry eyes after blepharoplasty. The value of a Shermer’s test is to identify an otherwise seemingly normal patient prior to surgery. This test measures tear production. A strip is folded at the notch and placed in the lower eyelid at the lateral edge of the limbus, which is the junction of the cornea and sclera, and the normal value is 15mm after a 5-minute period. This picture shows how tears are produced and released from the lacrimal gland, linked and distributed and pumped into the nasal lacrimal duct. Abnormal tear secretion is not an absolute contraindication to surgery, but the patient should be aware that the tear deficiency can be accentuated postoperatively. Most surgeons fear worsening of this condition and would take a conservative approach to surgery.

There are three other factors to be noted on preoperative exam of the eyes. An intact Bell’s reflex helps protect against corneal injury and exposure keratitis because the patient will be temporarily unable to close their eyelids fully after surgery. Some other relative contraindications to surgery include proptosis, either whether it is congenital or is the result of a metabolic disease such as the thyroid. And a naturally deep-set eye is another relative contraindication because surgery would further accentuate the hollow look. You want to be very conservative in fat removal in these patients. At rest, the upper eyelid normally closes the superior limbus by only 2 mm. Patients with ptosis can be characterized according to pathophysiology. Aponeurogenic ptosis is the most common type of acquired ptosis. In this condition the levator aponeurosis is dehisced or attenuated from its normal insertion on the tarsal plate and orbicularis muscle. This type of muscle is characterized by normal levator function and usually an elevated lid crease. Pseudoptosis can occur in cases of globe malposition or in thyroid-related disease. While completing the medical and ophthalmologic exam, aesthetic and technical details are also essential. The elements that can be altered in blepharoplasty include the skin, orbicularis, and the fat. Preoperatively, the surgeon should anticipate the amount of skin that must be excised, the presence of excess fat, and orbicularis muscle hypertrophy.

The eyebrow is very important in considering how to repair the upper eyelid. The perfect eyebrow begins at a point on a vertical line tangential to the lateral ala of the nose, which is this line of the triangle. The medial club head portion allies with the nasociliary line. The apex, right here, lies between the lateral limbus and the lateral canthus, and it ends laterally at an oblique line extending from the alar base to the lateral canthus. The brow arches above the supraorbital rim in women and lies at the level of the rim in men. The preferred position of the male brow is straighter along the horizon and is generally wider and thicker, and it does not taper laterally like the female brow. Brows tend to descend from their normal position as the patient ages and the brow may appear as it is resting on the eyelashes, making the patient look fatigued or angry, such as our patient here. The best aesthetic result in patients like this is obtained by surgically repositioning the eyebrow. A blepharoplasty may not correct hooding and may exacerbate brow ptosis.

This is our 63-year-old VA patient who presented to our clinic complaining of baggy eyelids and requested a blepharoplasty. However, after relaxing the frontalis and repositioning of the brow, the amount of dermatochalasis was less and he actually required minimal skin excision. On exam, he had brow ptosis with hooding and dermatochalasis and festooning and scleral show. This patient underwent mid-forehead brow lift and lower blepharoplasties and tarsal strips, with very good postoperative results.

In addition to brow position, skin type is also important in upper lid blepharoplasty. The thin-skinned older patient usually requires a conservative resection of fat from the central compartment to avoid a hollow look in the upper lid sulcus just below the superior orbital rim. True eyelid skin is distinct is its thinness, and it is important during blepharoplasty not to pull the cheek skin up onto the lid or to pull the brow skin down onto the lid.

