CME

Current Concepts in Aesthetic Upper

Blepharoplasty
Rod J. Rohrich, M.D., Dana M. Coberly, M.D., Steven Fagien, M.D., and James M. Stuzin, M.D.
Dallas, Texas; and Boca Raton and Coconut Grove, Fla.

Learning Objectives: After studying this article, the participant should be able to: 1. Discuss nomenclature and anatomy
associated with upper blepharoplasty. 2. Perform preoperative assessment, decision-making, and counseling of patients.
3. Describe current surgical planning, eyelid marking, and various techniques used in upper blepharoplasty, including
lasers. 4. Recognize and treat postoperative complications from blepharoplasty.

Traditional blepharoplasty has often involved the exci- not hollow, with a crisp tarsal upper lid crease
sion of both lax skin and muscle and excessive removal of fat, and elastic support of the underlying soft tis-
leaving patients long term with a hollow orbit and a harsh,
operated appearance that accelerates the aging process. Cur- sue, creating a smooth, taut pretarsal and pre-
rent methods of periorbital rejuvenation are more conser- septal upper eyelid (Fig. 1). The pretarsal eye-
vative, are based on concise preoperative evaluation, and lid show is often only 2 to 3 mm in the
involve the limited resection of the coveted soft tissue from aesthetically attractive eye. Periorbital skin is
the eye to restore a youthful appearance. The authors de- smooth with no rhytids or redundant folds.
scribe anatomy, preoperative assessment, decision-making
and counseling of patients, surgical planning, eyelid mark- The eyebrows must always be addressed in the
ing, and various techniques, including lasers, along with evaluation of the eyelid for proper restoration
postoperative complications associated with current con- of a youthful and functional eye.
cepts in aesthetic upper blepharoplasty. (Plast. Reconstr.
Surg. 113: 32e, 2004.)
HISTORICAL PERSPECTIVE
Eyelid surgery was described in an Indian
The eyes, or more precisely, periorbital tis- document, the Susruta, more than 2000 years
sues, are paramount in facial beauty, exhibit- ago. Arabian surgeons cauterized excess eyelid
ing youth and a plethora of expressions. Un- skin to relieve drooping in the tenth and elev-
fortunately, this area is also one of the first to enth centuries.1 Avicenna (980 to 1037) per-
show aging from the effects of gravity, ultravi- formed the first recorded blepharoplasty, ex-
olet radiation, and animation. Traditional cising excess upper eyelid skin. Paré2 described
blepharoplasty has involved the excision of lax the functional correction of excess eyelid skin
skin and muscle and the removal of fat, some- in the sixteenth century. In the 1830s several
times leaving patients long term with a hollow authors discussed the resection of redundant
orbit and harsh, operated appearance and of- eyelid skin.3–5 Sichel,6 in 1844, described her-
ten accelerating the aging process. Current niated intraorbital fat. Bourguet7 reported sep-
methods of periorbital rejuvenation are more arate fat compartments in the eyelids and his
conservative in the resection of coveted soft technique for excising excess fat through a
tissue from the eye. This is consistent with transconjunctival approach to prevent scar-
other areas of the face where precious soft ring. The modern blepharoplasty and detailed
tissue is shaped, not necessarily removed. The anatomy of the orbital fat compartments were
ideal youthful appearance can be seen in mod- described by Costañares in 1951.8 Loeb9 and
els and movie stars by studying the appearance Furnas10 described removing redundant mus-
of their eyes. Beautiful young eyelids are full, cle in the late 1970s. These techniques focused
From the University of Texas Southwestern Medical Center. Received for publication May 24, 2002; revised November 13, 2002.
DOI: 10.1097/01.PRS.0000105684.06281.32
32e
Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY 33e
In the Asian eyelid, the orbital septum in-
serts more inferiorly onto the distal expansion
on the levator aponeurosis, which allows more
preaponeurotic fat to reside lower on the up-
per eyelid. This results in a lower or absent
eyelid crease.16 Siegel reported that the levator
aponeurosis in Caucasians joins a network of
fascia in the upper lid rather than the dermis.17
He believes the major difference between Cau-
casian and Asian eyelids is the level at which
