the “bespoke” upper eyelid blepharoplasty and brow rejuvenation

8/13/2019 The Bespoke Upper Eyelid Blepharoplasty and Brow Rejuvenation

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The Bespoke Upper Eyelid Blepharoplasty andBrow RejuvenationMaeve O Doherty, FRCS1 Naresh Joshi, FRCOphth1

1 Department of Oculoplastics, Chelsea Westminster Hospital,London, United Kingdom

Facial Plast Surg 2013;29:264 272.

Address for correspondence Maeve O Doherty, FRCS, Department of Oculoplastics, Chelsea Westminster Hospital, 369 Fulham Road,LondonSW109NH, UnitedKingdom(e-mail:[email protected]).

A blepharoplasty of the upper eyelids is one of the mostcommonly performed procedures in aesthetic plasticsurgery.Aging changes in theupper third of theface canfalselyprojectan appearance of tiredness, sadness, anger, or lack of interest.

It is important to tailor upper eyelid blepharoplasty andbrow rejuvenation to the individual.

The goals for upper lid blepharoplasty include restora-tion of a naturallysharpand crisp tarsal fold and a pretarsalshow. Evaluation of the upper eyelid must include anevaluation of the eyebrow. Brow ptosis should be correctedto achieve repositioning of heavy eyebrow skin, which maybe compensated by frontalis contraction to keep the eye-brows above the orbital rim. Aging causes the eyebrow fatto descend over the upper lid, giving it a full appearance.Once the visual obstruction has been removed by eyelidskin resection, the brows may look even heavier becauseelevation is no longer needed for the visual eld. Thisresults in a more aged appearance. 1,2

It is this individualized or bespoke approach to uppereyelid blepharoplasty and brow rejuvenation that forces us tostructure this article based on patient presentation and howto address this in our surgical practice.

Some Important Anatomical Conceptsof the EyelidsThe pretarsal eyelid show is often only 2 to 3 mm in theaesthetically attractive eye ( Fig. 1 ).

The upper eyelid can be divided into tarsal and orbitalportions at the level of the supratarsal fold. In Caucasians, thisskin crease is located 7 to 10 mmfromthe palpebral marginand results from a fusion of the levator aponeurosis, orbitalseptum, and fasciaof theorbicularis oculi into thedermis.Thedeeper bers of this condensation inserts onto the anteriorsurface of tarsus. This area degenerates with age, which mayleadto a highfold ( Fig. 2A), with or without upper lid ptosisand/or skin laxity of the lid ( Fig. 2B). Loss of crease attach-ments may cause the skin to rest toward or beyond the uppereyelid/lash margin, with a tendency to interfere with upperouter visual elds. 1

Clinical EvaluationThe surgical approach must take into consideration therepositioning of underlying soft t issue and the redraping of skin. Evaluation of the upper eyelid must include an evalua-tion of the eyebrow. Brow ptosis should be corrected toachieve repositioning of heavy eyebrow skin, which may becompensated by frontalis contraction to keep the eyebrowsabove the orbital rim. Aging causes the eyebrow fat to

descend over the upper lid, giving it a full appearance( Fig. 2B). Once the visual obstruction has been removedby eyelid skin resection, the brows may look even heavierbecauseelevation is no longer needed for thevisual eld. Thisresults in a more aged appearance. 2,3 The brows will bediscussed in the latter section of this article.

Keywords blepharoplasty brow eyelid

Abstract Blepharoplasty of theupper eyelidsis one of themost commonlyperformed proceduresin aesthetic plastic surgery. In this article, we describe our approach to the patient withaging of the periorbita. At all times, the approach is tailored to the individual s needs,trying to achieve a natural result that will not in any way affect the function of the eyelid.Our current approach and techniques for upper eyelid blepharoplasty and brow liftingare described.

Issue Theme Periocular AestheticRejuvenation; Guest Editor, Naresh Joshi,FRCOphth

Copyright 2013 by Thieme MedicalPublishers, Inc., 333 Seventh Avenue,New York, NY 10001, USA.Tel: +1(212) 584-4662.

DOI http://dx.doi.org/10.1055/s-0033-1349360.ISSN 0736-6825.

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The skin of the upper eyelid is the thin and mobile andintegral to the functioning of the eye, so to avoid lagoph-thalmos, the excision must be conservative, especially in thenasal half.

Preoperative MarkingsPreoperative markings are critical in assessment of the pa-tient and are made with the patient sitting upright and inneutral gaze. The brow should be elevated to the properposition before any marks are made. The supratarsal fold islocated at 8 to 10 mm above the ciliary margin in womenand at 7 to 8 mm in men. A mark should be made on this fold( Fig. 3A). The upper marking must be at least 10 mm fromthe lower edge of the brow and not include any thick browskin. The use of a pinch technique with a nontoothed forcepsfor redraping the skin is helpful ( Fig. 3B).

