5 Upper eyelid blepharoplasty INSTRUMENTS Marking pen No. 15 scalpel blade Blade handle Castroviejo needle holder Castroviejo calipers 0.5 fixation forceps Westcott scissors 6-0 prolene suture Bovie cautery Needle tip for cautery 18-gauge angiocath for shielding the needle tip cautery 10 cc syringe 27-gauge needle ANESTHESIA Tetracaine hydrochloride 0.5% (topical anesthesia) 2% lidocaine with 1 : 100 000 epinephrine Wydase (sodium hyaluronidase) Sodium bicarbonate 8.4% 9 cc of 2% lidocaine with 1 : 100 000 epinephrine is mixed with 15 units of Wydase and 1 cc of injectable bicarbonate INDICATIONS Upper eyelid blepharoplasty is an operation that has the potential to both restore vision and improve the appearance of the eyelids. Blepharoplasty can be performed for both cosmetic and reconstructive purposes. The goal of both functional and cosmetic blepharoplasty is to remove tissue and re-contour the eyelid to achieve the desired results. Functional blepharoplasty is performed to restore vision. Excess skin, muscle and fat are removed so that tissue is no longer blocking the visual axis. Functional blepharoplasty is performed in patients who notice visual field loss due to the skin of the upper eyelids hanging across the eyelashes and obstructing the superior visual fields. For a blepharoplasty to be considered functional, three elements must be present: (1) patients must notice improved vision with the skin elevated off their eyelids; (2) the loss of the superior field of vision must be documented by a visual field test; and (3) photographs must demonstrate upper eyelid skin laying across the eyelashes. The goal of cosmetic blepharoplasty is to accentuate the appearance of the eyes. Cosmetic blepharoplasty is a surgery performed at the patient s request. Good candidates for cosmetic blepharoplasty have excess skin and fat on the upper eyelids and a reasonable expectation of what can be achieved with blepharoplasty. Cosmetic blepharoplasty will improve the patient s appearance but not the vision. Attainable goals for cosmetic blepha-
46 Upper eyelid blepharoplasty a b FIGURE 5.1a Local anesthesia is infiltrated below the eyelid crease to preserve the levator function. Intraoperative assessment of eyelid height and contour is difficult if the levator muscle is anesthetized. BOX 5.1. Clinical pearl Clinical pearl: Deep and forceful injections above the eyelid fold may compromise the eyelid function by anesthetizing the levator muscle. With the levator muscle unable to function, intraoperative assessment of lid height and contour is difficult. roplasty include improvement in eyelid symmetry and contour. Patients with unreasonable goals for blepharoplasty should not have surgery. A properly performed blepharoplasty does not compromise the eyelid function. The ability to open and close the eyelids remains unchanged after surgery. Blepharoplasty should not worsen a patient s symptoms of dry eyes or their ability to wear contact lenses. Blepharoplasty is a re-contouring operation, and not a circumcision of the eyelids. The goal of the surgery is not to remove all extra and redundant eyelid tissue. The goal of the surgery is to reshape the eyelids for a more pleasing, aesthetic result. Blepharoplasty must be individualized, with the position of the eyebrows, the prominence of the globes, the quality of the skin, and the desires of the patient all kept in mind. Performing blepharoplasty in the older patient is both challenging and rewarding. Brow ptosis, aging skin and eyelid laxity must be taken into consideration. The position of the brows is especially important in surgical planning. With increasing brow ptosis, there is a corresponding increase in redundant upper eyelid skin. Most patients with brow ptosis who request blepharoplasty do not need a brow ptosis repair at the same time as the blepharoplasty. If significant brow ptosis is present and the eyebrow is below the superior orbital rim, then consideration can be given to brow ptosis surgery. UPPER EYELID BLEPHAROPLASTY FIGURE 5.1b The incision is marked on the eyelid after the eyelid has been injected. The incision design is dependent on the individual eyelid contour and goals for the surgery. Step 1. Local anesthesia: Upper eyelid blepharoplasty is performed under local or modified local anesthesia. Patient cooperation is needed to ensure a symmetrical surgical outcome. With a 27-gauge needle directed at or below the eyelid crease, 5.1 2% lidocaine with 1 : 100000 epinephrine, Wydase and bicarbonate is injected into the eyelid. The injection is given slowly to minimize tissue distortion and pain. A total of 3 cc of local anesthesia is used for each eyelid.