the fascia fuses to create the fold. The layers of
fascia are infiltrated with fat in Asians.18 The
two main compartments of orbital fat are
found posterior to the orbital septum. They are
the nasal or medial (orbital) and temporal or
lateral (preaponeurotic) compartments, which
are separated by the superior oblique muscle.
The medial fat is usually pale yellow or white,
and the lateral fat is yellow.
Histologically, the differences are in a
FIG. 1. Periorbital volume depletion with aging. Adapted
greater amount of connective tissue and blood
from Fagien, S. Advanced rejuvenative upper blepharoplas- vessels in the medial fat; the lateral fat has a
ty: Enhancing aesthetics of the upper periorbita. Plast. Re- greater amount of carotenoids.19 Preseptal
constr. Surg. 110: 278, 2002. retroorbicularis fat is located between the or-
bital septum and the orbicularis. It is often a
on resection of redundant tissue, and only re- significant factor in lateral lid hooding and
cently have authors gained an appreciation for puffiness. Subcutaneous fat may be present be-
the conservative resection of periorbital fat.11–13 tween the orbicularis and the skin immediately
Deep or “hollow” upper eyelid sulci are com- beneath the eyebrow and also contributes to
mon results of the modern blepharoplasty, pre- full upper eyelids.20,21
sumably from overresection of soft tissue.14 The motor nerve supply to the upper eyelids
This is especially true in patients with a prom- is from the buccal, zygomatic, and frontal
inent globe or negative upper periorbital vec- branches of the facial nerve. Multiple inter-
tor. Siegel15 believes that the height of the fold communications among facial nerve branches
should be determined by the balance of mo- result in an extensive nerve supply to all pe-
tors—the levator versus the orbicularis. If the ripheral areas of the orbicularis.22 Studies in
levator is weak, a slightly lower fold should be monkeys showed that resection of preseptal
chosen. and supraorbital orbicularis oculi muscle or
pretarsal muscle only did not result in lagoph-
ANATOMICAL CONSIDERATIONS thalmos, but resection of all three components
The upper eyelid can be divided into tarsal did.23 During sleep there is a persistent tone of
and orbital portions at the level of the supra- the orbicularis to keep the eyes closed. If the
tarsal fold. In Caucasians, it is located approx- motor nerves are blocked, the upper lid will
imately 8 to 10 mm from the palpebral margin open.
and results from a fusion of the levator apo-
neurosis, orbital septum, and fascia of the or- CLINICAL EVALUATION
bicularis oculi into the dermis. In the tarsal The surgical approach must take into con-
portion, these layers insert onto the anterior sideration the repositioning of underlying soft
surface of tarsus. This area degenerates with tissue and the redraping of skin. These tissues
age, which may lead to a high fold, with or lose elasticity and support with aging, a condi-
without upper lid ptosis, and/or skin laxity of tion termed dermatochalasis in the skin.
the lid. Loss of crease attachments may cause Blepharochalasis is a recurrent, intermittent,
the skin to rest toward or beyond the upper inflammatory condition of the eyelids resulting
eyelid/lash margin, with a tendency to inter- in edema, erythema, and thin excess eyelid
fere with upper outer visual fields.14 skin secondary to histamine response and re-
34e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004
lated to increased immunoglobulin E. In con-
trast to dermatochalasis, blepharochalasis is
difficult to correct and likely to recur. In the
older population, a fold of excess upper eyelid
skin can impair the function of the eye, specif-
ically by obstruction of visual fields. A preoper-
ative workup may include a consultation with
an ophthalmologist for documentation of vi-
sual field impairment to determine whether
the obstruction is of visual significance (so that FIG. 2. The planned surgical incision is located 2 to 3 mm
its correction is medically necessary) to qualify below the apparent supratarsal fold. Adapted from Fagien,
patients for potential insurance benefits. S. Advanced rejuvenative upper blepharoplasty: Enhancing
aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110:
Evaluation of the upper eyelid must include 278, 2002.
an evaluation of the eyebrow.24 Brow ptosis
should be corrected to achieve repositioning of