The index of safety is much higher laterally (one can

remove more skin) and becomes more critical as the incisionproceeds medially. The incision may need to be extendedlaterally with a larger excision, but extension lateral to theorbital rim should be avoided if possible to prevent a promi-nent scar ( Fig. 4 ). Similarly, the medial markings should notbe extended medial to the medial canthus for larger resec-tions because extensions onto the nasal side wall result inwebbing. If excessive skin is present medially, an additionaltriangle of skin maybe resected. It is important to ensure thatthe preoperative markings, especially medially, disappearwhen the eye is open in the primary position. This ensuresthat any unsightly scars will be avoided. The amount of fat to

be resected should be determined preoperatively, with thepatient in upgaze, downgaze, andmedialand lateralranges of motion, with photographic documentation. In the rare in-stances that fat removal is required, with the patient prone,cross-hatching is used to indicate the amount and region of fat to be removed as this can become dif cult to assess afterlocal in ltration and in the supine position.

The Standard Upper Eyelid BlepharoplastySurgical Technique in the Older PatientTwo to three milliliters of a premade mixture of 4 mL of Lignospan (Novocol Pharmaceutical of Canada; 2% lignocainewith 1:80,000 adrenaline), 4 mL of bupivacaine, and 2 mL of dexamethasone (8 mg) is injected subcutaneously using a 30-gauge needle by rst pinching the skin and then rolling theorbicularis off the skin to ensure that the injection is justsubcutaneous. The speed of injection is crucial in avoiding

patient discomfort. Proxymetacaine topical anesthetic dropsare also instilled, and a corneal shield (made of soft rubber) isused in all eyelid procedures to avoid inadvertent damage tothe cornea. Incisions are made using a Colorado microdissec-tion needle. The skin, without muscle, is dissected off theunderlyingt issuemaintaining rigorous hemostasis ( Fig. 5A,B). Once the skin has been removed, a strip of orbicularis isthen removed using the Colorado needle. The upper one-third to upper one-half of muscle is removed ( Fig. 6A, B). If lateral brow elevation is required, more orbicularis muscle isremoved at the lateral corner. If preseptal muscle is left underthe skin excision, especially when large resections are

Fig. 1 The perfect eyelid and brow showing pretarsal lid show, lid tobrow distance.

Fig. 2 (A) The aged eyelid showing high skin crease and increased lidto brow distance. ( B) The aged upper one-third showing brow ptosis.

Fig. 3 (A, B) Pinch test technique with a nontoothed forceps. Starting with the natural skin crease.

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undertaken, there will be muscle over muscle when the nalclosure is performed. This redundancy can cause a heavier,fuller lid postoperatively and interfere with the creation of aclean, distinct supratarsal fold. If fat removal has been

deemed necessary, a small incision is made through theseptum, into the medial compartment of the eyelid. The fatis teased out and resected using a clamp, cautery, and curvedscissors. This fat usually contains white fat. It is rarely neces-sary, in my experience, to remove fat from the central andlateral fat pads, though lacrimal gland repositioning is oftenrequired and will be described later.

If a lateral canthopexy is required as part of a lower lidblepharoplasty procedure, it is done at this time. An incision ismade laterally to expose the lateral orbital rim. A stab incision iscreated at the lateral canthus and a 5 0 Prolene (Ethicon,Somerville, NJ) suture is placed through the stab at the lateralcanthus and secured to periosteum on the inside of the lateralorbital rim at the level of the upper limbus ( Fig. 7A, B). It isimportant that this suture disappears within the stab incision. Itis also important to place this suture within the orbital rim toavoid tenting the lower lid anteriorly away from the eye. Oncehemostasis is obtained, the incision is closed with 6 0 Prolenesuture. In cases where reformation of skin crease is necessary,the sutures should include the subcutaneous aponeurotic/septaltissue. Figs. 8 and 9 show pre- and postoperative appearancesof a blepharoplasty in an older patient.

Upper Lid Blepharoplasty in the YoungPatientThe surgical approach is exactly as described for the olderpatient; however, we do not remove the orbicularis muscle inthese patients. See pre- and postoperative photos in Fig. 10 .

Fig. 4 The preoperative markings for blepharoplasty.

Fig. 5 (A, B) Skin-only excision with Colorado needle.

Fig. 6 (A, B) Upper one-third orbicularis excision.

