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ATLAS OF AESTHETIC EYELID AND PERIOCULAR SURGERY ISBN 0–7216–8633–8

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The Publisher

Library of Congresss Cataloging-in-Publication Data

Spinelli, Henry M.
Atlas of aesthetic eyelid and periocular surgery / Henry M. Spinelli.—1st ed.
p. ; cm.
Includes bibliographical references.
ISBN 0–7216–8633–8
1. Blepharoplasty—Atlases. 2. Eyelids—Surgery—Atlases. 3. Surgery, Plastic—Atlases. 4.
Eyebrows—Surgery—Atlases. I. Title.
[DNLM: 1. Blepharoplasty—methods—Atlases. 2. Cosmetic Techniques—Atlases. 3.
Eye—pathology—Atlases. 4. Ophthalmologic Surgical Procedures—Atlases. 5.
Reconstructive Surgical Procedures—Atlases. WW 17 S757a 2004]
RD119.5.E94S657 2004
617.7’710592—dc22 2003059097

Vice President, Global Surgery: Richard Lampert

Acquisitions Editor: Peter McEllhenney
Design Coordinator: Steven Stave
Project Manager: Tina Rebane

Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

When Elsevier approached me concerning writing a text
on eyelid and periocular surgery I tried to determine
which books were popular and why they maintained
popularity. Given the incredibly busy schedule that most
surgeons and medical practitioners maintain in every
specialty, the texts that seem to be the most popular are
those that are quick and easy to read and review, are
well illustrated, and serve as small atlases in that they
serve as “how-to-tackle” books. Books of single author-
ship or limited authorship appear to be the most popu-
lar because these are well-organized and cohesive texts
that flow with a distinct beginning, middle, and end. In
my opinion these texts are usually purposefully drafted
and directed. We noted anatomy and physiology to be
fundamental and everlasting in their applicability. After
all, the foundation of any surgical procedure is solidly
grounded in the concepts of a basic understanding of
anatomy, physiology, and pathophysiology. Additionally,
excellent practical drawings, illustrations, and photo-
graphs of actual procedures, when organized and cross-
referenced, appear to provide the most salient teaching
tool in any text. These, combined with succinctly sum-
marized legends, enable the reader to quickly browse
through a chapter, gleaning its most important aspects.
A summary of each chapter, which delineates salient
positive and negative points, technical aspects, and
trouble spots within the concepts covered in each
chapter, appears to be extremely useful in capsulating
the topics covered and serves as a quick reference and
refresher for the reader.
With this in mind, I have compiled an atlas that
combines a directed practical narrative by a single
author with both illustrations, photographs, and a
summary in each chapter, which I have entitled Pearls
and Pitfalls. I hope I have created a text that may find
itself on the shelf of every practitioner of surgery and
treatment in the periocular and facial regions. These
Preface
include plastic surgeons, ophthalmologists (oculoplastic
surgeons), and otolaryngologists, as well as other
practitioners. I also believe that this text will be useful
to the cosmetic as well as the reconstructive surgeon in
its reliance on important principles and concepts. This
would make the text a long-lasting addition to the
library of the experienced and well-versed surgeon, as
well as of the resident and student.
In structuring the text I relied heavily on anatomy and
physiology, as well as pathophysiology. Within the
context of these basic science areas, I built on them
practical options and techniques for the treatment of
both functional and aesthetic problems. The single
authorship and strong illustrations should make for a
very directed and organized text; however, it is obvi-
ously biased toward the techniques and concepts that I
find most acceptable.
In the areas of eyelid, periocular, and orbital surgery,
there is considerable overlap in interest by multiple
specialties and there appears to be a drive on the part of
some practitioners to make this region esoteric and
especially complex.
I have made every effort in this text to demystify this
area through a fundamental understanding of anatomy,
physiology, pathophysiology, and good basic clinical
thinking. The “technical wizardry” is minor and within
the grasp of most practitioners. The concept of
identifying the pathophysiology and then how to tackle
it is a much more important principle for all of us to
understand and apply so that our patients may benefit.
I have attempted to compile an atlas that is easy to read
and reference and that unifies many of the principles
and techniques I have incorporated and taught. It
should enable most surgeons to feel more confident in
assessing and treating patients with cosmetic and/or
symptomatic periocular problems. I hope that you, the
reader, will agree.
v
P R E FA C E
I want to thank my family for their loving support
throughout this project, my office staff for their tireless
energy and enthusiasm, my mentors, my colleagues,
and my residents for contributing to my thought
Bibliography
Beard C: History of ptosis surgery. Advances in Ophthalmic,
Plastic, & Reconstructive Surgery 5:125–131, 1986.
Hughes SM: The history of lacrimal surgery. Advances in
Ophthalmic, Plastic, & Reconstructive Surgery 5:139–168,
1986.
Katzen LB: The history of cosmetic blepharoplasty. Advances
in Ophthalmic, Plastic, & Reconstructive Surgery 5:89–96,
1986.
Mikamo M: Mikamo’s double-eyelid operation: The advent
of Japanese aesthetic surgery. Plastic & Reconstructive
Surgery 99(3):664–669, 1997.
Miller CC: The excision of bag-like folds of skin from the
region about the eyes. By Charles C. Miller, 1906. Aesthetic
Plastic Surgery 12(3):155–156, 1988.
Miller CC, Miller F: Folds, bags and wrinkles of the skin
about the eyes and their eradication by simple surgical
methods. By Charles C. Miller and Florence Miller, 1907.
Aesthetic Plastic Surgery 12(3):157–158, 1988.
vi
processes and experiences. Without any of the
individuals I have mentioned, this text would not be
possible.
Henry M. Spinelli, MD, FACS
Patel BC, Anderson RL: History of oculoplastic surgery
(1986–1996). Ophthalmology 103(8 Suppl):S74–95, 1996.
Reifler DM: The tarsectomy operation of A.P.L. Gillet de
Grandmont (1837–1984) and its periodic rediscovery.
Ophthalmologica 89(1–2):153–162, 1995.
Rogers BO: History of oculoplastic surgery: The contributions
of plastic surgery. Aesthetic Plastic Surgery 12(3):129–152,
1988.
Safian J: A late report on an early operation for “baggy
eyelids.” Plastic & Reconstructive Surgery 48(4):347–348,
1971.
Servat J, Mantilla M: The history of ptosis surgery. Advances
in Ophthalmic, Plastic, & Reconstructive Surgery
5:133–137, 1986.
Silverstone P: History of surgery for involutional ectropion.
Advances in Ophthalmic, Plastic, & Reconstructive Surgery
5:97–123, 1986.
Watts MT: The history of oculoplastic surgery. Facial Plastic
Surgery 9(2):151–156, 1993.
Werb A: The history and development of lacrimal surgery in
England and Europe. Advances in Ophthalmic, Plastic, &
Reconstructive Surgery 5:233–240, 1986.

A fundamental concept in viewing the eyelid is that it is
composed of three distinct anatomic layers analogous
to those found in the nose. These include an external
coverage or skin, a middle support layer, and an internal
lining (Fig. 1-1). One should view the eyelids as tri-
lamellae squeegee-like structures supported in space
across the orbital rim by medial and lateral anchors,
namely, the medial and lateral canthal tendons
(Fig. 1-2A). In the case of the eyelid, the three lamellae
include an outside coverage of skin that is especially
thin over the tarsus and preseptal areas with minimal to
no subcutaneous fat. The middle, or supportive, layer
includes the orbicularis muscles, with the pretarsal por-
tion lying in front of the tarsal plate and the preorbital
2
CHAPTER ONE
Anatomy
portion lying anterior to the orbital septum. The tarsal
plate is a rigid cartilaginous-like structure that measures
4 to 6 mm in the lower lid and 8 to 10 mm in the
upper lid. This structural layer is pierced by glands that
drain or open posterior to the eyelashes or cilia line and
number on average 10 in the lower lid and 20 in the
upper lid. These meibomian glands and ducts are
responsible for oil secretion, and when they become
inspissated they may be responsible for hordeolums
or styes (acute inflammation) and chalazia (chronic
noncaseating granulomas) and other inflammatory
processes. These are also the sites for inflammation in
the postcosmetic blepharoplasty, meibomianitis, or
blepharitis.
 A NA T O M Y

Periosteum
Skin

Preaponeurotic
orbital fat Orbicularis
muscle
Orbital septum
Whitnall's ligament

Levator
Müller's muscle
palpebrae
aponeurosis

Conjunctiva

Tarsal plate

Capsulopalpebral
fascia
Orbital septum

Figure 1-1 Oblique cross-section of the right orbit and adnexa beginning anteriorly with skin and
ending posteriorly with conjunctiva covering the anterior sclera. The orbicularis muscle is contiguous
with the frontalis, occipitalis, and superficial musculoaponeurotic system (SMAS) layer. The orbital
septum is confluent with the periosteum of the skull and orbit, as well as the periorbita. The orbital
septum is also fused to the levator palpebrae and, therefore, serves as a complete boundary between the
anterior and deep orbit. One cannot access the preaponeurotic fat without violating the superior septum.
Analogously, the inferior orbital septum is intimately linked to the periosteum and the capsulopalpebral
fascial system. The main retractors of the upper and lower lids are the levator and capsulopalpebral
fascia, respectively. The levator is suspended from the superior orbit by Whitnall's ligament. This
structure allows the muscle to change vector forces from anterior to posterior to superior to inferior, thus
serving as a pulley. The preaponeurotic and precapsulopalpebral fat is loosely but definitively linked to
the respective retractors; hence, dehiscence of the levator from the tarsal plate will lead to a superior
sulcus deformity. The tarsal plates are the end point for retractor insertion and provide lid stability and
orientation.

