-Pearls of Plastic Surgery

- Blepharoplasty

Hisham Seify M.D, Mark A. Codner, MD, FACS

Introduction

What are the goals of modern blepharoplasty ?

Modern blepharoplasty seeks to achieve specific aesthetic goals which include correct

brow position and correction of midfacial descent. In the upper lid, the goals include

preservation of upper orbital fullness and a defined upper lid crease. In the lower lid, the

goals include a smooth transition between the cheek and lid junction while restoring

youthful eye shape. These ideals may be safely achieved by adhering to the principles of

canthal anchoring, periorbital fat preservation or repositioning and careful anatomical

manipulation of the brow and cheek. Less invasive approaches may be taken in younger

patients with fewer age related anatomical changes.

Eyelid Anatomy:

Discuss the  anatomy of the eye lid ?

The eyelid is a bilamellar structure consisting of an anterior lamella and a posterior 

lamella. The anterior lamella consists of skin and orbicularis oculi muscle, the posterior 

lamella includes the tarso­ligamentous sling consisting of the tarsal plate, medial and 

lateral canthal tendons along with the capsulopalpebral fascia and conjunctiva. The 
septum originates at the arcus marginalis along the orbital rim and separates the two 

lamellae .

Discuss the  tarsoligamentous structure of the eye lid ?

The tarsoligamentous sling creates the support structure for the posterior lamella . The 

tarsal plates constitute the connective tissue framework of the upper and lower eyelids. 

The upper lid tarsal plate is approximately 30 mm horizontally and 10 mm vertically at its 

widest dimension. Attachments to the upper lid tarsal plate include the pretarsal 

orbicularis and levator aponeurosis on the anterior surface, Muller’s muscle on the 

superior border, and conjunctiva on the posterior surface. The lower lid tarsal plate is 

approximately 24 mm horizontally and 4 mm in vertical dimension. The tarsal plates of 

the upper and lower eyelid are attached to the orbital rim by the medial and lateral canthal 

tendons and retinacular support structures

The lateral canthus also consists of a complex connective tissue framework that functions

as an integral fixation point for the lower lid . The lateral canthal tendon, which is

approximately 5 mm in length, is formed by the fibrous crura which connects the tarsal

plate to Whitnall’s lateral orbital tubercle within the lateral orbital rim. In addition, the

lateral retinaculum is formed by ligamentous structures from the lateral horn of the

levator aponeurosis, lateral rectus check ligaments, Whitnall’s suspensory ligament, and

Lockwood’s inferior suspensory ligament which converge at the lateral canthal tendon .

In addition to the tarsal plates and canthal tendons, support structures in the upper and
lower eyelid stabilize the tarsoligamentous sling. The superior transverse ligament of

Whitnall is partially formed by the fascia of levator palpebrae superioris. Whitnall’s

ligament has a medial insertion at the trochlea of the superior oblique and a lateral

insertion at the lacrimal gland pseudocapsule and the frontal bone of the lacrimal sac

fossa.

The lower eyelid has an analogous inferior suspensory ligament, Lockwood’s ligament.

Lockwood’s ligament arises from the medial and lateral retinaculum and fuses with the

capsulopalpebral fascia inserting on the inferior tarsal border. The arcuate expansion of

Lockwood’s ligament, Clifford’s ligament, inserts into the inferolateral orbital rim and

fuses with the interpad septum between the central and lateral fat compartments of the

lower eyelid. The function of Lockwood’s ligament is to stabilize the lower lid on

downward gaze while the lower lid retractors cause lid depression of the eyelid to

increase the inferior visual field during down gaze.

Discuss the fat compartments of the eye lid ?

There are three fat pockets in the lower eyelid; central, nasal, and lateral. The nasal

compartment in the lower eyelid is similar in makeup to the nasal compartment of the

upper eyelid with more fibrous, pale fat. The inferior oblique muscle is commonly visible

during blepharoplasty separating the nasal and central fat compartments. The central and

lateral fat compartments are also separated by an interpad septum as well as a fascial

extension from Lockwood’s ligament, the arcuate expansion. The arcuate expansion of

Lockwood’s ligament should be preserved during lower lid dissection to maintain lateral

support. Since the nasal and central fat pads envelope the inferior oblique muscle,

aggressive fat transposition techniques which suture the fat below the rim can result in
diplopia from impaired inferior oblique function. The lateral extent of the lateral fat

pocket includes the lateral retinaculum and lateral canthal tendon.