Moving on to the lower eyelid, the snap test is used to evaluate tenacity and strength of the lid. One pulls the lower lid from the globe and observes its return to the original position. The lid should spring back quickly to touch the globe without the patient blinking. If the lid settles back and does not snap back, a lid shortening procedure most be considered. Scleral show should be noted. The presence of pseudoherniated fat in the three compartments of the lower lid is evaluated by having the patient look superiorly. If the patient squints, the orbicularis muscle contracts. Lower lid fullness that reduces with a squint is suggestive of herniated fat. It is important to determine whether any degree of lagophthalmus or incomplete eye closure exists in either eye. Some degree of this is usually present in patients who have undergone previous blepharoplasty, but it may also be present in people who have had minor lid injuries during their youth. The strength of both lids should be tested under pressure to rule out seventh nerve weakness. Trigeminal nerve weakness would also alter the corneal reflex. In a patient with absent Bell phenomenon, any postoperative lagophthalmus can be especially devastating because the central cornea would be exposed. Aesthetic evaluation should be done of the entire face as well as the eyes. The position of the forehead to the brows and cheek complex all contribute to the position and appearance of the eyelids. The presence of malar or cheek bags is noted, and these edematous skin conditions can result from fluid retention.

Certain conditions cannot be improved or dramatically changed by blepharoplasty. Dark circles under the eyes will not be improved, although shadowing caused by fat herniation may be improved. Crows feet or laugh lines lateral to the lateral canthus can rarely be improved. Immediately after surgery they may decrease because of edema, but in a few months they will return. Fine wrinkling of the lower lids also cannot be removed by blepharoplasty alone and occasionally the wrinkling is accentuated. Lateral orbital rhytides, such as in the woman here, probably will not be removed by blepharoplasty. She would probably benefit from an auxiliary procedure such as chemical peel, laser resurfacing, or Botox injections. If there is excess damaged lid skin, lasers or peels will tighten and improve the skin quality and the glabellar furrow from lines can usually be addressed with Botox injections.

Finally, I will discuss three common pathologies addressed by blepharoplasty. Blepharochalasis is characterized by chronic recurrent edema of the eyelids with subsequent breakdown of the tissues within the eyelids. This causes prolapse of the orbital fat and drooping of the eyelid. This is a functional indication for a blepharoplasty. This is usually first seen as crows feet, and you can see wrinkling of their lower lids during facial animation. Dermatochalasis means relaxation of the skin. It is associated with the aging process and can cause pseudoptosis with a superior field defect. Fat pseudoherniation results in diminished local resilience in the orbital septum combined with continued gravitational force upon the orbital fat. The pseudohernias are observed most commonly in largest volume in the medial and central compartments of the lower lids.

And finally, preoperative clinical photography is essential in documenting existing eyelid and periorbital anatomy. The photographs are useful for preoperative surgical planning and intraoperative decision-making. The recommended standard preoperative photographic views include a full face in repose and smiling, close-up views of the eyelids and periorbital structures in repose, smiling, up gaze and down gaze, and right and left oblique and lateral views of the whole face and the eyelids. Again, blepharoplasty has evolved over the centuries to become the most popular cosmetic surgical procedure in America. All blepharoplasty patients require a complete preoperative medical, ophthalmologic and aesthetic evaluation. It is important to understand the underlying anatomy and to convey realistic, aesthetic expectations to the patient.

Case Presentation:

The patient was a 61-year-old Caucasian male veteran who complained of visual obstruction. He complained that his eyelids drooped and were blocking his vision. Outside ophthalmology exam confirmed a twenty-seven degree visual field defect with up gaze. He reported that this problem had grown progressively worse, and he had had a desire for the past decade to have this reversed. He denied previous vision problems or dry eye symptoms.

Past medical history was only significant for allergic rhinitis. He had no previous thyroid, psychiatric, or ophthalmology history. Past surgical history included back surgery and hemorrhoidectomy. Current medicines included flonase, claritin, rabeprazole, and guaifenisen. He denied tobacco and drug abuse, and drank alcohol occasionally.

On physical exam, his ear, nose, and throat exam were unremarkable. He was noted to have dermatochalasis and visual obstruction. He had hooding of upper eyelids bilaterally with increased redundant tissue, and lower lid festooning and tear trough deformities. His brows were in good position. There was no evidence of scleral show, lagophthalmus, lower lid laxity, or facial nerve weakness. The remainder of his general physical exam was unremarkable.

Preoperative photo documentation was taken. He was taken to the operating room in October 2003, and underwent bilateral upper and lower lid blepharoplasty and lower lid fat transposition.

Postoperatively, he did well. At four month follow-up, he reports that his vision is improved, and he is pleased with the cosmetic results.

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