Upper Blepharop las t y

The Aesthetic Ideal

Jon-Paul Pepper, MD*, Jeffrey S. Moyer, MD, FACS

KEYWORDS
 Blepharoplasty  Aesthetics  Upper eyelid anatomy  Aging face  Plastic surgery

KEY POINTS
 Upper lid aging is characterized by changes in the curvature of the upper lid and the position of the
lateral canthus. Periorbital volume loss and skin elasticity changes result in the characteristic derma-
tochalsis and smaller visible palpebral aperture associated with the aging upper lid.
 Accurate preoperative assessment of the anatomic problem is critical.
 Precise incision marking will in large part determine a successful upper lid blepharoplasty.
 Fat-sparing techniques are most commonly used to avoid a hollow upper lid and excessive pretarsal
show.

INTRODUCTION upper lid is analyzed simultaneously with the

brow and the entire periorbital region. As such,
Upper lid blepharoplasty was first described by the the eyebrows should be at or above the orbital
Hindu surgeon Susruta in approximately the rim, with the medial brow at a vertical line drawn
second century AD, in the Susruta Samhita.1 Eyelid through the alar-facial sulcus and the medial
surgery was largely forgotten for centuries but canthus. The lateral margin terminates at a line
experienced a revival in the eighteenth and nine- drawn from the ala, through the lateral canthus
teenth centuries via the work of Beer and Von (Fig. 1). The lateral canthus should be 2 mm ceph-
Graafe.2 Slowly there evolved a more detailed alad to the medial canthus, creating a positive can-
understanding of upper lid anatomy and the correc- thal tilt of 3 to 4 in the women and 1 to 2 in the
tion of age-related changes. Early approaches men.5
focused on the excision of redundant soft tissue.3
It was not until recently that surgeons gained an Supratarsal Crease
appreciation of the esthetic benefits of conserva-
tion of periorbital fat.3 In the past 15 years, many The essential landmark of upper lid blepharoplasty
authors have decried the skeletonized and hollow is the supratarsal crease. The supratarsal crease is
upper lid as the stigmata of overaggressive fat commonly 7 to 10 mm from the palpebral margin,
resection during upper lid blepharoplasty.4 usually 8 to 9 mm above the lid margin in women
and 7 to 8 mm in men. It is thought that the supra-
ANATOMY AND AGE-RELATED CHANGES IN tarsal crease is created by the fusion of the levator
THE UPPER EYELID aponeurosis with the orbital septum and the inser-
tion of the fascia of the orbicularis oculi into the
Perhaps the most critical component to perform- dermis.3 Recent anatomic studies reveal that
plasticsurgery.theclinics.com

ing consistently successful upper lid blepharo- the levator aponeurosis has 2 distinct layers.6
plasty is accurate facial analysis during the The anterior layer reflects upward and inserts on
presurgical consultation. As is widely known, the the orbital septum. The posterior layer inserts

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery,
Center for Facial Cosmetic Surgery, University of Michigan, Livonia, MI, USA
* Corresponding author.
E-mail address: jonpaul@med.umich.edu

Clin Plastic Surg 40 (2013) 133–138

http://dx.doi.org/10.1016/j.cps.2012.07.001
0094-1298/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
134 Pepper & Moyer

Fig. 1. Example of youthful periorbital anatomy. Note

the relationship of the medial and lateral ends of the
brow with respect to lines drawn through the alar-
facial sulcus and medial canthus as well as the alar-
facial sulcus and lateral canthus, respectively.

onto the tarsal plate and the subcutaneous tissue

superficial to the tarsal plate’s lower third.