3
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Orbicularis muscle
Whitnall's
ligament Orbital septum

Levator aponeurosis

Lower crus,
lateral canthal
ligament

Lockwood's
ligament

Arcuate
expansion

Capsulopalpebral fascia
A

Figure 1-2 A, An anterior oblique view of the orbit viewed with selective soft tissue layers removed. Deeper structures are viewed more
laterally. The orbicularis muscle is contiguous with the frontalis, occipitalis, and SMAS layers. The muscle has a medial and lateral raphe and
has three divisions (preorbital, preseptal, and pretarsal) based on important underlying structures. Access to the deep orbit is blocked by the
septum. The tarsal plates that give rigidity to the eyelids are engaged by their respective retractors (levator and capsulopalpebral fascia). The
lateral canthal tendon is formed by two crura, which are continuous with the tarsal plates. This common canthal tendon inserts at Whitnall's
tubercle 2 to 3 mm inside the orbital rim. Whitnall's tubercle serves as a common insertion point for a number of structures, which cumulatively
are known as the lateral retinaculum. These include the orbital septum, canthal tendon, Lockwood's ligament, and Whitnall's ligament, along
with the deep head of the orbicularis and check ligament of the lateral rectus muscles. Whitnall's ligament is the pulley that allows the levator
mechanism to change vectors, and Lockwood's ligament is a sling that serves to provide globe support.
Continued

4
 A NA T O M Y

Skin

Orbicularis
muscle
Levator palpabrae muscle
Orbital septum

Sup. rectus muscle Müller's muscle

Levator
aponeurosis
Tarsal plate

Conjunctiva

Inferior tarsal muscle

Inferior rectus muscle
Capsulopalpebral fascia

Orbital septum
Inf. oblique muscle

Figure 1-2 Continued B, On lateral view, the analogy between upper and lower eyelids is clear. The upper and lower septa merge with the
periosteum externally and the periorbita internally. The levator aponeurosis merges with the septum, and the preaponeurotic fat is linked to the
levator and only accessible by violating the septum. Müller's muscle is sympathomimetically innervated and is the flight/fright elevator of the
upper lid, responsible for 1 to 2 mm of excursion. The capsulopalpebral fascia or lower eyelid retractor system arises off the inferior oblique and
rectus muscles. Therefore, the lower eyelid "gets out of the way" when the globe is depressed, as when reading the newspaper. The conjunctiva
reflects on itself, covering the undersurface of the eyelids and then onto the eyeball. This is similar to visceral and parietal layers found
elsewhere in the body. The fat in the lower orbit is behind the septum but in front of the retractor system. Hence it may be termed
precapsulopalpebral fat. All orbital fat is linked by septa so that traction placed on anterior extraconal fat produces a disturbance in the deep
extraconal and intraconal fat. Note the coalescence of the inferior orbital septum with the capsulopalpebral fascia well below the inferior tarsal
plate. This zone of coalescence is a favored access route to the important potential space. I call this the postorbicularis precapsulopalpebral
fascial space, which is important in deftly executing both transconjunctival and transcutaneous blepharoplasties.

5
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The tarsal plate is especially important for vertical
support and rigidity of the eyelid. If one were to elimi-
nate it, an eyelid would conceivably flop or flutter like a
sail on a boat in changing or slack winds. This vertical
supportive task is important and fundamental in main-
taining the lower eyelid position 1 or 2 mm above the
corneoscleral junction or limbus. The internal lining of
the eyelid is mucosa. This layer reflects off the eyeball
and onto the back surface of the eyelids, including the
posterior surfaces of the medial and lateral canthal
tendinous structures. This reflection in itself is analo-
gous to the visceral and parietal pericardium or pleura.
The conjunctival surface provides a near frictionless
surface for the lids and eyeball to move against them-
selves and each other. The conjunctival surface is rich in
secretory cells and glands and includes mucin and
goblet cells and minor salivary glands. The upper lateral
fornix is especially rich in minor lacrimal glands,
including the glands of Kraus and Wolfring.
One should view the upper and lower lids as
analogous or similar, with a few specialized differences,
rather than the traditional fashion in which some
anatomy and surgical texts treat the upper and lower
lids as disparate anatomic and functional structures.
A sagittal section through the orbit viewing the upper
and lower eyelids and eyeball demonstrates how the
upper and lower eyelids and periocular structures are
quite similar (see Fig. 1-2B). First, there is an anterior
layer of skin followed by a middle structural support
layer or the tarsal plates. The tarsal plate is a little wider
on the upper lid than on the lower, and both upper and
lower lids enjoy a mucous membrane lining that is
applied to the visceral and parietal surfaces, namely, the
eyeball and posterior eyelids. The upper and lower
eyelids have a cul-de-sac that is the junction between
the parietal and visceral conjunctiva. Upper and lower
lids are surrounded by orbicularis muscle that is con-
tiguous with the superficial musculoaponeurotic system
(SMAS), platysma, and frontalis muscles. The orbicu-
laris functions as a sphincter, despite the possession of
a medial and lateral raphe. The orbicularis muscle is
traditionally divided into subdivisions depending on
where it lies, and these include the pretarsal, preseptal,
and preorbital areas. The orbicularis muscle is inner-
vated by the seventh nerve and, hence, with facial nerve
paralysis, the cornea and globe are typically exposed,
owing to an atonic eyelid left without the protractor
action of the orbicularis and with the overaction of the
unopposed retractors. The retractors of the eyelids are
analogous as well, with the upper lids possessing a
voluntary or primary retractor, namely, the levator
palpebrae superioris muscle and a secondary sympatho-
6
mimetically innervated muscle called Müller’s muscle.
Müller’s muscle is the so-called fright/flight response
muscle and is responsible for approximately 2 mm of
lid elevation as occurs in sexual excitation or being
chased by a ferocious dog. The levator palpebrae super-
ioris is responsible for the remainder of lid elevation
and is elective or voluntary. The levator palpebrae mea-
sures approximately 37 mm in length and is only 4 mm
in width at the apex of the orbit. It gradually widens
anteriorly until it fans out into an approximately
20-mm long aponeurosis that expands from 6 mm at
the distal end of the levator muscle to a width of 30 mm
where it inserts onto the tarsal plate. The levator muscle
sends some fibers to the dermal surface of the upper lid
skin, creating an upper lid fold. The exact fashion in
which fibers insert onto the skin and create this lid fold
has not been clearly elucidated. Surgical manipulation
of the levator aponeurosis is a very powerful tool for
altering upper lid height. This can be achieved by plica-
tion, advancement, or recession. A normal upper eyelid
lies midway between the upper aspect of the pupillary
aperture and the upper corneal scleral junction or limbus.
The apex of this arch lies just medial to the pupil, and
this is an important landmark in any ptosis correction.
The lower lid retractors are intimately linked to the
inferior extraocular muscles. The inferior rectus and
inferior oblique muscles send out extensions by way of
the capsulopalpebral fascia, and these insert onto the
inferior edge of the tarsal plate of the lower eyelid. This
is analogous to the levator aponeurosis of the upper lid.
The capsulopalpebral fascia is a “voluntary” retractor of
the lower eyelid and is understandably linked to the
depressors of the eyeball so that in electively looking
down the lower eyelid gets out of the way. The capsulo-
palpebral fascia is an important structure that is always
divided at some level in the transconjunctival blepharo-
plasty or in any transconjunctival route to the orbit.
Retractors of the upper and lower eyelids share a re-
orientation of their direction of pull within the orbit as
one follows them anteriorly. The levator palpebrae
superioris muscle has a significant change in direction
from anterior to posterior to cephalad to caudad just
as in the case of the inferior lid retractors. In the upper
lid the levator aponeurosis reorients directions, and in
the lower lid the capsulopalpebral fascia does the re-
orienting. In the case of the upper eyelid, this occurs by
way of an interesting and clinically relevant mechanism.
The levator palpebrae superioris muscle moves from its
insertion in the apex of the orbit, from the lesser wing
of the sphenoid bone, and runs in a horizontal
direction anteriorly in the orbit until it changes to a
vertical direction by way of a pulley system. It is this
 A NA T O M Y

pulley system that converts the vector force from hori-
zontal to vertical and allows elevation of the upper lid
analogously to a garage door. This is a fascial conden-
sation or ligamentous band stretching across the orbit
that is known as Whitnall’s ligament (Fig. 1-3).
Whitnall’s ligament should be visualized in all upper
eyelid blepharoplasties. Its fibers connect to the
trochlear medially, and laterally they extend to join the
lacrimal gland stroma and fascia and actually divide
the lacrimal gland into palpebral and orbital lobes
(Figs. 1-4 and 1-5). It finally inserts on a key anatomic
and surgical structure known as Whitnall’s tubercle,
which is a bony excrescence within the orbital rim and
below the zygomaticofrontal junction. This is also the
place where the lateral canthal tendon inserts and as
measured on a skull lies about 6 mm below the lacrimal
fossa and 2 mm within the orbit (Figs. 1-6 and 1-7). The
lateral horn of the levator aponeurosis also inserts at
this common anatomic focal point. This location is
important in any procedure that realigns the lateral
canthal tendon whether it be a periocular or cranio-
facial procedure. Because of the large number of ana-
tomic insertions in this area, complications can occur
when a procedure is not discrete or focused. For exam-
ple, the lateral horn of the levator may be incorporated
into a canthopexy procedure and lead to lateral upper
lid retraction or lag on attempted closure. This results in
a loss of the upper lid sweep and a peak laterally.

Orbital lobe of Whitnall's Levator palpebrae

lacrimal gland ligament superioris muscle Orbital septum
(partially removed)
Palpebral
lobe of
lacrimal gland Levator
aponeurosis

Superior crura
Upper
Whitnall's tarsal plate
tubercle

Lateral Medial
canthal canthal
tendon tendon

Inferior crura
Lower
tarsal plate

Recess of Eisler
Orbital septum Capsulopalpebral fascia
(partially removed)

Figure 1-3 The upper and lower eyelids are suspended in space, tethered medially and laterally by the
canthal tendons; and these in turn are linked to Whitnall's and Lockwood's ligaments. The orbital and
palpebral lobes of the lacrimal gland are divided by Whitnall's ligament. The orbital septum inserts at
the orbital rim, except inferolaterally where it inserts beyond the rim forming Eisler's recess.

7
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Figure 1-4 The upper lid incision with the orbital septum incised exposes the tarsal plate just above
the traction hook. The whiter levator aponeurosis above the tarsal plate merges into the redder
levator muscle. The dense white condensation of fibers known as Whitnall's ligament is easily
visualized lying at the junction of the preaponeurotic fat pad and the levator. The preaponeurotic fat
is retracted superiorly by the forceps. Note the loose but definitive attachments the fat has to the
levator. Also note the lateral third of Whitnall's ligament as it courses to insert on the internal orbital
rim. Here the lacrimal gland is bisected into orbital and palpebral lobes. The light yellow orbital lobe
is visualized here, sandwiched between the orbital rim posteriorly and above with Whitnall's ligament
below. A small segment of the palpebral lobe is visible medially and inferior to the ligament.

Figure 1-5 A lateral oblique view of another patient whose orbital

septum has been opened. The upper skin is retracted superiorly, and
the lower skin and lid margin are pulled inferiorly. The tarsal plate
(white) is seen just to the left of the inferior traction hook. Whitnall's
ligament and its coalescence with the lateral horn of the levator lies
above the forceps, and the yellow palpebral lobe of the lacrimal
gland lies just below.

8
 A NA T O M Y

Figure 1-6 Lateral cephalic dissection exposing the superolateral

orbit. Note the zygomaticofrontal junction, lacrimal fossa, and dense
white Whitnall's ligament, which extends from the trochlear
medially to Whitnall's tubercle laterally. The traction suture is
displacing the common canthal tendon with the orbital lobe of the
lacrimal gland between the blue and silver retractors. Again, note
the course of Whitnall's ligament laterally as it divides the lobes of
the lacrimal gland on its way to insert on the bony excrescence
(tubercle) just lateral to the silver (Freer) elevator.