Fig. 7 (A, B) Lateral canthopexy suture done through blepharoplasty incision in a combined upper and lower lid blepharoplasty.


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Lacrimal Gland ProlapseThe lacrimal gland can be found in the lacrimal fossa. In somepatients prolapse of the gland leads to a lateral fullness thatcan be misinterpreted as prolapsed fat ( Fig. 11A). Thetechnique for lacrimal gland repositioning is simple; themost dif cult part is the visualization, identi cation, andseparation of the gland itself.

The procedure is often incorporated with blepharoplasty,the approach described previously. The skin is opened as for

blepharoplasty and a strip of skin is removed. The lateralorbital fat pad is exposed by opening the septum. Theprolapsed lacrimal gland can be visualized on the undersur-face of the lateral fat pad ( Fig. 12A ). The orbital rim shouldalso be identi ed at this stage. Using a 6 0 double-endedVicryl (Ethicon)suture,the undersurface of thelacrimal glandcapsule is grasped and sutured in two bites to the innersurfaceof theorbital rim. When thesuture ispulled, theglandretracts backward behindthe suture ( Fig. 12B ). Twoto threesutures can be placed in this manner.

Fig. 8 (A, B) Skin septum skin sutures and orbicularis resection allows an eyelid show in the presence of a large amount of skin excess.

Fig. 9 (A, B) Blepharoplasty with skin orbicularis and deep skin crease reformation suture to hold up folded skin in low brow position.

Fig. 10 (A, B) Pre- and postoperative blepharoplasty in a young patient without muscle excision.




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Minimally Invasive One-SutureBlepharoptosis Repair

Before placing protective corneal shields, the position of themidpupil is marked on the upper lid margin. A maximum of 1 mL of our standard premade mixture is injected subcuta-neously. We normally perform all ptosis procedures undersedation so we rarely require more than 1 mL. In a combinedblepharoptosis procedure, the ptosis is performed rst. A lidcrease incision is made using a Colorado microdissectionneedle. The anterior surface of the tarsus is exposed andcleaned. The orbital septum is opened horizontally 1 cmacross the central upper eyelid. This exposes the preaponeur-otic fat, which is then retracted gently to expose a smallportion of the aponeurosis. The aponeurosis alone or withMller muscle is then dissected off the tarsus for a short

distance of 2 to 4 mm so that access to the aponeurosis fromits undersurface is possible. A double-armed 6 0 Prolenesuture is used to take a 3- to 4-mm horizontal bite across theupper one-third of the tarsus in line with the preoperativemark on the upper eyelid (ensuring that this is not fullthickness through the tarsus by checking the conjunctivalsurface). Each end of the suture is then brought through theaponeurosis from the posterior surface to the anterior surfaceat the desired height and a small bow is tied to assess heightand contour ( Fig. 13A, B ). Once the contour and height aresatisfactory, the bow is cut, the unattached end is pulledthrough, and the suture is secured in the standard manner.

Further anesthesia is administered and the skin is thenresected as per a normal blepharoplasty and the orbicularismuscle strip is also removed. The wound is closed with 6 0Prolene sutures including four to ve skin crease reformation

Fig. 11 (A) Prolapsed lacrimal gland preoperatively. ( B) Post lacrimal gland repositioning.

Fig. 13 (A, B) One-suture ptosis repair.

Fig. 12 (A, B) Lacrimal gland repositioning suture.




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sutures. These are created by including a small bite of theaponeurotic tissue in the skin suture.

Postoperative CarePreservative free ocular lubricants are prescribed four timesper day for 2 weeks. Chloramphenicol ointment is usedtopically on the eyelid incision and in the eye for 2 weeks

at night. The sutures are removed at 10 days.Contraindications to surgery include patients with psy-chological issues, dry eyes, uncontrolled in ammatory skinconditions such as eczema and psoriasis, multiple redosurgeries, and in situations where removing skin wouldlead to lagophthalmos.

Our Approach to the BrowElevation of the ptotic brow and forehead complex has longbeen recognized as integral to upper facial rejuvenation. Theaging changes of the brow can be classi ed into two maincharacteristics.

1. De ationary characterizedby volumeloss( Fig. 14 A to D)2. Positional either high or low depending on the level of

overaction of the frontalis muscle ( Fig. 2A, B)

The ideal brow position has been described repeatedly. 4 6

There are also a variety of eyebrow shapes depending onfashion. Although the brow position becomes lower with agefrom the effects of gravity and the depressor muscles of thebrow, the youthfulbrowcan also be quite low ( Fig. 1 ). Oftenlaxityof thetissues and volume de ciency confer to the agingappearance ( Fig. 2A).