heavy eyebrow skin, which may be compen- mm from the lower edge of the brow and not
sated by frontalis contraction to keep the eye- include any thick brow skin. The use of a pinch
brows above the orbital rim. Aging causes the test for redraping the skin is helpful.14 The
eyebrow fat to descend over the upper lid, shape of the skin resection is lenticular in
giving it a full appearance. Once the visual younger patients and more trapezoid-shaped
obstruction has been removed by eyelid skin laterally in older patients (Fig. 3). The index of
resection, the brows may look even heavier safety is much higher laterally (one can remove
since elevation is no longer needed for the more skin) and becomes more critical as the
visual field. This results in a more aged appear- incision proceeds medially (Figs. 4 and 5). The
ance.25–27 If this tissue is resected rather than incision may need to be extended laterally with
resuspended, an overexposure of under- a larger excision, but extension lateral to the
lying tissues may result, giving a hollow orbital rim should be avoided if possible to
appearance.14,28 prevent a prominent scar, especially in male
Medical and ophthalmologic histories must patients and patients with thick skin. Similarly,
be obtained from the patient, including any the medial markings should not be extended
history of chronic illness, hypertension, diabe- medial to the medial canthus for larger resec-
tes, cardiac disease, bleeding disorders, thyroid tions because extensions onto the nasal side-
disturbances, or surgery. Medications, includ- wall result in webbing. If excessive skin is
ing aspirin and other anticoagulants, are listed present medially, a W-plasty may need to be
and withheld for at least 2 weeks preopera- performed. The amount of fat to be resected
tively. Patients must be specifically questioned should be determined preoperatively, with the
concerning dietary supplements that may also patient in up-gaze, down-gaze, and medial and
affect clotting29 as well as concerning their vi- lateral ranges of motion, with photographic
sion, corrective lenses, previous surgery or documentation.
trauma, glaucoma, allergic reactions, excess
tearing, and dry eyes.30 A Schirmer test should SURGICAL TECHNIQUE
be conducted if the patient has dry eyes or Subcutaneous injection with 3 cc of 1% lido-
occasional symptoms, and referral to an oph- caine with 1:100,000 epinephrine using a 27-
thalmologist is recommended.31–33 gauge, 11⁄2-inch needle 7 minutes before oper-
ative scrub preparation will allow time for
PREOPERATIVE MARKINGS maximum vasoconstriction. Hyaluronidase has
Preoperative markings are critical to assess been added to the local anesthetic for more
and are made with the patient sitting upright rapid and even spreading of local anesthesia,
and in neutral gaze. The brow needs to be but diplopia and pupillary dilatation can occur
elevated to the proper position before any secondary to posterior spread of lidocaine.28
marks are made. The supratarsal fold is located The local anesthetic should be injected super-
at approximately 8 to 9 mm above the ciliary ficially to avoid any subcutaneous or intraor-
margin in women and at 7 to 8 mm in men. A bicularis hematoma formation. Incisions are
mark should be made just inferior to this fold made superficially with a fresh no. 15 blade
(Fig. 2). The upper marking must be at least 10 through the epidermis only, and the pre-
Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY 35e
white fat; this fat is usually preserved to avoid
volume depletion of the upper periorbita that
can manifest as notches or depressions in this
region (Fig. 9).
Once fat resection is completed, a lower lid
lateral canthopexy may be performed through
the upper blepharoplasty incision (Figs. 10 and
11). An incision is made laterally to expose the
lateral orbital rim. A 5-0 Vicryl suture is placed
through the anterior lamella of the lateral can-
thus and secured to periosteum on the inside
of the lateral orbital rim at the level of the
upper limbus. It is important to place this su-
ture inside the rim and posteriorly to avoid
tenting the lower lid over the eye. This lift will
be subtle and will resolve over time while pre-
venting ectropion in the postoperative course.
Once hemostasis is obtained, any final adjust-
ments concerning shape are made, especially
laterally, to maximize the appearance of bilat-
eral eyelid symmetry. The incision is closed