Superior orbital fissure Palatine

Sphenoid bone bone
Optic canal
Ethmoid bone
Frontal bone
Figure 1-7 The eight bones of the
orbit basically create two significant
facial buttresses, the frontal- Lacrimal fossa
zygomatic-maxillary and the frontal-
nasal-maxillary. The sphenoid Zygomatico
frontal suture
articulates with the zygoma and is
the major delineator between the Whitnall's
middle cranial fossa and the orbit. tubercle
The optic foramen is in the body at
the sphenoid. Medially, the lacrimal Zygomaticofacial
fossa is visualized between the foramina
anterior and posterior lacrimal crests.
These crests serve as insertions for
Inferior orbital
respective elements of the medial
fissure
canthal tendon. The lacrimal sac lies
within the fossa, between the anterior Lacrimal bone
and posterior crests. Whitnall's Zygomatic
tubercle is seen lying 2 to 3 mm bone
within the orbit and 6 to 8 mm Lacrimal fossa
below the lacrimal fossa. The position
of this important tubercle is salient Infraorbital foramen
in performing an anatomically
functional and aesthetic canthoplasty Maxilla bone
procedure.

9
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
EXTRAOCULAR MUSCLES
The so-called check ligaments serve to prevent extremes
in extraocular muscle excursion with resulting snapping
or uncontrolled spastic movements. The versions or
movement of the eyeball is controlled by the extra-
ocular muscles. The fascial system within the orbit
supports the globe and limits ocular movement. This
fascial system provides an interconnecting scaffold from
one structure to the other and extends both extraconally
(outside the muscle cone) and intraconally, trans-
gressing the orbital fat. The extraocular muscles form a
conical network within the orbit with the apex forming
the origin of the extraocular muscles at a fibrous
thickening of the periosteum known as the annulus of
Zinn (Fig. 1-8A). The orbital apex delineated by the
greater sphenoid wing separates the middle cranial
fossa from the orbit, and it is at this juncture where a
number of nerves pass between the intracranial com-
partment and the orbit. These include the optic, oculo-
motor, trochlear, and abducens nerves. The superior
oblique and the levator muscles arise at the orbital apex
but outside the common tendinous ring of Zinn. The
functions of the extraocular muscles include not only
abduction and adduction but also intorsion and extor-
sion. These latter functions allow the world to remain
upright when one tilts one’s head toward the shoulders.
Of course this is all orchestrated by the vestibulo-
cochlear system and the brain stem. The vascular supply
to the extraocular muscles is principally from the oph-
thalmic artery, with each muscle receiving two anterior
ciliary arteries, except for the lateral rectus, which
10
receives only one. The anterior ciliary arteries continue
on to penetrate the sclera of the eyeball beyond the
muscular insertions and thus contribute significantly to
nourishing the anterior segment of the globe. Therefore,
disinsertion of more than two rectus muscles from the
globe can result in anterior segment necrosis.
Two important muscles in anterior orbital surgery are
the inferior oblique and, to a lesser extent, the superior
oblique. The inferior oblique is the most anterior mus-
cle within the orbit and is the most commonly damaged
muscle in blepharoplasty or surgical approaches to the
orbital rim and zygoma in fracture treatment. The
inferior oblique muscle originates from the periosteum
lateral to the nasolacrimal canal and then courses
posteriorly and laterally within the orbit to insert on the
eyeball. Therefore, one can see by the origin and in-
sertion the mechanical results of its contraction on the
globe. These are primarily elevation, secondarily abduc-
tion, and finally extorsion or rotating the eyeball
clockwise as viewed from inside the skull. The superior
oblique muscle that arises superomedial to the annulus
of Zinn functions in depression, abduction, and intor-
sion. From a practical standpoint, the inferior oblique
muscle should always be identified in transconjunctival
blepharoplasty, as it divides the medial and central fat
pads. In a transcutaneous route this is less important;
however, I prefer to identify it in every approach. The
superior oblique muscle divides the medial and central
fat pads in the upper compartment, and, although it arises
at the orbital apex, it changes direction and vector forces
after looping around the trochlear in the superomedial
orbit, producing a near mirror image of the vector forces
created by the inferior oblique muscle (see Fig. 1-8).
 A NA T O M Y

A Most anterior portion

of inferior oblique muscle

Inferior oblique muscle

Check ligaments
of medial
rectus muscle

Superior
Superior rectus muscle
oblique muscle
Check ligaments of
Inferior lateral rectus muscle
rectus muscle

Levator palpebrae
superioris muscle Superior Annulus of Zinn
rectus muscle Central fat pad

B
Trochlea
(pulley)

Superior
oblique
muscle
Medial
Lateral fat pad
rectus
muscle Medial
rectus
muscle

Medial
fat pad

Lateral Inferior
fat pad oblique
muscle

Central fat pad

Inferior rectus muscle

Figure 1-8 The extraocular muscles form a cone whose apex lies near the optic foramen (A). All
muscles insert at the annulus of Zinn except the levator and the superior oblique. The most
anterolateral rectus check ligament inserts on Whitnall's tubercle. On anterior view (B), the most
anterior muscle in the orbit, the inferior oblique, can be seen dividing medial and central fat pads.
The lateral fat pad can be seen draping over the orbital rim into the recess of Eisler. This may be one
factor contributing to its reputation as the most frequently missed fat.

11
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
THE MEDIAL CANTHUS
The medial canthus contains a number of structures
compactly arranged in a small space oriented around the
lacrimal fossa. Pretarsal, preseptal, and preorbital orbi-
cularis oculi fibers have both superficial and deep heads,
and these components envelop the lacrimal sac,
inserting on the anterior and posterior lacrimal crest,
respectively. The medial canthal tendon extends beyond
the anterior lacrimal crest to the frontal process of the
maxilla and like the orbicularis oculi fibers has both
anterior, posterior, and even a superior component
(Fig. 1-9). The anterior and posterior components of the
medial canthal tendon similarly envelop the lacrimal sac.
Hence, the lacrimal system is an active pump mechan-
ism in which orbicularis fibers inserting on fascia sur-
rounding the lacrimal sac actively dilate and passively
contract the sac, altering pressure within the middle and
distal lacrimal system. These orbicularis fibers also enve-
lop the canaliculi of the upper and lower lids, allowing
this proximal aspect of the lacrimal drainage system to
alter length and width with cyclical muscular contraction.
The medial canthus is less likely to be addressed in
standard cosmetic and periocular surgery, that is, in the
absence of nasal orbital ethmoid trauma and/or elective
osteotomies. However, there are instances in which
the medial canthal tendinous complex needs to be
12
addressed. Generally, the upper and lower puncta lie
midway between the caruncle or medial lid commissure
and the medial limbus (corneal scleral junction). Laxity
of the medial canthal tendinous complex produces
both lateral and inferior displacement of the medial
commissure and canaliculi. This is especially true when
concomitant lateral canthal laxity is noted and the
surgeon chooses to address the lateral canthal complex
with a tightening or suspension procedure. In these
instances, the laxity of the medial canthal tendon allows
the puncta to be displaced temporally on lateral canthal
tendon tightening alone. This can have significant con-
sequences in terms of tear drainage and patient dis-
comfort. The surgeon must be cognizant of significant
laxity in the medial canthal complex when he or she
chooses to tighten or suspend the lower lid. In these
cases, the medial canthal tendon may require plication
or reefing before lateral canthal tightening, to obviate
displacement of the lacrimal drainage system. In
plication or suspension of the medial canthal tendinous
complex, one must be aware of the course of the
lacrimal drainage system and protect it. I recommend
intubation of the lacrimal system as a prophylactic
measure in many cases (Fig. 1-10). The lacrimal pump
refers to the dynamic nature of the medial canthal
complex, including the lacrimal sac, which sits between
the anterior and posterior lacrimal crest with two thirds
of it lying within the bony fossa.
 A NA T O M Y

Posterior limb,
medial canthal tendon

Superior limb,
medial canthal tendon
Figure 1-9 The medial canthal tendon envelops
the lacrimal sac. It is tripartite, with anterior,
posterior, and superior limbs. Like the lateral
canthal tendon, its limbs are continuous with the
tarsal plates. The components of this tendon along
Anterior limb,
with its lateral counterpart are enveloped by deep
medial canthal tendon
and superficial aspects of the orbicularis muscle.
This arrangement is important in maintaining a
functional and active lacrimal drainage system.
The upper, lower, and common canaliculi closely Lacrimal fossa
approximate this tendon system; and care should
be taken to preserve their integrity when altering
any aspect of the medial canthal tendon. This
tendon may require an elective tightening Anterior and posterior
procedure, especially in cases in which a lateral lacrimal crests
canthal procedure alone would produce punctal
and lacrimal dystopia.

Figure 1-10 A medial canthal curved incision exposes the anterior

component of the medial canthal tendon overlying micro forceps.
The traction hooks expose the anterior lacrimal crest (medially and
superiorly), and the proximal aspect of the superior component of
the tendon is just visualized. Note the lower lid punctum cannulated
with a probe. It normally lies lateral to the upper punctum, but here
it is pushed medially by the probe. In special cases, plication of the
anterior component of the medial canthal tendon is necessary to
avoid overlateralization of the punctum associated with lateral
eyelid tightening.

13
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The upper and lower canalicular systems are basically
two pipes connected to the lacrimal sac, which in 90%
of instances coalesce into a common canaliculus. Each
system is approximately 2 mm in vertical height and 6
to 8 mm in horizontal distance before coalescing with
the lacrimal sac. The lower canaliculus is slightly more
lateral than the upper; and this entire system, as men-
tioned earlier, is enveloped by superficial and deep
heads of the orbicularis muscle and respective compo-
nents of the medial canthal tendon (Fig. 1-11). The
lacrimal sac dilates and collapses with different phases
of the blinking process and, hence, is an extremely
14
active or dynamic process that does not depend on
gravitational forces. The lacrimal pump is related to
orbicularis muscle contraction and relaxation and
therefore cycles with blinking (Fig. 1-12). Tear drainage
is independent of head position; therefore, epiphora
does not generally occur even while one stands on his
or her head. Cosmetic or reconstructive surgical proce-
dures in addition to trauma can disrupt fibers of the
orbicularis muscle, causing anatomic and/or physio-
logic alterations in lacrimal drainage and creating
symptoms (Figs. 1-13 and 1-14).
 A NA T O M Y

Upper puncta

Common
Tarsal plates canaliculus

Lacrimal sac

Ampulla
Lacrimal duct

Papilla

Inferior meatus

Figure 1-11 Much of the soft tissue of the medial canthal region is
composed of the lacrimal drainage system. The vertical, horizontal, and
common components of the canaliculi along with the lacrimal sac are
enveloped by superficial and deep heads of the orbicularis muscle (pretarsal
orbicularis posterior and preseptal anterior). The tarsal plates are perforated
by the upper and lower canaliculi. The lower is more lateral, and both
vertical components are 2 mm in height. The horizontal components are 6 to
8 mm long and converge into a common system before the lacrimal sac (90%
of the time). The lacrimal sac has an investing fascia that allows the
orbicularis muscle to exert forces on it as well as the canaliculi. The lower
third of the lacrimal drainage system is intraosseous (lacrimal duct). The
entire system drains into the inferior nasal meatus and can be affected by
turbinate lateralization or hypertrophy.