Upper eyelid blepharoplasty 47 BOX 5.2. Clinical pearl Clinical pearl: In men, it is usually a good idea to plan on excising less skin. Remember that an upper eyelid blepharoplasty is a re-contouring operation and that the outcome of surgery is not only determined by the amount of skin removed, but also by the amount of skin left behind. BOX 5.3. Clinical pearl Clinical pearl: Regardless of the amount of brow ptosis present, the lateral aspect of the eyelid incision should never drop below the horizontal. Dropping this lateral aspect of the incision below the horizontal will promote brow ptosis in the postoperative period and lead to an unnatural-appearing eyelid crease. Step 2. Incision design: The design of a blepharoplasty incision is entirely dependent on each individual s eyelid, facial, and eyebrow contours. As a general rule, the eyelid crease incision in men should be placed 6 7 mm above the midpoint of the eyelid margin. In women, the eyelid crease incision should be placed 8 9 mm above the midpoint of the eyelid margin. The eyelid crease incision should be placed closer to the eyelid margin in patients with prominent globes. A lower eyelid crease will help camouflage the prominent globe. The medial end of the eyelid crease incision is placed 3 mm above the midpoint between the punctum and the medial canthus The lateral end of the eyelid crease incision is placed 5 mm above the lateral canthus. A curvilinear line is drawn to allow for a pleasing eyelid contour. The amount of vertical skin excision is determined by pinching the excess skin between two forceps at the midpoint of the eyelid. With the skin pinched in the forceps, the upper eyelid margin position should not be elevated. The superior line of excision should never enter the relatively thick eyebrow skin. The skin excision should be confined entirely to the thin eyelid skin. Even in patients with brow ptosis, the thicker skin of the eyebrow should not be excised. The junction between the thin eyelid skin and relatively thicker eyebrow skin represents the natural anatomic upper limit of skin excision possible with blepharoplasty. Once the vertical extent of the skin excision is determined, a curvilinear line is drawn from the medial end of the eyelid crease incision to the spot marked with the pinch technique. The placement of the lateral skin incision is determined by the position of the lateral eyebrow. The lateral eyebrow is lower than the medial portion of the eyebrow. The last hairs present on the lateral eyebrow provide a target for the planned lateral skin excision. From the lateral end of the eyelid crease incision, a line is drawn towards the last hair on the eyebrow. The curvilinear line defining the upper extent of the blepharoplasty incision is then extended laterally to where it intersects this line. Typically, the blepharoplasty incision will include some skin overlying the lateral orbital rim. Step 3. Skin excision: The first incision with the scalpel in a blepharoplasty should be at the eyelid crease. With the skin held taut, the scalpel blade incises skin and orbicularis muscle. In this location, the levator muscle is close to the skin surface and a deep incision in this area risks iatrogenic damage to the underlying levator muscle. The second incision is along the curvilinear superior aspect. A deeper incision in this area is possible since the levator muscle is beneath the septum and orbital fat. The third incision is the lateral extent
48 Upper eyelid blepharoplasty c d FIGURE 5.1c The skin incision is made with a scalpel blade with the first cut nearest to the eyelid margin. In this area, the levator aponeurosis is closest to the skin and the risk for iatrogenic damage is the greatest. Following the skin incisions, the skin and muscle flap is removed with Westcott scissors. BOX 5.4. Clinical pearl FIGURE 5.1d A strip of orbital septum is excised across the entire eyelid. The orbital fat should be visualized beneath the septum to prevent damage to the underlying levator aponeurosis. Clinical pearl: Closure of the eyelid septum is contraindicated in blepharoplasty surgery. The septum is attached to the superior orbital rim and to the levator aponeurosis. Closing the septum will produce an undesirable contour of the eyelid and may lead to poor lid function. of the eyelid, from the lateral canthus towards the lateral eyebrow. In this area, a deep incision is possible since the levator muscle is not present. Incision of eyelid skin should be performed in a controlled manner, utilizing the bevel of the blade, with attention directed to the depth of the cut. Once the blade is applied to the skin, it is desirable to keep the blade engaged until the entire incision has been made. Replacing the blade or attempting to re-deepen the cut often leads to unintentional skin incisions or an overly deep incision. Following the skin incision, Westcott scissors are used to remove the skin and muscle flap from the upper eyelid. When excising tissue along the eyelid crease, the scissors should be parallel to the eyelid skin to control the depth of the cut. Step 4. Orbital septum excision: A strip of septum is removed across the entire eyelid. Removing the septum allows access to the underlying eyelid fat pads. Many of the complications traditionally associated with upper eyelid blepharoplasty