FIG. 3. Upper eyelid skin resection increases in size both

vertically and laterally as the periorbital area ages: young
(above), middle age (center), and old (below). Adapted from
Fagien, S. Advanced rejuvenative upper blepharoplasty: En- FIG. 4. Surgical markings in a lenticular shape. Adapted
hancing aesthetics of the upper periorbita. Plast. Reconstr. from Fagien, S. Advanced rejuvenative upper blepharoplas-
Surg. 110: 278, 2002. ty: Enhancing aesthetics of the upper periorbita. Plast. Re-
constr. Surg. 110: 278, 2002.
marked strip of skin is resected with fine
curved scissors (Fig. 6). If redundant orbicu-
laris muscle is present, this resection can in-
clude the predetermined amount of orbicu-
laris muscle to be resected. This can also be
used to define the supratarsal fold. Hemostasis
is obtained using pinpoint insulated cautery
(Colorado microdissection needle, Stryker-
Leibinger, Inc., Kalamazoo, Mich.). A small
incision is made into each fat compartment of
the eyelid in which resection of redundant fat
has been planned. The fat is teased out and
resected using pinpoint cautery (Fig. 7). This
fat usually includes the medial or nasal com-
partment, which contains white fat (Fig. 8).
Yellow fat can also be found in this area but it
is usually more superficial and lateral to the FIG. 5. Preoperative markings.
36e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004
LASER BLEPHAROPLASTY
Laser blepharoplasty was first described in
1984 by Baker et al.34 Incisions may be made
with a scalpel or with a laser. The 1997 Amer-
ican Society for Aesthetic Plastic Surgery/
American Society of Plastic and Reconstructive

FIG. 8. White fat resection, medial compartment (only if

indicated). Necessity is determined preoperatively by a phys-
ical examination.

FIG. 6. Skin resection. (Above) During resection. (Below)

Resection completed.

FIG. 9. Amount of fat to be resected is determined

preoperatively.

FIG. 7. Yellow fat resection, medial compartment (only if

indicated). Necessity is determined preoperatively by a phys-
ical examination.

using a running subcutaneous 6-0 Prolene su-

ture followed by interrupted simple 6-0 nylon
sutures. At the conclusion of the case, the pa-
tient should have approximately 2 to 3 mm of
lagophthalmos bilaterally (Fig. 12). Sutures
should be placed 1 mm into skin over an intact FIG. 10. Intraoperative view of a lower lid canthopexy per-
formed through the upper lid incision. Adapted from Fagien,
orbicularis, allowing the muscle to fold on it- S. Advanced rejuvenative upper blepharoplasty: Enhancing
self in a pleated fashion with skin closure (Fig. aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110:
13).14 278, 2002.
Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY 37e
when compared with electrocautery, resulting
in better scars and decreased postoperative
edema and ecchymosis.12 Safety issues include
eye protection for the patient with stainless
steel eye shields and for the operative team
with protective goggles.35 In our experience,
laser use does not have a significant advantage
and is used infrequently.
Before the initial incision is made, it must be
decided whether laser resurfacing is to be per-
formed. This results in at least 4 to 6 mm of
upper lid shortening, so skin resection must be
adjusted accordingly. Cutting of the skin
should be performed in the ultrapulse mode.
Dissection is then performed in the continuous
mode for more coagulation. Conservative fat
resection may also be performed using the la-
ser. Once the incision is closed, the carbon
dioxide laser, alone or in combination with the
FIG. 11. Illustration demonstrating suture placement. erbium:yttrium-aluminum-garnet laser, may be
Adapted from Fagien, S. Advanced rejuvenative upper used for resurfacing.36 Eye shields are placed to
blepharoplasty: Enhancing aesthetics of the upper periorbita. protect the eyes, and eyelids need to be re-
Plast. Reconstr. Surg. 110: 278, 2002. flected with a wet cotton-tipped applicator.
The skin is covered postoperatively with a semi-
permeable dressing to maintain moisture and
minimize pain.37 Seckel et al.38 use the carbon
dioxide laser directly on the orbicularis muscle
to cause visible shrinking of the muscle and
septum.

MALE BLEPHAROPLASTY
In the United States, 16 percent of blepha-
roplasties are performed on men, and blepha-
roplasty is the second most common cosmetic
surgery performed on male patients.39 Men

FIG. 12. Closure of incisions: (above) a 6-0 Prolene run-

ning subcuticular suture; (below) 6-0 nylon interrupted simple
sutures. Approximately 2 mm of lagophthalmos is noted at
the completion of the procedure.