15
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Lacrimal gland
Upper and lower
canaliculi
Lacrimal sac
Tear film

Lacrimal duct

Inferior turbinate

Figure 1-12 The lacrimal production and drainage systems are both
active, not passive. Tears produced mostly in the upper outer quadrant of
the adnexa are mixed into a trilaminar film that gets distributed by the
muscular action of the eyelids. The blinking cycle is largely initiated by
orbicularis muscle action. The canaliculi and lacrimal sac, surrounded by
investing fascia, are cyclically altered by lid position, with alternating
traction and compression creating a lacrimal pump mechanism. On opening
the lids, tears produced in the upper outer fornix are distributed as the
precorneal tear film. The ampullae and distal canaliculi are widely dilated
to accept tears, which have collected nasally into the system. On closure,
tears are squeezed across the cornea toward the canaliculi. At the same
time, orbicularis action causes a foreshortening and compression of the
canaliculi and a dilation of the lacrimal sac. Tears are propelled from distal
to proximal in the canaliculi and concomitantly sucked into the lacrimal
sac, which has negative intraluminal pressure owing to its dilation. On
reopening, tears are again redistributed, the ampullae and distal canaliculi
dilate, and tears are drawn in. The lacrimal sac propulsively collapses and
tears are propelled through the lacrimal duct and into the nasal cavity.

16

Figure 1-13 Close-up view of the medial canthal region of a
postoperative patient shown in Figure 1-14. Note the upper and
lower canalicular system intubated with silicone tubes that course
through the lacrimal sac and into the nose. The lower punctum is
more lateral than the upper punctum.
A NA T O M Y
Figure 1-14 The medial canthal incision is shown with the
lacrimal sac reflected laterally out of the lacrimal fossa. Medially
behind the retracted skin edge is the anterior lacrimal crest. The
lower portion of the sac is fixed by the superior portion of the
nasolacrimal duct that drains into the inferior meatus of the nose.
17
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The lateral canthal tendon should be a most familiar
structure to the surgeon and is more commonly
addressed than the medial canthal complex. It should
be thought of as contiguous with the tarsal plates and
measures approximately 2 mm in width and 6 mm in
length. It is a rather thin structure that splits into an
anterior and posterior leaflet, with the anterior being
contiguous with the orbital rim periosteum and the
posterior element inserting on the lateral orbital
tubercle (Whitnall’s), approximately 3 mm behind the
orbital rim. This structure lies approximately 6 mm
below the lacrimal gland fossa. Superficial and deep
components of the orbicularis oculi muscle (both
preseptal and pretarsal) accompany the superficial and
deep layers of the lateral canthal tendinous complex.
The lateral horn of the levator aponeurosis, which splits
the lacrimal gland into orbital and palpebral lobes, also
inserts on Whitnall’s tubercle, blending with the
insertion of the lateral canthal tendon. Therefore,
Whitnall’s tubercle is analogous to the lacrimal fossae
in that there is a convergence of support and suspensory
structures that coalesce as anchor points for the eyelids,
which otherwise are “floating in space” (Fig. 1-15). The
18
lateral canthal tendon complex or lateral retinaculum
additionally contains a coalescence of the inferior sus-
pensory ligament of Lockwood and the check ligament
of the lateral rectus muscle. It is also firmly adherent to
the orbital septum and lateral orbital periosteum,
which is definitively thickened in this region. From a
clinical perspective one key anatomic point is that
division of the lateral canthal tendon in and of itself is
not sufficient to mobilize the lateral canthal tendon
complex or lateral retinaculum and, hence, lower
and/or upper eyelid mobility and transposition can
only be achieved with division of additional structures
in the lateral canthal tendon complex. Failure to address
all key elements of the lateral retinaculum will result in
an inability to mobilize the lateral canthus in reposi-
tioning and/or tightening procedures. Typically, this is
illustrated when “lateral canthopexies” do not achieve
lower eyelid or lateral canthal elevation or suspension
and tightening. Topographically, the lateral canthal
tendon should be inclined 10 to 15 degrees when com-
pared with the medial canthal tendon, and it is this
position that is anatomic, physiologic, and most
aesthetically pleasing.
 A NA T O M Y

Superficial portion Orbital septum

of orbicularis muscle

Deep portion of
orbicularis muscle

Whitnall's
ligament
Tarsal plates

Lateral canthal tendon

divided and inserting
into Whitnall's tubercle

Orbicularis muscle (superficial

portion) and orbital septum
contributing to the lateral
retinaculum

Figure 1-15 The anatomy of the lateral canthal region shows the integration of muscular,
tendinous, and other components of the lateral retinaculum. The pretarsal orbicularis muscle
follows the deep portion of the lateral canthal tendon behind the septum inserting on Whitnall's
tubercle. The preseptal orbicularis muscle moves superficially with the superficial aspects of the
lateral canthal tendon, just anterior to the orbital septum. Note the orbital septum dividing into
anterior and posterior leaflets in continuity with the periosteum and periorbita. Whitnall's ligament,
seen through the septum (insert) sends a small component superiorly and a main component to split
the lacrimal gland and insert on Whitnall's tubercle.

19
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
ORBITAL FAT
Orbital fat is generally the focus of much of the cos-
metic surgery in the periocular region. Whether resec-
tion, repositioning, or a combination of both is chosen
for an individual patient, some fundamental anatomic
points are helpful. First, all fat lies behind the orbital
septum, which is contiguous with the periosteum of the
bone surrounding the orbit. Here the orbital septum
serves as a boundary against infection and tumor spread
and basically prevents contiguous access from the ante-
rior tissue planes to the deeper orbit where vital struc-
tures transgress bony apertures into the anterior and
middle cranial fossae. In the upper lid all fat that is
to be addressed is anterior to the levator aponeurosis
and, hence, is termed preaponeurotic. Analogously, all
postseptal fat in the lower eyelid is in the pre-
capsulopalpebral fascial plane (see Fig. 1-2B). All fat
accessed through the orbital septum is contiguous with
the entire extraconal (outside the muscle cone) and
intraconal (within the muscle cone) spaces (see Fig. 1-8B).
Therefore, traction on fat just posterior to the orbital
septum can produce forces in the posterior extraconal
and even posterior intraconal and perioptic nerve
region (see Fig. 1-8). The linkage of fat within the orbit
by way of septa that transgress the extraocular muscle
cone is the reason why there is a small but definitive risk
of orbital hemorrhage and even blindness when
addressing anterior orbital fat in surgical procedures.
These interconnecting septa are also the reason why
orbital hemorrhages do not spontaneously decompress
with opening the orbital septum. Blood is generally
trapped within the intraconal and extraconal spaces
by this fascial network, and “indirect” decompression
requires division of the inferior crus of the lateral
canthal tendon and sometimes decompression of the
anterior chamber of the eye, along with medical therapy
such as corticosteroids, acetazolamide, and mannitol. I
20
use the term indirect because the decompression is only
aimed at decreasing intraocular pressure and not at
evacuation of intraorbital blood.
THE LACRIMAL APPARATUS
The lacrimal apparatus consists of structures that pro-
duce, distribute, and drain tears. The tear film is ex-
tremely important because it provides a wetting surface
for gliding of the eyelids and eyeball structures against
one another. Tears are rich in immunoglobulins and
lysozymes and are the reason the eye can be exposed to
ambient air without breakdown and infections. The tear
film in and of itself has refractive properties and bends
light with the power of approximately 0.5 diopter. Tears
are basically trilaminal with an inner layer consisting of
a mucoprotein that serves to decrease surface tension
and allows the middle aqueous phase to spread out
more uniformly over the cornea. This is produced by
goblet cells within the conjunctival tarsus and limbus.
The middle layer, or aqueous phase, is produced by the
subconjunctival glands of Krause and Wolfring. The
aqueous phase is augmented by the reflexly stimulated
main lacrimal gland. Oil-producing glands such as the
meibomian glands located in the upper and lower
eyelids and the palpebral glands of Zeis and Moll
provide an oily covering to the tears that prevent
evaporative loss and provide stabilization and duration
to the tear film. The reflexly stimulated lacrimal gland is
divided into two portions by the lateral horn of the
levator palpebrae superioris. The main orbital lobe is
approximately three times the size of the palpebral lobe,
and in many instances the palpebral lobe is visible with
eversion of the upper lid (Fig. 1-16). Prolapse of this
gland can be corrected by suspension with the use of
surrounding periosteal sutures (Figs. 1-17 and 1-18).
 A NA T O M Y

Lacrimal
gland, Glands of
orbital and Krause
palpebral and Wolfring
lobes

Glands of
Conjunctival, Zeis and Moll
tarsal and
limbal
goblet cells

Meibomian glands

Figure 1-16 Close-up view of the upper lateral adnexa and Whitnall’s ligament with the septum
divided. This region of the fornix is rich in conjunctival cells specializing in the production of tear
components. The upper and lower lids are perforated by tarsal meibomian glands, and each follicle
has associated glandular elements (Zeis and Moll). Whitnall’s ligament can be seen extending over a
medial-to-lateral course dividing the lacrimal gland into orbital and palpebral lobes and inserting at
Whitnall's tubercle. More centrally, it can be seen in its primary role as a vector conversion pulley for
the levator muscle.

Figure 1-17 The upper eyelid is everted, demonstrating a prolapsed
lacrimal gland. Lacrimal gland prolapse must be distinguished
from subconjunctival orbital fat. The latter can be resected, and
the former should be suspended, except in cases of malignancy,
and so on.
Figure 1-18 An upper lid incision exposing the levator aponeurosis
has been disinserted from the tarsal plate. The levator is thickened
secondary to thyroid infiltrative disease. The lacrimal gland and
orbital and palpebral lobes are visualized in their respective
positions. The orbital lobe is prolapsed from its usual cephalic
location within the lacrimal fossa. The lobes of the gland are
divided by the lateral horn of the levator, which has been lysed
surgically in this photograph.

