Blepharoplasty

Considerations

• Indications

  • • Dermatochalasis - an excess of skin in the upper or lower eyelid, also known as "baggy eyes"

    • See AAO EyeWiki - Dermatochalasis

    • Upper lid: Hooding, preaponeurotic fat herniation (steatoblepharon)

      • may be cosmetic or functional

    • Lower lid: Pseudo-herniation of periorbital fat, pronounced nasojugal groove, infraorbital/malar deflation, malar mounds or festoons, lid asymmetry

• • Anatomy

    • Arterial supply 

      • Internal carotid a. --> ophthalmic a.  

      • External carotid a. --> facial a., angular a., infraorbital a. 

    • Venous drainage

      • Ophthalmic v., facial v., cavernous sinus, pterygoid plexus 

    • Musculature

      • orbicularis oculi (orbital, palpebral, lacrimal)

      • levator palpebrae superioris 

      • Mueller's muscle (superior tarsal muscle)

    • Sensory innervation 

      • Forehead, brow, upper lid

        • CN V-1 --> supraorbital n., supratrochlear n., lacrimal branches 

      • Lower lid

        • CN V-1 --> infratrochlear n. 

        • CN V-2 --> infraorbital n.

    • Lamella 

      • Outer / superficial = skin + orbicularis 

      • Inner / deep = tarsus + conjunctiva 

    • Fat compartments

      • Upper 

        • Medial (nasal) and middle (central) 

          • Separated by the superior oblique muscle 

      • Lower

        • Medial, central, and lateral 

          • Inerior oblique muscle separates medial and central

          • Fascial sheath of the IOM separates the central and lateral 

        • Medial fat appears more fibrous and pale compared to the more yellow central fat

    • conjunctiva

    • canthus

    • palpebral aperture

    • epicanthal fold

    • tarsal plate

    • Whitnall's tubercle

Preparation

• • Assess patient's wishes for surgery

  • Document any preoperative ocular pathology, visual acuity, visual field testing if functional

  • Thorough documentation of preoperative exam including photos

    • Brow ptosis - consider brow lift

    • See AAO EyeWiki - Brow Ptosis and Repair

    • Lagophthalmos - contraindication to surgery

      • See AAO - Lagophthalmos 

    • Lid laxity - consider canthoplasty vs canthopexy

Procedure

Upper Lid - Transcutaneous approach 

• • Mark the natural lid crease

    • 7-9 mm in men and 8-10 mm in women above lash for inferior limb of the incision

  • Mark the skin excision

    • Grasp redundant skin superior to the marked crease without opening the lids nasally, centrally, and temporally and mark a gentle curve connecting these points 

    • Address lateral hooding with a temporal arc extension 

    • Preserve at least 20 mm of skin between the lid margin and thick brow skin

    • Optional: Measure each marking with calipers for symmetry 

  • Lacrilube and corneal shield (no shield for Dr. Shih)

  • Infiltrate local anesthesia

    • 1% lidocaine with 1:100,000 epinephrine subcutaneously at the marking 

  • Incise the marked skin with 15 blade

    • Optional: Colorado tip Bovie 

  • Excise skin using Westcott (micro ophthalmic curved tip) scissors

  • Excise orbicularis muscle, if needed 

    • Optional: Include orbicularis muscle with the skin incision

  • If also resecting periorbital fat, incise the septum and tease fat through incision with Q-tip by applying pressure to eye

    • Resect fat in each compartment, as needed - save and compare to contralateral side.

  • Hemostasis using pressure and fine Bipolar 

  • Close incision with running simple 6-0 Prolene

Lower Lid

• • transcutaneous vs transconjunctival approach

  • lateral canthoplasty secured with 3-0 maxon using vertical mattress suture technique

Sample operative report

Post-op

• • Wound care: Bacitracin TID-QID, and wound care with daily dressing changes x 1 week and then QHS moving forward

• Analgesia: Norco

  • Optional: Celebrex

  • Optional: Arnica montana

  • POD 1-3: Ice compress, HOB elevated

• POD 5: suture removal 

• Patient instructions

  • • Avoid lifting, bending, straining, exercise during the first 10 days after surgery

    • Call if experiencing loss of vision, double vision, bleeding, severe swelling or pain

  • 1 month post op photos 

  • Complications

    • Retrobulbar hematoma/loss of vision

    • Perforation of globe

    • Scarring at incision

    • Asymmetry

    • Overcorrection

    • Undercorrection

    • Medial canthal webbing

    • Lagophthalmos

    • Ocular surface exposure

    • Ptosis

    • Numbness beneath incision

Pearls & Pitfalls

High-Yield

• • Plication vs imbrication

Links

• AAO EyeWiki - Upper eyelid blepharoplasty

• AAO EyeWiki - Lower eyelid blepharoplasty

• Plastic Surgery Key - Blepharoplasty

• YouTube (51:11) - Watch Upper and Lower Blepharoplasty with Surgical Adjuncts | Dr. Guy Massry