Surgeons Laser Task Force Survey found that

84 percent of respondents performed laser
blepharoplasty. A median time of 3 hours of
hands-on training with the technique was re-
ceived before it was incorporated into their
practice. Disadvantages of the laser technique
include the potential for poor wound healing, FIG. 13. Sutures should be placed 1 mm into skin over an
loss of tactile (sensation) feedback, time spent intact orbicularis, allowing the muscle to fold on itself (left)
in a pleated fashion with skin closure (right). Adapted from
learning, and expense. Possible advantages in- Fagien, S. Advanced rejuvenative upper blepharoplasty: En-
clude decreased bleeding, less time spent ob- hancing aesthetics of the upper periorbita. Plast. Reconstr.
taining hemostasis, and less tissue damage Surg. 110: 278, 2002.
38e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004
tend to seek out blepharoplasty more for func- sia or amaurosis fugax (like a “window shade”
tional reasons than women, but this difference over the lower half of the visual field), and
has become less and less distinct in recent scintillating scotomas (sparkles and flashes)
years. A more natural look is preferred, and (Fig. 14). Examination will often reveal a tense
the “operated look” will not be tolerated well and protuberant periorbital area with dimin-
by most male patients. Men will typically not be ished or absent extraocular movements. Once
wearing cosmetics, so all scars must be carefully the diagnosis is made, treatment should be
concealed. This also makes male patients sub- implemented immediately because 90 to 120
optimal candidates for laser resurfacing. The minutes of ischemia leads to irreversible blind-
lateral incision should only infrequently be ex- ness. Wolfort et al.43 reviewed the diagnosis and
tended beyond the later orbital rim. In men treatment of retrobulbar hematoma. All dress-
with heavy brows, resection of upper eyelid ings should be removed and sutures need to be
skin only will result in profoundly ptotic brows. released. An ophthalmologic consultation
Therefore, one should counsel combined brow should be obtained immediately. The patient
surgery with upper blepharoplasty. Many men should be given mannitol 20% 1.5 to 2 g/kg
are reluctant to have cosmetic surgery to cor- intravenously (with the first 12.5 g over a
rect brow ptosis, so careful preoperative coun- 3-minute period and the remainder over a 30-
seling is needed to prevent a dissatisfied pa- minute period), 500 mg of Diamox (acetazol-
tient with worse brow ptosis postoperatively.40 amide; Lederle Pharmaceutical Division,
Often, conservative eyelid resection is all that is American Cyanamid Company, Pearl River,
required. N.Y.) intravenously, 95 percent oxygen/5 per-
cent carbon dioxide to dilate intraocular ves-
POSTOPERATIVE MANAGEMENT sels, Solu-Medrol (Pharmacia & Upjohn, New
Postoperative care should include a chilled York, N.Y.) 100 mg intravenously, and Betoptic
light gel compress (Swiss Eye Therapy, Invotec (Allen USA, Fort Worth, Texas), one drop im-
International, Jacksonville, Fla.) for 48 hours, mediately, then twice daily. These actions
saline eye drops (Refresh Plus, Allergan Inc., should be taken as the patient is being taken
Irvine, Calif.) while the patient is awake, and back to the operating room for reexploration
lubricating ointment (Refresh P.M., Allergan) and evacuation of hematoma, as well as possi-
for night use. Tobramycin ophthalmic drops ble lateral canthotomy and release of the arcus
may be used prophylactically in the early post- marginalis.
operative period, typically three times per day Vision loss can also result from globe perfo-
for 3 to 5 days. The patient’s head should ration44 during infiltration with local anes-
remain elevated to reduce edema and ophthal- thetic. This is extremely rare and, along with
mic pressure. The patient is seen in the recov- corneal abrasion, can be prevented with cor-
ery room to evaluate and document vision be- neal protectors.
fore discharge and followed up 4 to 5 days Superficial hematomas usually result from
postoperatively, when all sutures are removed. orbicularis muscle vessel bleeding and do not
Lagophthalmos is usually secondary to perior- threaten vision. When small, they can usually
bital edema and resolves in 1 to 2 weeks. Pre- be allowed to resolve spontaneously. If larger,
operative and postoperative patient education they can be evacuated after liquefaction occurs
on the use of eye drops and ointment, espe- 7 to 10 days later.45 Careful control of blood
cially at night, is essential to prevent corneal pressure, use of ice, and elevation of the head
abrasions and exposure problems. help to prevent hematoma and ecchymosis.
Diplopia may result from impaired ocular
COMPLICATIONS motility, more commonly in lower blepharo-
Vision loss due to retrobulbar hematoma is plasty from involvement of the inferior oblique
the most feared complication resulting from but also from upper lid surgery from the verti-
blepharoplasty; fortunately, the occurrence is cal recti and superior oblique. The etiology is
rare. The incidence is reportedly 0.04 percent, postulated to be from edema or stretch result-
or one in 2500 cases.41,42 Acute retrobulbar ing in perimuscular hemorrhage. Conservative
hematoma may compress neurovascular struc- management is recommended since the diplo-
tures, leading to ischemia of the retina, central pia will often resolve as the edema and inflam-
artery, and optic nerve. Symptoms include se- mation subside.46,47
vere pain, visual changes, including hemianop- Lagophthalmos may result from edema or
Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY 39e