21
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The aqueous phase of tears is produced in the upper
lateral fornix or cul-de-sac and then structured into
three layers and distributed by means of the squeegee
action of the upper and lower eyelids. These are
distributed across the eye and then repeatedly pumped
into and through the lacrimal system with the cyclic
action of blinking. This forceful yet subtle muscular
action eventually propels tears, which begin in the
upper outer corner of the orbit, into the nasal cavity
beneath the inferior turbinate.
In the context of cosmetic surgery one can see how
easily the precorneal tear film can be disturbed by, for
example, changing the pattern in which the eyelids mix,
distribute, and pump tears. A patient who has border-
line tear production and/or quality may be sufficiently
altered by surgery so that he or she may complain of dry
eyes or epiphora. A change in the refractive index of the
precorneal tear film may lead the patient to complain of
a change in the quality of his or her vision, even when
objective testing (Snellen chart) does not discern a
difference from the preoperative and postoperative
examinations.
The blinking cycle is an important physiologic mech-
anism for draining tears. This mechanism is propulsive
and, therefore, independent of gravity. The movement
of tears into the nose is assisted by an active “lacrimal
pump,” which is dependent on the superficial and deep
heads of both the pretarsal and preseptal orbicularis
oculi muscles as well as the lacrimal diaphragm, which
is a condensation of fascia around the lacrimal sac (see
Fig. 1-11). The canaliculi remain patent with the
ampullae in contact with the tear lake formed in the
medial canthus when the eyelids are open and the
orbicularis oculi muscle is relaxed. On contracture of
the orbicularis muscle, eyelid closure ensues with a
milking of tears from superolateral to inferomedial over
the ocular surface. Muscular contracture causes short-
ening of the canaliculi and closing of their ampullae.
Concomitantly, the deep heads of the preseptal muscles
attached to the fascia or lacrimal diaphragm dilate the
22
sac and, hence, create a negative pressure within its
lumen. The closing of the ampullae with shortening
of the canalicular system causes propulsion of tears
medially, and the negative pressure generated within
the lacrimal sac causes tears to be sucked into the sac
nasally on eyelid closure. As the lids reopen, the orbicu-
laris muscle relaxes, causing collapse of the lacrimal sac
and propulsion of tears into the nose beneath the
inferior turbinate along with a relaxation and length-
ening of the canaliculi and a redilatation of the am-
pullae. This cycle repeats over and over again with
efficient smooth drainage of tears (see Fig. 1-12). The
lacrimal sac is approximately 15 mm in height with one
third of it extending above or superior to the medial
canthal tendon. The nasolacrimal duct refers to the
intraosseous portion, and this is approximately 12 mm
in length. The duct empties into the inferior meatus
of the nose approximately 15 mm from the floor (see
Fig. 1-11). To commit this to memory, I prefer to divide
each of these three distinct vertical segments into
15-mm lengths.
The balance between tear production and evapora-
tion is critical to patient comfort because this deter-
mines whether there is sufficient wetting of the corneal
surface. Production of adequate tears is a function of
both quantity and quality. That is, a patient may make
a lot of tears as measured on Schirmer’s test but produce
insufficient oils, which prevents evaporative loss to
ambient air and, hence, may have a relatively dry eye
despite adequate volumetric tear production. The
homeostasis between production and evaporative loss
is a critical concept in appreciating nuances in patient
presentation and in deciding which procedures appro-
priately address aesthetic and/or reconstructive issues.
For example, a patient who produces a small amount of
good quality tears but has a small lid aperture that
minimizes evaporative tear loss must be approached in
a different way than the patient who has a large lid
aperture (higher evaporative loss) with tears of a similar
quantity and quality. Therefore, in choosing an appro-

priate procedure for a patient, one must take into
account the aesthetic objectives and weigh those against
the need to maintain an adequate precorneal wetting
surface. Some patients may require an overall reduction
in lid aperture, some may not tolerate an increase in
aperture and maintenance is the goal, and still others
may produce enough of a quality tear film so as to
tolerate a larger lid aperture, which may be an ideal
cosmetic result. The concept of production and evap-
oration, taking quantity as well as quality into account,
should be part of the surgeon’s preoperative thought
process for every patient. In some cases it may only
require a few seconds, and the surgeon and patient may
have great latitude in choosing an optimal procedure. In
others it may require a more prolonged consideration
and leave the surgeon and patient with few options.
Nevertheless, this preoperative process will serve to
limit postoperative complications and complaints.
HOMEOSTASIS OF THE LOWER
EYELID
As we have discussed, the normal lower eyelid position
is 1 to 2 mm over the corneoscleral junction, with the
central lower eyelid being the lowest point with a gentle
sweeping upward inclination toward the lateral and
medial canthi. The lateral canthus is approximately 15
degrees more inclined than the medial canthus. If one
views the lower eyelid as floating in space anchored
between the medial and lateral canthi, there is a balance
of forces maintaining this normal anatomic position. A
knowledge of the forces acting on the lower eyelid and
how they interact is important in understanding,
treating, and providing prophylaxis against lower eyelid
malposition. I like to term the forces holding the lower
eyelid above the limbus and against the eye as intrinsic
support. Intrinsic support is generated in part by cephalic
A NA T O M Y
vector forces contributed by the tarsal plate. It is also
produced by the cephalic and posterior support gen-
erated by the orbicularis muscular complex (anterior
and posterior heads) and the medial and lateral canthal
tendons. The tarsal plate integrates these appropriate
vector forces by providing three-dimensional spatial
orientation. There are physiologic forces always working
on the lower eyelid whose net effect is to distract the
lower lid inferiorly and anteriorly away from the globe.
Generally, there is a balance or homeostasis of these
forces with intrinsic support overcoming extrinsic
distraction forces. Patients will be comfortable with an
adequately shielded and wet cornea, provided intrinsic
support is greater than extrinsic distraction forces
(Fig. 1-19). There are two basic scenarios in which the
normal balance of forces can be disturbed with dis-
traction overcoming support. These are when intrinsic
support is weakened by the normal senescent process or
by intervention in which intrinsic support forces im-
parted by the canthal, tarsal, or muscular elements are
surgically weakened. A second mechanism for displace-
ment of the lower eyelid down and/or away from the
globe is to increase distraction forces while maintaining
intrinsic support forces intact. In this case, the lower
eyelid would be displaced away from the globe by
excessive distraction forces despite an intrinsic support
mechanism that would otherwise be adequate. This
scenario may be created by burns, contractures, or sur-
gical intervention (e.g., excessive skin resection in a
transcutaneous blepharoplasty, laser contracture, or
chemical peels) (Figs. 1-20 and 1-21). Therefore, lower
eyelid position is dependent on a balance of vector
forces, with intrinsic support always exceeding extrinsic
distraction forces in the maintenance of normal ana-
tomic position. This normal anatomic position is
critical in maintaining adequate corneal wetting, elimi-
nating excessive evaporative loss, assisting in the
physiologic squeegee and distribution effects of the lid,
and maintaining an intact lacrimal pump mechanism,
not to mention appropriate aesthetic appearance.
23
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Intrinsic
Support IS ED
Forces (ISF)

Extrinsic IS
Distraction
Forces (EDF)
ED

Figure 1-19 The adnexa, and especially the lower eyelid, is held in normal anatomic
position against the globe by intrinsic support provided by the tarsal plate, the canthal
tendons, and the orbicularis muscle sling. These elements provide a net vector that is
posterior and superior. There are forces that are acting on the lid that are in opposition
to its intrinsic support. These extrinsic distraction forces provide a net vector that is
inferior and anterior from the globe. The lid will maintain a functional anatomic
position as long as intrinsic support is at least as strong as the extrinsic distraction
forces. An unfavorable imbalance can be created by weakening the support, as in
senescence, or by strengthening the distraction forces, as occurs from surgery, lasers, or
trauma. This tips the scale in favor of a lid that no longer provides anatomic and
functional position.

24
 A NA T O M Y

Figure 1-20 Normal lower eyelid position is shown with the lid at or above the lower limbus
(corneoscleral junction). This is not only cosmetically pleasing but serves to maintain adequate
corneal wetting by minimizing ambient evaporative loss. Note the cephalic inclination of the
lateral commissure compared with the medial commissure.

A B
Figure 1-21 The two basic mechanisms for lower eyelid malposition due to an imbalance in the normal forces, with distraction overcoming
support, are demonstrated clinically. In A, a 61-year-old man demonstrates scleral show and slight ectropion on lateral view. In this case, the
intrinsic support mechanisms of the lower eyelid (canthal, tarsal, muscular, etc.) have weakened so as to allow the lower eyelid to be displaced
down and away from the globe by normal extrinsic forces (gravity, etc.). In B, a 64-year-old woman became symptomatic after having had
eyelid and facial procedures in which excessive distraction forces were created. These forces exceeded her own intrinsic support mechanism,
which was likely weak to begin with. This patient would have benefitted by having her own intrinsic support mechanism strengthened during
her cosmetic procedure so as to resist both physiologic and iatrogenically induced extrinsic distraction forces. Note the scleral show, left lower lid
ectropion, lateral canthal dystopia, and injection of the conjunctiva especially on the left, indicating an eyeball that is inadequately wetted and
covered. The yellow-green color along the lower lid scleral junction is fluorescein dye.