Many techniques have been described for elevating thebrow and forehead. 7

13 These include techniques to suspend

the brow to the forehead periosteum through a post hairlineapproach or through an upper blepharoplasty incision; tissueexcision techniques directly above the brow and tissue exci-sion higher in the forehead creases are also possible. Thecommon technique of endoscopic browlift will not be dis-cussed in this article. Alternatives to the standard practicewill behighlighted.Any surgical techniquemust be tailored tothe individual patient s needs and acceptability.

Nonsurgical BrowliftBotulinum toxin is used whenever nonsurgical browlift isrequired. The ideal application for botulinum toxin A use inbrowlift would be a young patient with isolated ptosis of thelateral brow who desires nonsurgical treatment. The primaryadvantage of this technique is that it is an of ce-based

Fig. 14 (A, B) A freshplumshowinggoodskinqualityand volume comparableto theyouthful brow. ( C, D) A prunecomparable tothe aging brow;both have experienced volume change leading to a shriveled-up appearance.

Fig. 15 Excessive nonsurgical browlift with botulinum toxin.




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outpatient procedure with minimal patient morbidity. Theprocedure has limitations including temporary ef cacy withthe need for repetitive treatments, minimally uncomfortableinjections, and sometimes unpredictable results. Maas andKim noted that more ef cacious results were found in youn-ger patients. 14 As a consequence of injection to depressormuscles in the glabellar region, the medial brow becomeselevated due to unopposed action of the frontalis muscle.However, excessive injection to the depressor muscles canresult in overelevation of the brow, resulting in an unaesthet-ic, surprised look ( Fig. 15 ).15 The paralysis of the lateraldepressor orbicularis elevates the lateral eyebrow. A titratedparalysis of the two zones can determine the shape of browelevation.

Crenated Direct Browlift Technique

In older patients where brow descent is evidentand all planesof tissue are lax (anterior lamellae slippage from the perios-teum), we favor the direct browlift. However, the technique ismodi ed, the crenated browlift, to disguise the scar. Markthe full length of the superior border of the brow adjacent tothe uppermost brow hairs. Pull the brow up to its intendedpostoperative height and hold the marker pen at this point.With the pen held steady above the forehead skin, allow the

browto drop back toits ptoticposition and mark the foreheadskin at the level of the pen. Repeat this maneuver at severalpoints along the brow to outline the amount of skin, subcu-taneous tissue, and muscle to be resected. Join the line of these marks to form an ellipse as usual, then form zigzagpattern, dipping just into the brow hairs to form a crenatedeffect ( Fig. 16A ).

The surgical procedure is similar to that described for anydirect browlift.

Close thewound intwo layers. Usea 5 0 absorbablesutureat the apex of one edge to the valley of the opposing edge toclose the deep layers. The suture should pass close theepidermis and the knot should be placed deeply. Close theskin with a 5 0 mono lament suture. These are placed atright angles to the linear edges. This zigzag hides the scar.The postoperative scar is almost imperceptible after a fewmonths ( Fig. 16B, 17 ).

Pretrichial BrowliftPretrichial denotes an incision in front of the hairline. Inyounger patients with a lateral brow ptosis, a pretrichial smallincision browlift (browpexy) is offered. This is effectiveespecially in those with a low hairline laterally. The amountof skin to be resected is determined with the patient sittingup; usually 1 cm of the line of pull required is drawn on theforehead. The area is in ltrated with anesthetic. Skin andsubdermal tissue are incised and resected ( Fig. 18A, B ).Super cial subdermal plane dissection is carried downwardwith care. The facial nerve lies at a slightly deeper plane. A

deep 4 0 Prolene suture is used to elevate the underminedforehead section to the superior deep temporalis fascia( Fig. 19A, B ). The skin is sutured using 5 0 Prolene inter-rupted sutures.

This technique elevates and reorients the ptotic lateralbrow ( Fig. 20A, B ).

Postoperative CareSutures are removed at 10 days postoperatively. Chloram-phenicol ointment is applied topically twice per day to theincisions. Massage to the area is avoided for the rst2 weeks.

Fig. 16 (A) Crenated brow lift, intraoperative. ( B) Crenated brow lift results, 8 weeks postoperatively.

Fig. 17 Well-healed direct crenated browlift scar at 1 year.




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Fig. 18 (A) Crescent-shaped post hairline incision site. The arrow shows the direction of pull. ( B) Sutured pretrichial browlift.

Fig. 19 (A, B) Fixation to deep temporalis fascia.

Fig. 20 (A, B) Pretrichial lift reorients crow

s-feet upward.




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the “bespoke” upper eyelid blepharoplasty and brow rejuvenation

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