Age-Related Changes in the Periorbital Area

Fig. 2. Sagittal section of the periorbital region and
The tarsal portion of the orbicularis is thought to be upper lid. Note the connections between the poste-
particularly susceptible to age-related changes, rior layer of the levator aponeurosis and the pretarsal
and the involution of the pretarsal soft tissue skin. Abbreviations: AL, anterior layer of levator
causes a concomitant elevation in height in the aponeurosis; LPS, levator palpebrae superioris muscle;
supratarsal fold and increased skin laxity in this MM, mullers muscle; OOM, orbicularis oculi; OS,
location. As attachments to the thin dermis at the orbital septum; PAF, preaponeurotic fat; PL, posterior
supratarsal crease are lost, the soft tissue herni- layer of levator aponeurosis; Ta, tarsus; WL, Whitnall’s
ates inferiorly, creating the characteristic dermato- ligament.
chalasis of the aged upper lid (Fig. 2).
The orbital fat of the upper lid is thought to fat pad, in contrast, seems to diminish in terms of
comprise the medial (nasal) and preaponeurotic its apparent volume as patients age. This is the
(“prelevator”) fat pads. Anteriorly, there is a relative driving factor in the skeletonized or hallowed
demarcation between the 2, whereas posteriorly look of the superior periorbital region. The supra-
the fat pads comingle with little distinguishing tarsal crease often migrates cephalad as the eye
features.7 The preaponeurotic fat traverses the ages; it is thought that relative volume loss may
lateral portion of the superior periorbita, curling either cause or exacerbate this cephalad reposi-
behind the posterior aspect of the lacrimal gland. tioning of the supratarsal crease (Fig. 3).
There is a clear demarcation between the preapo- As summarized by Lambros, the 2 key stigmata
neurotic and medial fat pads. The medial horn of of periorbital aging include10:
the levator aponeurosis and the lateral fascia on
1. Upper lid “arc shift” from medial to lateral
the superior oblique muscle both serve to separate
2. Apparent decrease in size of palpebral fissure
the central compartment from the medial
compartment. The medial compartment is pale
yellow or white due to a greater percentage of
connective tissue, thereby imbuing this tissue
with paler hues.3 The central/preaponeurotic fat
has a higher concentration of carotenoids, which
gives this fat a yellow hue, in contrast to the pale
medial compartment fat.8
General loss of skin elasticity and loss of soft
tissue volume combine to increase upper lid skin
redundancy.4 Oh and Colleagues9 demonstrate Fig. 3. Aged periorbital region. Note the elevation of
a relative increase in the subjective volume of the the supratarsal fold in combination with asymmetric
nasal fat pad during the aging process. The central blepharoptosis.
 Upper Blepharoplasty 135

The arc of the upper lid has its peak on the sagging is often more pronounced in men and
medial aspect of the lid in the youthful face in may therefore be of higher concern to male
both men and women (see Fig. 1; Fig. 4).10 As patients seeking periorbital rejuvenation.12 Both
patients age, the peak of the upper lid’s arc genders experience more superior placement of
migrates to a more lateral position. Depending the supratarsal crease as they age, as well as
on the method of study, it has been assumed eyebrow elevation.13 This is a burgeoning area of
that the periorbital retaining ligaments lose elas- research, and nearly all preliminary data show
ticity as patients age,11 which may contribute to significant differences between different genders
migration of the lateral canthal angle.10 This is and different ethnic groups that exert an influence
a matter of some debate. A cross-sectional study on the periorbital aging process.12–14
of 320 patients found little to no migration of the As a whole, these studies have begun to estab-
lateral canthal angle with respect to other lid lish an understanding of the normative anatomy of
photogrammetric landmarks.12 Contrary to the periorbital region as it varies by race and age.
conventional assumption, the lateral canthal angle Although this certainly impacts the esthetic ideal, it
did not descend inferiorly with age with respect to by no means defines it. Future investigations will,
the pupil and lid surface reference landmarks. we hope, elucidate to what extent gender and
Instead, the lateral canthus was found to be ethnicity may affect a patient’s assessment of
migrating anteriorly with respect to the anterior surgical outcome as well as their goals when
corneal surface on lateral view. The end sum of initially seeking blepharoplasty.
this migration is the perception of a smaller palpe-
bral aperture and a smaller surface area of
EVALUATION FOR UPPER LID
conjunctiva in the aging eye, which seems to be
BLEPHAROPLASTY
a point of consensus in the literature.10 It is worth
noting that the medial canthal angle, by contrast, The most critical aspect of successful upper lid
is thought to be relatively stable throughout the blepharoplasty is the preoperative office evalua-
aging process. Also, the globe itself does not tion, which enables accurate preoperative incision
change size as patients age, nor is globe descent planning. The presurgical consultation must
a prominent part of the aging process.10 include an examination of visual acuity as well as
Although many anthropometric analyses are visual field testing. The Snellen chart is the stan-
beginning to scratch the surface of the myriad dard for monocular visual acuity. A thorough visual
age-associated changes of upper lid anatomy, field examination is critical, particularly if the
there are several additional considerations that patient seeks blepharoplasty for functional
directly impact surgical esthetic goals. Particu- reasons and may be covered by his or her insurer.
larly, gender- and ethnicity-related influences
exert independent effects on the aging process
Dry Eye
of the periorbital region. Furthermore, there may
be significant a priori differences between genders All patients must be queried regarding dry eye
and races in terms of the esthetic goals with regard symptoms, and this is an important consideration
to upper lid surgery. For instance, lower eyelid given the high prevalence of dry eye complaints in
patients seeking upper eyelid surgery (up to
15%).15 A Schirmer’s test is no longer considered
the standard of care for the diagnosis of dry eye
syndrome.15 There is a well-documented associa-
tion between dry eye symptoms and autoimmune
disease, and therefore patients with suspected
undiagnosed autoimmune disease are referred to
a rheumatologist for further evaluation. Other rele-
vant aspects of the past medical history include
glaucoma, hypertension (the patient’s blood pres-
sure is measured), anticoagulation (including low-
dose aspirin), renal failure, and edema of the
extremities.
Patients are specifically asked if they have
Fig. 4. Youthful periorbital region in a male patient. recently undergone laser vision correction surgery.
As in the photograph of a female patient (see Current guidelines recommend that patients wait
Fig. 1), there is an arc that is highest laterally and at least 6 months before undergoing blepharo-
a superolateral fullness of the upper lid. plasty due to temporary dysfunction in tear film
136 Pepper & Moyer