25
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
P E A R LS A N D P I T FA L LS
1. The orbital septum is confluent with the periosteum of the
skull and orbit and serves as the defining structure of the
deep orbit.
2. The orbital septum must be violated in order to access
preaponeurotic and/or pre-capsulopalpebral fat.
3. Whitnall’s tubercle is a common insertion point for a number
of structures, including the orbital septum, Lockwood’s
ligament, Whitnall’s ligament, deeper aspects of the
orbicularis, and check ligaments of the lateral rectus muscle.
4. The bony anatomic location of Whitnall’s tubercle (below the
lacrimal fossa and several millimeters within the orbit) must
be appreciated to properly execute lateral canthal suspension
procedures.
5. The upper and lower eyelids and orbit are anatomically
analogous and are suspended in space by the medial and
lateral canthal anchors. The eyelids are laminar, like most
structures in the body (external, middle, and lining).
6. In the lower eyelid, the post-orbicularis pre-capsulopalpebral
space is fundamental in the execution of both trans-
conjunctival and transcutaneous procedures.
7. The capsulopalpebral fascia is an extension off the extra-
ocular muscles and is always divided at some level in the
transconjunctival route to the orbit.
8. The levator palpebrae superioris runs horizontally from the
lesser wing of the sphenoid and reorients to a vertical
direction at Whitnall’s ligament.
9. Whitnall’s ligament divides the lacrimal gland laterally where
it contributes to the lateral retinaculum. Medially it anchors
on the trochlear.
10. The anatomic complexity at Whitnall’s tubercle can lead to
complications from canthopexy procedures. For example, care
must be taken to exclude the lateral horn of the levator in
lateral canthal suspension procedures.
11. The fascial system of the orbit provides a scaffold that extends
intra- and extraconally from anterior to posterior within the
orbit. This system allows the transduction of forces from one
location to another distant site within the orbit.
12. The greater wing of the sphenoid is the primary delineator of
the orbit from the middle cranial fossa. Laterally it articulates
with the zygoma.
26
13. The extraocular muscles serve as conduits for the blood
supply to the anterior eyeball. Disinsertion of more than two
muscles can lead to anterior segment necrosis.
14. The inferior oblique muscle is most anterior in the orbit,
followed by the superior oblique muscle. They should be
visualized and protected in retroseptal dissections. Both
muscles delineate the medial from the central fat
compartment.
15. The medial canthus is enveloped by deep and superficial
muscular and fascial extensions, which contribute to the
active lacrimal pump mechanism.
16. Significant medial canthal laxity can lead to a displaced and
compromised lacrimal pump when a lateral canthal tightening
procedure is performed alone. This problem can be obviated
with a concomitant medial canthal tightening.
17. Division of the lateral canthal tendon in and of itself is not
sufficient to mobilize the lower and/or upper eyelid.
18. The lateral canthus is optimally inclined, compared with the
medial canthus, from an anatomic, physiologic, and aesthetic
point of view.
19. In the upper lid, all the fat that is altered (removed, reposi-
tioned, grafted) is preaponeurotic.
20. Orbital hemorrhage and possible visual loss can be produced
by traction on the most anterior orbital fat.
21. Tears are trilaminar, are important for corneal integrity, and
have refractive properties.
22. Eyelid integrity and the blinking cycle are important for
proper tear distribution and drainage.
23. The balance between tear production and evaporative tear
loss determines whether there is sufficient corneal wetting.
The third element in this equation is tear quality.
24. The surgeon can alter evaporative loss by changing eyelid
aperture.
25. The lower eyelid is suspended in space, and its normal
anatomic position is sustained by a balance between intrinsic
supportive and extrinsic distraction forces.
26. The tarsal plate provides spatial orientation and integrates
components of the intrinsic support system.

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Aiache A: The suborbicularis oculi fat pad: An anatomic and
clinical study. Plast Reconstr Surg 107:1602-1604;
discussion 1605-1606, 2001.
Barretto RL, Mathog RH: Orbital measurement in black and
white populations. Laryngoscope 109(7 pt 1):1051-1054,
1999.
Berke A, Mueller S: The kinetics of lid motion and its effects
on the tear film. Adv Exp Med Biol 438:417-424, 1998.
Borodic G, Townsend D: Atlas of Eyelid Surgery. Philadelphia,
WB Saunders, 1994.
Bosniak S: Principles and Practice of Ophthalmic Plastic and
Reconstructive Surgery. Philadelphia, WB Saunders, 1996,
vols 1 and 2.
Carter SR, Seiff SR, Grant PE, Vigneron DB: The Asian lower
eyelid: A comparative anatomic study using high-resolution
magnetic resonance imaging. Ophthalmic Plast Reconstr
Surg 14:227-234, 1998.
Cheng J, Xu FZ: Anatomic microstructure of the upper eyelid
in the Oriental double eyelid. Plast Reconstr Surg 107:1665-
1668, 2001.
Craig JP, Singh I, Tomlinson A, et al: The role of tear
physiology in ocular surface temperature. Eye 14(pt 4):635-
641, 2000.
Della Rocca R, Nesi F, Lisman R: Ophthalmic Plastic and
Reconstructive Surgery. St. Louis, CV Mosby, 1997, vol 1.
Della Rocca RC, Bedrossian EH, Arthurs B: Ophthalmic plastic
surgery: Decision Making and Techniques. New York,
McGraw-Hill, 2002.
Dutton J: Atlas of Clinical and Surgical Orbital Anatomy.
Philadelphia, WB Saunders, 1994.
Ettl A, Koornneef L, Daxer A, Kramer J: High resolution
magnetic resonance imaging of the orbital connective tissue
system. Ophthalmic Plast Reconstr Surg 14:323-327, 1998.
Ettl A, Kramer J, Daxer A, Koornneef L: High resolution
magnetic resonance imaging of the normal extraocular
musculature. Eye 11(pt 6):793-797, 1997.
Ettl A, Priglinger S, Kramer J, Koornneef L: Functional
anatomy of the levator palpebrae superioris muscle and its
connective tissue system. Br J Ophthalmol 80:702-707,
1996.
Hamra S: Composite Rhytidectomy. St. Louis, Quality Medical
Publishing, 1993.
Haramoto U, Kubo T, Tamatani M, Hosokawa MK: Anatomic
study of the insertions of the levator aponeurosis and
Muller’s muscle in Oriental eyelids. Ann Plastic Surg
47:528-533, 2001.
Hwang K, Joong Kim D, Chung RS: Pretarsal fat compartment
in the lower eyelid. Clin Anat 14:179-183, 2001.
A NA T O M Y
Hwang K, Kim DJ, Chung RS, et al: An anatomical study of the
junction of the orbital septum and the levator aponeurosis
in Orientals. Br J Plast Surg 51:594-598, 1998.
Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper
eyelid: An anatomical study with comparison to the
Caucasian eyelid. Arch Ophthalmol 117:907-912, 1999.
Leone C, Grove A, Lloyd W, Wojno T: Atlas of Orbital Surgery.
Philadelphia, WB Saunders, 1992.
Malbouisson JM, Baccega A, Cruz AA: The geometrical basis of
the eyelid contour. Ophthalmic Plast Reconstr Surg 16:427-
431, 2000.
Matsuo K: Stretching of the Mueller muscle results in
involuntary contraction in the levator muscle. Ophthalmic
Plast Reconstr Surg 18:5-10, 2002.
Nesi F, Lisman R, Levine M, et al: Ophthalmic Plastic and
Reconstructive Surgery. St. Louis, CV Mosby, 1998.
Pessa JE, Zadoo VP, Adrian EK, et al: Anatomy of a “black eye”:
A newly described fascial system of the lower eyelid.
Putterman A: Cosmetic Oculoplastic Surgery, 2nd ed.
Philadelphia, WB Saunders, 1993.
Schoenwald RD, Vidvauns S, Wurster DE, Barfknecht CF: The
role of tear proteins in tear film stability in the dry eye
patient and in the rabbit. Adv Exp Med Biol 438:391-400,
1998.
Shinohara H, Taniguchi Y, Kominami R, et al: The lacrimal
fascia redefined. Clin Anat 14:401-405, 2001.
Thale A, Paulsen F, Rochels R, Tillmann B: Functional
anatomy of the human efferent tear ducts: A new theory of
tear outflow mechanism. Graefes Arch Clin Exp
Ophthalmol 236:674-678, 1998.
Tiffany JM, Pandit JC, Bron AJ: Soluble mucin and the physical
properties of tears. Adv Exp Med Biol 438:229-234, 1998.
Tsubota K: Tear dynamics and dry eye. Prog Retin Eye Res
17:565-596, 1998.
VanDen Bosch WA, Leenders I, Mulder P: Topographic
anatomy of the eyelids, and the effects of sex and age. Br J
Ophthalmol 83:347-352, 1999.
Wilhelmi BJ, Mowlavi A, Neumeister MW: Upper
blepharoplasty with bony anatomical landmarks to avoid
injury to trochlea and superior oblique muscle tendon with
fat resection. Plast Reconstr Surg 108:2137-2140: discussion
2141-2142, 2001.
Wolfort FG, Vaughan TE, Wolfort SF, Nevarre DR: Retrobulbar
hematoma and blepharoplasty. Plast Reconstr Surg
104:2154-2162, 1999.
Yamamoto H, Morikawa K, Uchinuma E, Yamashina S: An
anatomical study of the medial canthus using a three-
dimensional model. Aesthetic Plast Surg 25:189-193, 2001.
Zide B, Jelks G: Surgical Anatomy of the Orbit. New York,
Raven, 1985.
27

Evaluation of the Patient
Every patient should have a detailed history before
undergoing a physical examination. In addition to elic-
iting a chief complaint or reason for seeking a surgical
consultation from the patient, it is always helpful to
have the patient describe his or her complaints while
looking in a mirror. The surgeon should obtain a de-
tailed history concerning a history of dry eyes or use of
ophthalmic lubricants and artificial tears, contact lens
wear and the type of lenses used, thyroid or Graves’
disease, previous refractive surgery, recurrent acute or
chronic blepharitis, and other ocular or periocular con-
ditions that are relevant. This detailed history may guide
the surgeon in choosing an optimal procedure for the
patient. For example, a patient with a history of dry eyes
who wears contact lenses will certainly demand greater
tear production and tolerate less evaporative loss than
the patient who does not present with these underlying
demands. A patient with Graves’ disease may have lid
retraction, which can be confused with contralateral
ptosis. Chronic blepharitis may be exacerbated by eyelid
surgery, and prophylactic therapy including antibiotics
may be warranted before embarking on eyelid surgery
in these patients. Recurrent herpes zoster may serve as
a contraindication to periocular laser therapy, and
prophylactic antiviral agents may be indicated before
embarking on surgical procedures in patients who are
predisposed to these outbreaks. Refractive surgery,
which has enjoyed recent popularity, predisposes some
patients to dry eyes and glare, which may alter indica-
tions and choices for cosmetic procedures. The most
important aspect of obtaining a good history is to tailor
the surgical procedure to the individual patient. This
28
CHAPTER TWO
will serve to diminish the risks as much as possible and
maximize the cosmetic and therapeutic aspects of any
procedure.
PHYSICAL EXAMINATION
Gross physical examination of the patient can begin by
simply viewing the patient at a comfortable distance
and noting gross anatomic abnormalities and/or nor-
malcy. For example, in viewing the general periocular
region including the upper and lower eyelids, one may
be looking for proper anatomic position of the upper
and lower lids. The upper lid should divide the width of
the upper iris in half. That is, the distance between the
corneoscleral junction and the pupillary aperture
should be bisected by the upper lid. The lower lid
should lie above or at the corneoscleral junction, and
upper and lower lids should have a smooth sweeping
arch or contour. The highest point or maximal arch of
the upper lid should lie at the most medial aspect of the
pupillary aperture. This is especially relevant in cor-
recting ptosis and/or lid retraction (discussed in detail
later in this text). Inflammatory changes and crusting
along the eyelid margins or within the eyelashes are
indications of blepharitis. A clear glistening corneal
surface and white scleral surface without injection is an
indication of a healthy and “happy” eyeball. Conjunc-
tiva that is glistening, flat, gossamer, and without injec-
tion or vascular engorgement is also an indication of
adequate coverage, lid excursion, and adequate wetting