can be minimized by the removal of a strip of orbital septum. Step 5. Fat removal: Once a strip of orbital septum has been removed, the medial fat pad, the central eyelid fat pad, the lacrimal gland, and subcutaneous brow fat are all readily identified. At this point, re-contouring the eyelid continues with a graded removal of the eyelid fat pad. Initially, half of the presenting fat is removed. The eyelid contour is then assessed. Additional fat can be removed to alter the eyelid in a desirable manner. The majority of the fat removed in upper eyelid blepharoplasty is from the central eyelid fat pad. Under no circumstances should this fat be forcibly pulled from the orbit. Only fat presenting in front of the superior orbital rim should be excised. The medial fat pad has a slightly lighter color and consistency. A portion of this fat pad is also excised. Brow fat and the lacrimal gland position can be assessed and remediated if necessary. Remember, the goal is to re-contour the eyelid, not to remove as much tissue as
Upper eyelid blepharoplasty 49 e f FIGURE 5.1e A graded amount of orbital fat is removed from the eyelid. Over-excision of fat is to be avoided and fat should never be removed from behind the superior orbital rim. BOX 5.5. Clinical pearl Clinical pearl: The successful outcome of blepharoplasty is often determined by how much tissue remains in the eyelid as opposed to how much tissue was removed during the blepharoplasty. It is important to leave enough fat behind to provide an adequate bursa for the levator muscle. BOX 5.6. Clinical pearl FIGURE 5.1f Bleeding encountered during a blepharoplasty requires meticulous cauterization of bleeding vessels to prevent a postoperative orbital hematoma and excessive bruising. Clinical pearl: In spite of meticulous cauterization during blepharoplasty surgery, patients will become black and blue in the postoperative period. The blood supply to the eyelids is very generous, and a variable amount of ecchymosis and swelling is expected in the postoperative period. possible. In patients with heavy eyebrows, a strip of subcutaneous brow fat can be removed in the lateral aspect of the blepharoplasty. A prolapsed lacrimal gland can be resuspended behind the superior orbital rim with a Dexon suture if needed. Step 6. Hemostasis: Control of bleeding during a blepharoplasty is critically important. The most vascular tissue encountered in the blepharoplasty operation is the orbicularis muscle. Bleeding from the fat pads is much less common. The removal of a strip of septum during the blepharoplasty procedure accentuates the safety of the operation since the septum will not trap or mask any bleeding in the orbital space. Step 7. Closure: Absorbable or non-absorbable sutures can be used to close the blepharoplasty incision. An interrupted suture is placed perpendicular to the lateral canthus. This is the area where the eyebrow excursion is the greatest and the tension on the wound will be the highest. Scarring is minimized by meticulous wound closure and the timely removal of the sutures at 7 8 days following surgery. Following blepharoplasty, patients can expect a variable amount of ecchymosis and swelling over the next 7 days. Ice, restricted activity, and an elevated head position can all promote rapid, uneventful recovery from blepharoplasty.
50 Upper eyelid blepharoplasty BOX 5.7. Clinical pearl Clinical pearl: During closure of the eyelid, care must be taken to not create a deficit of skin in the medial canthal region. The distribution of skin during closure should allow adequate skin to be present in the medial canthal area to prevent webbing. Shifting the skin along the superior border of the skin incision slightly medial in relationship to the skin along the lower border of the incision can prevent webbing in the medial canthus. FIGURE 5.1g Absorbable or non-absorbing sutures may be use to close a blepharoplasty incision. An interrupted suture is placed above the lateral canthal angle to reinforce the eyelid closure. g COMPLICATIONS The most dreaded complication following blepharoplasty is orbital hemorrhage. While vision loss following blepharoplasty is rare, any orbital bleeding must be recognized and managed effectively. If an orbital hemorrhage develops the wound can be opened and all retained blood removed. Control of the bleeding and management of ocular and orbital pressure are critically important. Over-excision of eyelid tissue during blepharoplasty will lead to a compromise in eyelid function. Lagophthalmos, dry eyes and pain will develop if the movement of the eyelid is compromised. Transient stiffness of the eyelid is often seen, and can be treated with ocular lubricants. FURTHER READING 1. Shorr N, Seiff SR : Cosmetic Blepharoplasty. An Illustrated Surgical Guide. Slack, Inc., Thorofare, NJ, 1986. 2. Bartley GB, Bullock JD, Reifler DM : Ophthalmic procedures assessment. Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology 1991 ; 98 : 1461. 3. Rees TD, Jelks GW : Blepharoplasty and the dry eye syndrome: guidelines for surgery? Plast Reconstr Surg 1981 ; 68 : 249. 4. American Academy of Ophthalmology : Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology 1991 ; 98 : 1461. 5. American Academy of Ophthalmology. Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology 1995 ; 102 : 693.