Midfacial Anatomy:

The anatomy in this region is important to the morphological changes seen in the lower

eyelid/cheek junction with aging. Using cadaveric dissection, the prezygomatic space

has been described by Mendelson . The layers of this space include the skin and

subcutaneous fat which cover the orbicularis oculi muscle and sub-orbicularis oculi fat

(SOOF). A separate, fixed adipose layer, the preperiosteal fat is found deep to origins of

the lip elevator muscles. The upper border of the prezygomatic space is formed by the

orbitomalar ligament, a structure which arises from a thickened area of periosteum along

the inferior orbital rim and travels through the SMAS and subcutaneous fat to insert into

the skin . The orbitomalar ligament along with the levator labii superioris and levator

aleque nasi are responsible for defining the tear trough. With age, there is a herniation of

post septal fat over this ligament. Along with prezygomatic fat ptosis, the region of the

tear trough becomes visible as a deep triangular groove between these muscles . The

lower border of the prezygomatic space is outlined by the zygomatic ligaments which

arise from the origins of the elevator muscles of the upper lip. From the skeletal plane,

these osteocutaneous ligaments radiate outward to insert into the dermis of the cheek.

This prezygomatic space is triangular in shape with the apex being nasal. Malar mounds

are the result of edematous fat in the prezygomatic space which is restricted by the

zygomatic ligament. The malar fat pad is a subcutaneous trianglular shaped fat pad

which contributes to the fullness of the midface and is distinct from the malar mound.

Elevation of the malar fat pad and correction of malar mounds require a more aggressive
subperiosteal midface lift in order to meet the aesthetic goals.

Discuss the key elements for preopreative blepharoplasty evaluation

Pre­Operative Evaluation

Forehead
Brow Position
Bony brow prominence or retrusion
Fat excess or deficiency
Glabellar and forehead furrows

Orbit
Visulal acuity
Visual fields
EOM testing
Eye prominence
Canthal tilt
Upper and lower eyelid laxity
Lower eyelid malposition
Orbicularis oculi hypertrophy
Lacrimal gland ptosis
Upper eyelid ptosis
Skin quality and excess
Post septal fat herniation

Midface
Vector analysis
Tear trough deformity
Malar bags
Cheek ptosis
Skin quality and excess

D-Operative Technique
Describe the markings for Upper blepharoplasty:

First, the upper eyelid crease is marked at the level of the mid pupillary line. In women,

this is 8-10 mm superior to the lash margin and roughly 7 mm above the lash margin in

men . The marking is tapered caudally at the nasal and lateral lid margins following the

gentle curve of the upper lid crease. The nasal aspect of the marking should not extend

medial to the caruncle, as to avoid webbing or the development of epicanthal folds above

the medial canthus. At the lateral canthus, the lateral marking should be 5-6 mm above

the lash line. The lateral extension should be hidden in a crow’s foot skin fold and not

extend past the lateral orbital rim. The superior margin of the planned excision is

determined by using utility forceps to pinch and identify the quantity of excess skin and

muscle. At a minimum, 10 mm of skin should be preserved between the lower border of

the eyebrow and the upper lid marking at the level of the lateral canthus. The superior

mark is drawn parallel to the contour of the lower marking. Nasally, the amount of tissue

to be excised is tapered in a conservative fashion.

Describe the difference in markings for asian eye lids:

Modification of standard technique is required during blepharoplasty on Asian patients.

In the Asian eyelid, one must determine if a single eyelid fold (absent crease) or a double

eyelid fold (single crease) is desired. It is also important to define the desired location of

the crease as this is typically lower than in the Caucasian upper eyelid. A distance of 4-6

mm above the lid margin is usually used depending on the patients’ desires. A plan is

made to limit the amount of skin and preaponeurotic fat excision since this can lead to a

high crease and supratarsal hollowness. Furthermore, an epicanthal fold if present is

usually preserved unless change is specifically requested by the patient.

Describe the markings for lower blepharoplasty:

From the level of the lateral canthus, a line is extended inferior-laterally for

approximately 6 to 10 mm within a prominent crow’s foot crease. Roughly 10 mm of

skin is preserved between the lateral extension of the upper and lower blepharoplasty

incisions. If the incisions are placed too close together, postoperative webbing or

distortion can occur. The nasal extension of the marking parallels the lid margin and

should be as close to the lashline as possible because the scar becomes more apparent

when placed lower.