of the ocular surface. Look for symmetric lid folds that
lie at an appropriate height for the patient’s sex and
racial makeup. Look carefully at the patient’s superior
sulcus and note the level of concavity or convexity and
its relationship to eyelid movement. Look for lid margin
positional abnormalities such as ectropion or entropion
and whether these change with the blinking cycle. For
example, patients with involutional entropion will
usually present with lax lower eyelids, scleral show, and
sometimes a tendency toward ectropion until they are
asked to close their eyes forcibly. Almost immediately,
their lower eyelid will briskly roll inward against the
globe. A “hands on” examination can be initiated once
the examining surgeon has a chance to view the patient
grossly. It is the attentive observational stage of the
examination that allows for a focused and detailed
physical review. This will enable the surgeon to make
anatomic and physiologic correlates to what is observed
and to make a plan for surgery in an efficient manner.
It is appropriate to ascertain and document a baseline
visual acuity whether using a standardized Snellen chart
at a distance or a hand-held Snellen card. A visual acuity
assessment is obtained of the right and left eye without
correction and then with correction. It is not uncom-
mon for patients to note or complain of visual acuity
changes postoperatively, and it is, therefore, important
to document presurgical visual acuity. Occasionally,
more discriminating patients will note worsened or
improved visual acuity after surgery, and I believe this
may be caused by corneal curvature changes related to
selective pressure alterations on the surface of the cor-
nea. Astigmatism in a selective meridian can be either
alleviated or induced by surgery. The patient is asked to
grimace and contract the orbicularis oculi muscles so
that facial nerve competence in this region can be
assessed. Next, extraocular motion and pupillary func-
tion are assessed, with asymmetries being most notable.
The lower eyelid is gently pulled down and distracted
away from the globe and then allowed to retract back
into its regular anatomic position. Delays or asym-
metries in the rate or position of the lower lid snap back
should be sought. A youthful and intact lower eyelid
should position itself against the globe and revert to an
E VA LUA T I O N O F T H E PA T I E N T
appropriate height within 1 second of distraction. I pre-
fer to grade the snap back as weak, moderate, or brisk.
In planning a procedure on a patient with anything but
a brisk snap back, one must either increase intrinsic
support factors or at least not increase extrinsic distrac-
tion forces. The level of zygomatic or malar support
should be assessed by visualizing and palpating the
orbital rim and malar eminence. On lateral view, one
should compare the anterior projection of the eyeball
and malar eminence. Patients whose malar eminence
lies posterior to their cornea have poor lower lid sup-
port and are prone to malposition. In patients with
lower eyelid malposition (scleral show) the lower eyelid
should be digitally elevated and tightened while con-
comitantly visualizing the tension created on the
suborbital soft tissues. The surgeon should try to assess
which lamella (anterior, middle, posterior) is deficient.
This will serve to assist the surgeon in planning comple-
mentary procedures to the canthopexy such as cheek or
midface suspension, interposition grafts, or even skin
grafts or external flaps. All patients should be assessed
for the quantity of tears produced, and the surgeon
should be familiar with how to assess the quality of
tears in the difficult, problematic, or complex case.
Baseline tear production should be assessed with the
Schirmer test utilizing topical anesthesia and precut
standardized No. 41 filter paper strips, which may be
obtained from a number of ophthalmic pharmaceutical
houses. I prefer to place the patient in a dark room
while testing baseline tear production to obviate the
effect that ambient light has on tear production. As in
the snap back test, one may divide the Schirmer test
strip results into three categories, thereby labeling the
patient as a low tear producer (0 to 9 mm), moderate
tear producer (10 to 20 mm), or high tear producer
(21 to 30 mm). Of course, in the case of very high tear
producers, one should entertain the possibility of tear
drainage problems induced by nasolacrimal obstructive
problems. These patients usually present with a
spectrum of complaints that may range from simply
epiphora to recurrent medial canthal swelling and
mucopurulent discharge on the other end of the
spectrum.
29
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The ability to withstand evaporation or its staying
power is a simplistic assessment of precorneal tear film
quality. The surgeon should be familiar with a simple
method of evaluating tear film quality: the tear film
break-up time. Basically, fluorescein is introduced onto
a topically anesthetized eye and, after the patient is
allowed to blink and disperse the agent, the eyelids are
then held apart and the uniform tear film is visualized
over the corneal surface through a cobalt blue filter. The
30
time period between holding the patient’s eye open and
the deterioration of the tear layer (tear film breakup) is
an assessment of tear film break-up time and is usually
over 20 seconds. Of course, given the trilaminar struc-
ture of tears, quality is a multifactorial entity and no
specific conclusions concerning the cause of poor tear
film quality can be drawn from this quick office test
(Fig. 2-1).
 E VA LUA T I O N O F T H E PA T I E N T

20/20
Va < 20/40 <
20/40 Va 20/20 2. Schirmer's test
sc cc
1. Visual acuity via Snellen chart

4. Malar support

3. Snap back test

Good

Poor

5. Tear film break up time

Figure 2-1 Evaluation of the patient should include an appreciation of visual acuity (with and without correction), baseline tear production,
intrinsic lid tone, lower eyelid support, and tear film quality. Of course, the specific tests performed and their interpretation should be tailored
by the clinician within the context of each patient and applied on an individual basis. For example, a low Schirmer test reading alone may not
be an absolute contraindication to a cosmetic procedure. Instead, it should direct the surgeon to look at other parameters (i.e., tear film quality)
and then design a procedure that compensates for anatomic and/or physiologic shortcomings.

31
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The bottom line in evaluating the history and physi-
cal examination in each patient is to first identify the
problem and second to tailor the surgical procedure
according to the specific patient’s findings. There are
almost no contraindications to surgery in the periocular
region but rather definitive historical and physical signs
that indicate an appropriate surgical procedure of
choice for an individual patient. Simply put, given four
or five surgical procedures that make it possible to
P E A R LS A N D P I T FA L LS
1. A detailed history and physical examination assist the surgeon
in choosing an optimal procedure for the patient.
2. It is helpful for patients to point out their aesthetic concerns in
a mirror for the surgeon.
3. Chronic blepharitis, Graves’ disease, herpes zoster infection,
and refractive surgery are some of the conditions that may
predispose to surgical complications.
4. The surgeon can ascertain a significant amount of information
by simply studying the macro and micro anatomy of the
eyelids and periocular region.
32
achieve an objective for the patient and surgeon, there
is likely only one procedure of choice a surgeon may
entertain once the preoperative evaluative tools have
been fully utilized. This statement is more likely to be
applicable to aesthetic surgery in the periocular region
than aesthetic surgery in any other region, given the
high functional demands imparted by the globe and
associated adnexal structures (Fig. 2-2).
5. A preoperative baseline visual acuity test and Schirmer’s test
are useful in assisting the surgeon to choose the most ideal
procedure and to follow and treat postoperative problems.
6. The lower lid intrinsic tone can be appreciated using a snap-
back test.
7. Upper lid position and excursion can assist the surgeon in
determining levator function and whether and which ptosis
procedure is indicated.
8. There are almost no contraindications to surgery in the
periocular region, but an appropriate procedure of choice
should be based on specific historical and physical signs.
 E VA LUA T I O N O F T H E PA T I E N T

A B
Figure 2-2 A, Front view of a patient with weak intrinsic support of the lower eyelid resulting in malposition and a symptomatic dry eye
syndrome. Note that despite upper eyelid ptosis he fails to maintain adequate corneal coverage and suffers excessive tear loss from ambient
evaporation and poor tear film distribution. B, Lateral view demonstrates poor malar support, with the plane of the zygoma lying far posterior
to the vertical plane of the lower lid tarsus. This patient also has large eyeballs (myopic) and, therefore, is more prone to having poor malar
support or so-called negative vector.

References Kim P, Berdoukas P, Francis IC, et al: Kinetic observational

Carruthers J: Brow lifting and blepharoplasty. Dermatol Clin
19:531-533, 2001.
Cheng J, Xu FZ: Anatomic microstructure of the upper eyelid
in the Oriental double eyelid. Plast Reconstr Surg 107:1665-
1668, 2001.
Della Rocca R, Bedrossian E, Arthurs B: Ophthalmic plastic
surgery: Decision Making and Techniques. New York,
McGraw-Hill, 2002.
Gallo SA, Wesley RE, Klippenstein KA, Biesman BS: Cosmetic
eyelid surgery. Ophthalmol Clin North Am 13:749-764,
2000.
Gorla MS, Gorla RS: Nonlinear theory of tear film rupture. J
Biomech Eng 122:498-503, 2000.
exophthalmometry: A simple clinical method of assessing
the relative axial positions of the eyes. Ophthalmic Surg
Lasers 32:257-259, 2001.
Mulliken JB, Godwin SL, Prachanktam N, Altobelli DE: The
concept of the sagittal orbital-globe relationship in
craniofacial surgery. Plast Reconstr Surg 97:700-706, 1996.
Olver JM, Sathia PJ, Wright M: Lower eyelid medial canthal
tendon laxity grading: An interobserver study of normal
subjects. Ophthalmology 102:2321-2325, 2001.
Papas E: Tear break-up time: Clinical procedures and their
effects. Ophthalmic Physiol Opt 19:274-275, 1999.
Van Den Bosch WA, Leenders I, Mulder P: Topographic
anatomy of the eyelids and the effects of sex and age. Br J
Ophthalmol 83:347-352, 1999.

