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BLEPHAROPLASTY 101

Topic 13 - 1
Upper Eyelid
Blepharoplasty 
  upper crease height


"The weight that hangs upon our eyelids . . is of lead."

-- Mary Boykin Chestnut


Other names for upper blepharoplasty

Eyelid lift, eye lift, cosmetic eye surgery, upper bleph


Primary goal

Removal of excess skin and sometimes fat and/or orbicularis muscle with the intent of restoring the upper eyelids to a more youthful appearance


Secondary goals

Uplift of drooping eyelashes, increase in peripheral vision, restoration of the eyelid crease


 

attention
Upper Eyelids Are Not "Easy"

More than a few cosmetic surgeons (although seldom experienced ocuoplastic specialists) tend to dismiss upper blepharoplasty as a quick and simple operation. While easier to perform than lower blepharoplasty, any flaws or slight asymmetry after eyelid surgery -- even when tiny -- are more obvious than with just about any other cosmetic procedure in all of plastic surgery.


Anesthesia

Most commonly performed under local anesthesia with oral sedation as an out-patient.


Anatomy

The anatomy of the upper eyelid is detailed in Topic 4.


upper eyelid anatomy

Legend
Skin Subcutaneous Fat
Orbicularis Muscle Eyebrow Fat Pad
Orbital Septum Orbital Fat
Levator Aponeurosis Tarsal Plate


Upper Blepharoplasty Technique

A marking pen is used to outline the amount of excess skin to be removed. The initial incision is made along the normal eyelid crease (about 7-10 mm above the lashes) across the entire lid and extending slight upward and outward into the lateral canthus. The second incision is made a variable distance above the first, depending on the amount of skin that needs to be removed. Only if the orbicularis muscle is unusually thickened is a tiny strip trimmed.

The orbital septum is opened, thus exposing the fat pockets overlying the levator aponeurosis (tendon of the eyelid opening muscle). The first or "middle" pocket is inspected and trimmed as indicated using a process of dissection, clamping, excision, and cauterization. The second or "nasal" fat pocket requires a slightly deeper dissection. A graded removal of any excess is performed is a similar fashion. Fat removal is intentionally conservative to avoid a hollowed look after surgery as well as in later age when the body may absorb facial fat. In some cases, no fat is removed.

The skin edges are closed using sutures to reform, reposition, and/or deepen the eyelid crease.

Upper Blepharoplasty
Before and After Photos



Variations

"Tissue-sparing upper blepharoplasty" provides a means to avoid an artificially high crease as well as eyelid hollowing. No orbicularis muscle is thinned, the orbital septum is left essentially intact, and little or no orbital fat is removed.

"Laser-assisted upper blepharoplasty," in which the actions of the traditional scalpel and scissors are undertaken with the use of a laser, has received widespread attention in recent years. Other approaches to incising and excising skin and deeper eyelid tissues have been and are currently used, including electrocautery, heat cautery, heated scalpels, and radiofrequency ( RF ) energy. While such approaches each have some proponents, none have demonstrated convincing advantages over the stainless steel scalpel and scissors.

In selected patients, a modification known as "deep fixation" may be used to deepen the eyelid crease, achieve a more stable platform of skin on which to apply cosmetics, strengthen support for drooping eyelashes, and prevent later scar "migration" out and above the hidden area of the normal crease. At the time of skin closure, the cut skin edges are lightly attached to the underlying levator aponeurosis (tendon) using either permanent or removable sutures.

A tissue adhesive (Dermabond) resembling super-glue may be used to help close the upper eyelid incision, but usually at least a few sutures are placed for reinforcement. This method is seldom employed.

If the lacrimal gland (tear gland) has dropped down from its normal position just inside the orbital rim of bone, it may create a bulge that mimics eyelid fat at the lateral (towards the temple) side of the upper eyelid. If severe, the gland may require resuspension with sutures.

If only the nasal fat pocket is bulging and there is no excess upper eyelid skin, fat removal may be undertaken through a transconjunctival incision (i.e., from the inside surface of the eyelid) without creating an external scar.


Benefits

Upper eyelid blepharoplasty is a relatively safe and proven operation. Because the eyes are the focal point on the face, the procedure may achieve anything from a subtle to dramatic improvement in a person's appearance, depending of the starting point and patient preferences. For this and such reasons as its relatively modest cost and much quicker recovery, many people choose blepharoplasty over full face lift. A reasonable expectation is that you will obtain about a 75-90% improvement.

Limitations

If the presence of a weakened or already droopy eyebrow, added brow stabilization may be indicated to prevent further descent; browpexy can be performed through the same eyelid incision used for blepharoplasty. "Crow's feet" (wrinkles at the lateral canthus) are only minimally improved. If true ptosis (a droopiness of the eyelid due to a defective levator muscle or aponeurosis), blepharoplasty alone will not remedy the problem. Because every patient possesses some pre-existing anatomical limitations and because no wound ever heals perfectly, some slight asymmetry after upper blepharoplasty is the rule rather than the exception.


Patient photos

Upper blepharoplasty before and after photos >


Comments

As the most popular operation in the field of cosmetic eyelid surgery, many chapters in this resource discuss upper eyelid blepharoplasty. While some cosmetic surgeons seem to emphasize brow and forehead lifting to the virtual exclusion of upper blepharoplasty, one procedure does not replace the other.

"Functional upper blepharoplasty" or eyelid surgery undertaken with the primary purpose of increasing the field of vision narrowed by overhanging skin, entails the removal of skin only. While vision may be improved, the results compared to a full blepharoplasty may, in fact, be disappointing to a patient who was hoping to coax his or her insurance company into paying for what is, for the most part, a cosmetic operation.


the chest that launched a athousand slips


Next: Upper Eyelid Shapes
and Height Ranges


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