Describe the technique for transconjunctival blepharoplasty:

The orbital fat can be removed by a transseptal approach which divides the conjunctiva,

capsulopalpebral fascia and septum or a retroseptal incision through the conjunctiva and

capsulopalpebral fascia leaving the septum intact.

Discuss the objective of canthopexy/canthoplasty:

The objective of lateral canthopexy is to suture the tarsal plate and lateral retinaculum to

the periosteum of the lateral orbital rim thereby tightening the lower lid tarsoligamentous

Patients who have significant lid laxity with lid distraction greater than 6 mm require

lateral canthotomy and canthoplasty. Lateral canthoplasty is performed following

canthotomy of the inferior limb of the lateral canthal tendon followed by cantholysis

which allows mobilization of the lower lid. The lid is then transposed over the lateral

orbital rim and 2 to 3 mm of full thickness lid margin is resected in order to correct

significant lid laxity.

Discuss postoperative blepharoplasty care :

-Head elevation and the application of ice to the periorbital region is used for 48 hours

after surgery.

-Ophthalmic antibiotic ointment is applied along the suture line as well as on the globe to

prevent or to reduce evaporative tear film loss.

-Sutures, including the Frost suture, are removed 5 to 7 days after surgery. Patients are

asked to avoid the use of eyelid make-up on the suture lines and contact lenses for two

weeks following surgery.

-Persistent postoperative chemosis can be treated with liberal ophthalmic ointments and

eye drops.

-Additionally, Voltaren drops and fluoromethalone 0.1% ophthlamic suspension can be

used for two weeks in order to minimize early inflammatory changes that result in

chemosis.

-Severe chemosis which herniates through the palpebral fissure requires more aggressive

management with liberal ophthalmic ointment, patching the eye closed for 24 to 48

hours, and applying gentle pressure from an ace wrap to reduce the swelling.

Occasionally the edematous conjunctiva can be surgically drained.

Discuss the Complications of blepharoplasty:

-The most devastating complication after blepharoplasty is visual loss. Although rare, the

estimated incidence is 0.04% and is caused by retroorbital hemorrhage compromising

ocular circulation or direct globe perforation. Rapid surgical decompression,

administration of mannitol, acetazolamide, and oxygen is advocated as part of the initial

management of retroorbital hematoma.

- Diplopia can also occur following blepharoplasty and is usually temporary resulting

from edema. Permanent diplopia can occur from thermal injury to the inferior oblique or

superior oblique muscles from electrocautery. Strabismus surgery may be required for

patients who do not improve with conservative management.

- In the upper lid, ptosis may occur after surgery from failed preoperative recognition or

from levator dehiscence during surgery. To minimize this risk, supratarsal fixation of the

pretarsal skin muscle to the levator aponeurosis should be performed.

-Signs of corneal irritation or impaired visual acuity require careful ophthalmological

evaluation. This includes a slit lamp examination with the use of Fluorescein eye drops

to evaluate the cornea along with visual acuity testing.

- Mild lid malposition may contribute to lagophthalmos and corneal exposure.

Lagophthalmos may require bandage contact lenses to protect the cornea and

conservative massage of the lower lid margin until the patient has passed the critical six

week postoperative time period, which corresponds with the proliferative phase of

healing. Lower lid ectropion or persistent lid malposition following a 2 to 3 month

period of conservative management may require surgical intervention including

placement of a posterior lamella spacer graft and lateral canthoplasty (16).

References

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Philadelphia: Lippincott-Raven, p. 200, 1995.
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4. Muzaffar, A.R., Mendelson, B.C. and Adams, W.P.  Surgical anatomy of the 
ligamentous attachments of the lower lid and lateral canthus.  Plast. Reconstr. Surg.  110: 
873, 2002.
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moderate to complex blepharoplasty problems. Perspectives in plastic surgery. 15:1, pp.
15-32, 2001.
6. Flowers, R.S.: Canthopexy as a routine blepharoplasty component. Clin. Plast. Surg.
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Bypassing the pitfalls. Clin. Plast. Surg. 20: 213, 1993.
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following blepharoplasty. Plast. Reconstr. Surg. 85:971-981, 1990.
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