production and corneal sensation that may occur  The brow is elevated with the surgeon’s
after laser vision surgery.16 nondominant hand so as to minimize the
confounding effect of the brow soft tissues
Facial Nerve Function, Lagophthalmos, Bell’s on true upper lid dermatochalasis. Failure to
Phenomenon, Ectropion, Blepharochalasis suspend the brow soft tissue may result in
overresection and a supratarsal crease
The role of the lid in corneal protection is para- that is more superior than originally in-
mount; therefore, careful evaluation of facial nerve tended. Given that elevated supratarsal
function and determination of the presence or crease position is associated with the
absence of lagophthalmos, Bell’s phenomenon, aged eye, this is a complication that should
and ectropion are critical. During the evaluation be avoided.
of the upper lid, blepharochalasis is ruled out.  The usual location of the supratarsal crease
Blephrochalasis is an IgE-mediated condition is 8 to 9 mm above the lid margin in women
marked by recurrent swelling and erythema.3 It is and 7 to 8 mm in men. A fine-tipped skin
likely to recur and these patients are poor candi- marker is used, with alcohol pads available
dates for blepharoplasty. for remarking as needed. It may be easier to
identify the crease by having the patient
Dermatochalasis look downward.
 The inferior incision line is marked first. For
Dermatochalasis may result in compensatory fron- a patient with a supratarsal crease that is 9
talis contraction and this should be pointed out mm above the lid margin, the inferior mark
during the patient consultation and evaluation. is begun 1 to 2 mm inferior to the actual
Once the dermatochalasis is surgically corrected, crease.
the compensatory contraction may cease. This  Medially, the planned incisions slope down-
may result in the brow soft tissue to slide inferiorly, ward toward the medial canthus, approxi-
thereby minimizing the impact of the blepharo- mately 7 to 8 mm.
plasty. Tonic, subconscious compensatory fronta-  The incision is stopped at the superior
lis contraction is common. Mild scarring forces lacrimal punctum. This is thought to lessen
after upper lid blepharoplasty may further exacer- the chance of forming a medial canthal
bate undiagnosed brow ptosis. web.
 The lateral extent of the inferior limb incision
Ptosis drops inferiorly to within approximately
5 mm of the lateral canthus.
Both bilateral and unilateral blepharoptosis can  The incision is then brought back superiorly
have important ramifications for presurgical plan- into a natural skin crease. We avoid extend-
ning before upper lid blepharoplasty. Ptosis can ing the lateral incisions beyond the orbital
be most accurately assessed via an anterior view rim if possible due to the unfavorable scar
photograph, by comparing the margin to corneal that may result, particularly in the patient
light reflex distance of the upper and lower lids. with few lateral periorbital rhytids. However,
Note that unilateral ptosis is often accompanied the presence of lateral hooding may require
by compensatory brow elevation. Ptosis should a lateral extension of the incision with
be suspected in any patient with more than 2 to a gentle curve upward past the lateral
3 mm of lid overlap of the upper limbus of the canthus.
iris. In the patient with a high supratarsal crease  Higher placement of the inferior incision will
and unilateral ptosis, the surgeon should suspect result in more pretarsal show. This may also
levator palpebrae superioris dehiscence. This create the illusion that the upper lid margin
may be addressed simultaneously with upper lid has a more caudal resting position and
blepharoplasty but should be evaluated by an therefore can be used to the surgeon’s
ophthalmologist before surgery. advantage if there is any preoperative
asymmetry with respect to the resting posi-
INCISION PLANNING tion of the upper lid margin.
 The superior incision is marked based on
The patient is positioned upright, as analysis and the degree of soft tissue redundancy. We
marking while supine can cause any medial pseu- use Green fixation forceps to grasp redun-
doherniation to seem less severe due to the effect dant soft tissue, placing them sequentially
of gravity. Also, the brow and lid are pulled superi- in the medial, central, and lateral portions
orly by the scalp when the patient lies supine. of the lid to determine the width of the
 Upper Blepharoplasty 137