FIG. 14. Algorithm for retrobulbar hematoma diagnosis and treatment.

excessive skin resection, but is usually managed and/or systemic antibiotics. If a fluid collection
conservatively with patient reassurance, light is present, it should be drained.49
massage, taping, and proper nocturnal lubrica- Postblepharoplasty ptosis is a common finding
tion. Studies show no change in blink dynamics in the recovery room and for several hours fol-
following blepharoplasty.48 lowing the procedure, due to the effect of local
Cellulitis is extremely rare in this highly vas- anesthesia on the levator. Ptosis that develops in
cular area, but it can be treated with topical the postoperative period is an uncommon com-
40e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004

FIG. 15. Upper blepharoplasty using selective skin resection only with orbicularis preservation. No fat removal
was performed. Lower blepharoplasty was also performed. (Left) Preoperative and (right) 2-year postoperative views.

FIG. 16. Upper blepharoplasty using selective skin resection, orbicularis preservation, and central fad pad removal. Endo-
scopic brow lift, laser resurfacing, and lower blepharoplasty were also performed, with no lower lid skin resection. (Left)
Preoperative and (right) 15-month postoperative views.

FIG. 17. Selective skin resection only, with orbicularis preservation and central fat pad removal. Levator advancement and
lowering of the supratarsal fold for correction of levator dehiscence. (Left) Preoperative and (right) 13-month postoperative views.

plication of blepharoplasty that should be evalu- and muscle have been replaced with conser-
ated thoroughly to determine the cause. Lid vative and careful resections of only redun-
asymmetry that persists after surgery or develops dant soft tissue. Ptotic soft tissues are relo-
postoperatively should be evaluated to determine cated rather than resected. The eyelid must
the degree of ptosis and the amount of levator always be considered in conjunction with the
function. Ptosis can be secondary to edema, op- eyebrow, and correction of periorbital aging
erative technique, or injury to the levator com- may require brow repositioning as well. Care-
plex. Severe ptosis with poor levator function ful perioperative technique, meticulous he-
requires reexploration with levator repair. Mild mostasis, and attentive postoperative man-
cases may resolve spontaneously and can be man- agement of blood pressure will prevent most
aged expectantly.50 complications.
CONCLUSIONS Rod J. Rohrich, M.D.
Blepharoplasty is a highly successful aes- Department of Plastic Surgery
thetic surgical procedure that requires care- University of Texas Southwestern Medical Center
ful preoperative planning and examination 5323 Harry Hines Boulevard, Suite E7.210
of the patient’s concerns and desires (Figs. Dallas, Texas 75390
15, 16, and 17). Standard resections of fat rod.rohrich@utsouthwestern.edu
Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY 41e
ACKNOWLEDGMENT perimental surgery on the monkey. Plast. Reconstr.
Surg. 87: 32, 1991.
We sincerely thank Vikram Gavande, M.S., University of 24. Gunter, J. P., and Antrobus, S. D. Aesthetic analysis of
Texas Southwestern Medical School, Dallas, Texas, for his the eyebrows. Plast. Reconstr. Surg. 99: 1808, 1997.
assistance with the manuscript. 25. Flowers, R. S., and Flowers, S. S. Precision planning in
blepharoplasty: The importance of preoperative map-
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