excised tissue. This width determines the satisfaction following blepharoplasty demon-
location of the superior incision. strated that patients may underestimate the
 Care is taken to preserve at least 15 mm of amount of postoperative swelling and pain and
skin between the superior incision and the the degree to which their recovery affects their
lower margin of the brow and 8 to 10 mm ability to function in their daily activities.17 It
of eyelid skin between the incision and the seems, then, that despite the long track record
eyelid margin. The total amount removed of success, there may still be room for more accu-
is variable but is greater in older patients rate preparation of patients, particularly for the
with more lax tissues. Overaggressive early stages of surgical recovery.
resection places the patient at risk of post- In the senior author’s view, both male and female
operative lagophthalmos. patients are in search of a more youthful upper lid. It
 Not all patients have a supratarsal crease that is commonly presumed that male patients seeking
is the classic 8 to 9 mm from the ciliary margin blepharoplasty more frequently do so for functional
of the upper lid. If the crease is caudal, such reasons (ie, restriction of the temporal visual
as in the lid of Caucasian male patients, the fields).18 However, this is tempered by an individu-
entire inferior incision line should be adjusted alized approach that takes into account the
to accommodate the difference and avoid the patient’s age, ethnicity, and gender.
creation of a double crease. Additionally,
larger amounts of dermatochalasis may AFTERCARE
demand more aggressive resection of the
medial skin. A W-plasty may be helpful in Immediately on skin closure, ice packs are applied
these instances to keep the medial incision and replaced every half hour once the patient is in
from extending beyond the lacrimal punctum. the recovery room. Ophthalmic bacitracin oint-
ment is used on the incision line. We ask that
A detailed description of the surgical technique is patients apply ice packs every hour after leaving
made elsewhere in this issue. Briefly, following the recovery room. Patients are counseled to
sharp elevation and excision of the thin skin flap avoid the use of alcohol and anticoagulant medi-
as described above, the surgeon is faced with the cations if feasible, based on their medical history
decision to either incise the orbicularis oculi muscle and comorbidities. Patients are asked to avoid
or perform plication of the muscle. The surgeon significant physical activity for 1 week to limit post-
must keep in mind that the orbicularis is the main operative edema and ecchymosis. The patient is
depressor muscle of the upper lid. Incision through seen in clinic for postoperative evaluation 5 to 7
the muscle may denervate distal pretarsal fibers, days after surgery, at which time the sutures are
thereby allowing more unopposed levator palpe- removed and any concerns are addressed.
brae superioris function and, therefore, an eleva-
tion in the resting position of the lower lid. This is
a favorable result for most blepharoplasty proce- SUMMARY
dures. This should be considered carefully, Upper lid blepharoplasty is a surgical procedure
however, if the surgeon is performing an orbicularis with a high level of patient and surgeon satisfac-
plication alone without resection and limited fat tion. Keys to successful results and reproducible
cautery versus resection. Notably, some authors technique depend greatly on accurate preopera-
believe that preservation of orbicularis in the upper tive assessment of the anatomic problem and
lid allows for an “accordion” effect of bunching the precise marking of the soft tissues in the presurgi-
muscle fibers and thereby providing more fullness cal suite. The anatomy of this region is complex,
to the upper lid.4 The esthetic principle is to and our understanding of the periorbital aging
preserve or restore a convex contour to the lid process is a work in progress. First and foremost,
brow junction in addition to resecting redundant our ability to more precisely understand the age-
tissue. related changes of the upper lid will drive future
surgical (and nonsurgical) innovation. Last, our
grasp of the efficacy of the existing surgical tech-
PATIENT PERSPECTIVE
niques will improve as more evidence-based
During the preoperative counseling session, outcomes studies are performed.
patients are counseled about the attendant risks
of blepharoplasty. On average, upper lid blepharo- REFERENCES
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