33

Eyelid Malpositions
Malpositions of the eyelid, specifically the lower eyelid,
include ectropion (turning out of the eyelid margin),
entropion (turning in of the eyelid), and retraction
(scleral show) and can be grouped together despite a
variety of causes. Classically, ectropion and entropion
are classified as cicatricial, senile or involutional,
mechanical, paralytic, or congenital. Despite these clas-
sifications, it is most useful to identify the pathophysi-
ology in each instance and address it appropriately.
Involutional or senescent eyelid malpositions are the
most common. Typically, the medial and lateral canthal
tendons become lax or attenuated and there is usually
an inferior canthal descent, noted especially in the
lateral canthus. Clinically, the approximately 15-degree
lateral canthal inclination compared with the medial
canthus is lost with laxity of the lateral canthal tendon.
Usually with frank lower eyelid malpositions, the lateral
canthal tendon is at least coplanar with the medial
canthal tendon or, in more severe cases, inferiorly de-
clined by 5 to 15 degrees. Descent of the lateral canthal
tendon leads to a shortening of the intercommissure
distance (the distance between the medial and lateral
34
CHAPTER THREE
commissures). Secondarily, the lower eyelid and the
inferolateral aspect of the orbital septum develops
redundancy. This results in entropion, ectropion, scleral
show, or some combination of the three. Pseudo-
herniation of orbital fat, most notably in the lateral
inferior compartment, occurs from laxity of the orbital
septum (Figs. 3-1 and 3-2).
Inferior lid retractor disinsertion or capsulopalpebral
fascial dehiscence is associated with involutional or
senescent changes. Remember the primary lower lid
retractor is merely an extension of the inferior rectus
and inferior oblique muscles. A loosening of the attach-
ments of the preseptal orbicularis muscle may cause it
to override the pretarsal orbicularis, converting patho-
physiology appropriate for ectropion into involutional
or senescent entropion. That is, on brisk blinking or
forcible closure, the lax lower eyelid rolls in, causing an
irritative entropion that may produce corneal ulcera-
tion, breakdown, and severe cosmetic deformities. In
extreme cases, patients may be forced to tape their lower
eyelids down to prevent the rolling-in process.
 EYELID MALPOSITIONS

LATERAL CANTHAL CHANGES WITH AGE

+10–15°
0°

Figure 3-1 A to C, The lateral

canthus is normally inclined
cephalad by 10 to 15 degrees
compared with the medial canthus.
Attenuation with aging produces a 0° 0°
descent of the lateral canthus so that
the lateral canthus rotates (clockwise
on the left and counterclockwise on
the right) around the medial canthus.
The end result is a lateral canthus
that is coplanar or declined B
compared with the medial canthus.
As the lateral canthus sags inferiorly,
the intercommissure distance
shortens (distance between medial
and lateral canthus) and the lower
lid and inferior lateral septum 0°
become lax. This produces scleral -10–15°
show, ectropion or entropion, orbital
fat prominence especially laterally,
and tear film distribution and
drainage problems.
C

Figure 3-2 An 81-year-old patient with involutional entropion

presented with lateral canthal changes associated with the aging
process. Note the shortened intercanthal distance (medial to
lateral), downward drift of the lateral canthus, lower lid laxity,
scleral show, and “pseudoherniation” of the lower lateral fat
pad. These clinical changes occur as a result of lateral canthal
tendon attenuation and lengthening, with the lateral
commissure moving lower and medially. Therefore, if one views
the right eye, the lateral canthus is winding in a
counterclockwise direction around the cornea, producing lateral
septal laxity and all of the other characteristic changes.

35
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
ECTROPION
There has been a plethora of procedures describing
different procedures for the treatment of ectropion. In
my view only a few are effective in addressing the
underlying pathophysiology and that provide repro-
ducibly good results. As described previously, the lower
eyelid should spontaneously return back to a normal
anatomic position when distracted inferiorly and away
from the globe. Eyelid laxity of some degree is present
when a spontaneous snap back is absent. The classically
described pinch test, in which the examining surgeon
can pull the lower eyelid more than 10 mm from the
eyeball, may also demonstrate significant eyelid laxity. A
positive pinch test is sometimes viewed as an indication
for full-thickness lower eyelid shortening. This pro-
cedure may be performed transcutaneously or subcu-
taneously by first elevating a skin muscle flap. In either
case, I do not advocate lower eyelid shortening proce-
dures in the treatment of lower eyelid laxity. The patho-
physiology of lower eyelid laxity as described previously
is due to lateral and medial canthal attenuation along
with attenuation of other supportive structures. Short-
ening the lower eyelid produces further inferomedial
displacement of the lateral canthal complex and com-
missure along with a further diminution in the inter-
commissure distance. Although the lower eyelid may be
tightened, the procedure in and of itself produces the
exacerbation of the pathophysiologic processes that led
to lower eyelid laxity in the first place. Anatomically
tightening the lower eyelid by reversing the patho-
36
physiology of lower eyelid laxity is the method of choice
and appropriate procedures will be described later.
A cicatricial etiology for lower eyelid malposition,
especially in patients seeking aesthetic surgery, is rare.
Examination of a lower eyelid malposition should
include a thoughtful examination and assessment of the
external, middle, or internal lamellae of the lower
eyelid. Cases in which there is a frank deficiency require
grafting of either skin (external layer), mucosa (internal
layer), or structural support tissue such as tarsal
analogues (middle layer). All other cases of lower eyelid
malposition can be addressed using a canthopexy with
or without other procedures (Figs. 3-3 and 3-4).
CANTHOPEXY AND
CANTHOPLASTY
Because the mainstay of treatment in almost all cases of
lower eyelid malposition includes tightening of either
the inferior crus of the lateral canthal tendon or
repositioning the entire lateral canthal tendon, it would
be most appropriate to elaborate on several techniques
that are useful in achieving this end. Technically and for
clarity of communication, I will term a procedure that
tightens or suspends the lateral or medial canthus,
without division of one or more of its elements, a
canthopexy. Once division or disinsertion is performed,
then I will use the term canthoplasty.
 EYELID MALPOSITIONS

Figure 3-3 A 51-year-old man presented with lower lid ectropion

and secondary conjunctival hyperplasia secondary to exposure. Note
the lateral canthus is coplanar with the medial canthus and the
intercommissure distance is not substantially shortened, indicating
relative lower lid redundancy.

Figure 3-4 In this patient ectropion was corrected with a lateral

tarsal strip procedure only. Note that both low lid height and
malrotation are corrected. Also note that intercommissure distance is
maintained.

37
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
THE MODIFIED LATERAL
TARSAL STRIP PROCEDURE
The most useful procedure in addressing lower lid mal-
position and laxity is probably the lateral tarsal strip or
tarsal tongue procedure. Although there is a shortening
of the lower eyelid in this procedure, it differs from a
wedge resection in that a tarsal strip is created, and this
will serve as the new inferior crus of the lateral canthal
tendon. It is also imperative that the tarsal strip be
inserted at Whitnall’s tubercle, the insertion point for
the superior crus of the lateral canthal tendon, which is
described in detail in Chapter 1.
Unlike some classic descriptions of this procedure, I
recommend division of the inferior crus of the lateral
canthal tendon by means of a lateral canthotomy. Once
the inferior crus is severed, it is most important to
mobilize the lower lid. This is achieved by dividing the
subcutaneous tissues, including the lower lid retractors
and the orbital septum. It is only when these structures
are divided that the lower eyelid can be mobilized
almost to the eyebrow when placed on stretch. I believe
the most significant error in failing to achieve adequate
results with this procedure is by not completely mobi-
lizing the lower lid by lysis of the lateral retinacular
structures, despite all other aspects of the procedure
being performed satisfactorily. Once the lower eyelid is
mobilized, a tarsal strip is created by circumferentially
de-epithelializing a lateral segment of the lower eyelid,
which is back-cut below the tarsal plate. Approximately
3 mm of distal tarsal plate is isolated by carefully
removing hair follicles superiorly, skin anteriorly, and
mucous membrane posteriorly. The isolated tarsal strip
will then serve as a neocanthal tendon that will be
inserted into the lateral orbital rim. Proper insertion
requires surgically isolating Whitnall’s tubercle. This
involves lateral displacement of the lateral canthal soft
tissue with digital or instrument retraction and medial
retraction of the orbital soft tissue with superior
dissection to the orbital rim. This serves to isolate the
anterior orbital rim and then its internal aspect, at the
level of Whitnall’s tubercle. This area can be readily
discerned not only by its bony excrescence but also by
38
the insertion point of the superior crus of the lateral
canthal tendon. The orbital rim periosteum is incised
and then elevated from anterior to posterior within the
orbital rim, without division or raising any flaps. I
prefer to anchor the tarsal strip to the orbital rim perio-
steum utilizing a double-armed braided nonabsorbable
4-0 suture on a spatulated semicircular needle; however,
other sutures, depending on the surgeon’s preference,
are acceptable. The lateral tarsal strip is engaged with
the double-armed suture, and each arm of the suture is
brought through the internal orbital rim periosteum
from Whitnall’s tubercle anteriorly. The path of the
sutures will ride between the orbital rim periosteum
and the internal orbital bony surface. If one were to
visualize lower lid position without a corneal protector,
the lower eyelid should ride 1.5 to 2 mm above the
lower limbus once adequate positioning of the tarsal
strip is achieved. The next step should involve refining
the lateral commissure (commissuroplasty), and this is
achieved by precisely aligning the analogous elements
of the upper and lower eyelids (i.e., hair follicles or gray
line) with a single small absorbable suture (i.e., 6-0
Vicryl). This can be brought through the upper and
lower eyelids and tied subcutaneously just lateral to the
eyelids. Mild degrees of lid rotation may be invoked
with this technique, and it allows fine adjustments of
the eyelids and orientation of lateral canthal elements. I
have found it technically easier to pre-place the canthal
suture (tarsus and periosteum) and, before tying it down,
completing the commissuroplasty. Once the commis-
suroplasty is completed and the canthal suture tied
down, the orbicularis muscle should be suspended with
one or two absorbable sutures in a cephalolateral direc-
tion at the level of the lateral canthotomy. Closure of the
skin can be achieved after desirable trimming, depend-
ing on the degree of redundancy and the desired results.
Some skin tailoring, especially laterally, may be indicated
when some form of cheek suspension is performed con-
comitantly. However, skin conservation should be the
general rule, with secondary skin trimming always a
viable option (Figs. 3-5 and 3-6). Periosteal flaps raised
lateral to the orbital rim and based medially can serve
as an excellent salvage canthal tendon for reconstruc-
tion and should be kept in mind should a tarsal strip be
avulsed or excessively shortened (Fig. 3-7).
 EYELID MALPOSITIONS

CANTHAL SUSPENSION BY LATERAL TARSAL STRIP

Figure 3-5 The canthus may be A Lateral canthotomy

suspended by a lateral tarsal strip
procedure. There are a few steps that
when properly executed allow for this to
be completed quickly and simply.
B Division of lower crus and wide
A, First, the lateral canthus is divided. lateral lysis
B, The inferior crus of the lateral canthal
tendon is lysed, and the lateral
retinacular elements are incised (arrows)
to allow complete lower eyelid
mobilization. C, A transverse back cut is
made in the lateral tarsal plate, and
epithelium is denuded circumferentially.
It is especially important to remove hair C Denude lateral
follicles to avoid lateral distichiasis. tarsal strip
D, The lateral orbit is exposed and
periosteum is engaged with a double-
armed suture that has already been
passed through the tarsal strip. It is
sometimes helpful to incise the D Suture fixation of strip to internal
periosteum vertically so as to engage the periosteum of lateral orbital rim
internal orbital reflection “deeply” (2 to
3 mm) within the orbit. A small amount
of lateral orbicularis muscle may be
trimmed. E, The muscle is suspended
laterally and cephalad with a small
absorbable suture. F, Alignment of the
lateral commissure is achieved with a
small absorbable suture (preferably
double-armed) that is passed between
the upper and lower eyelids at their most
lateral aspects. I prefer to complete this
step before tying down my suspension
suture linked to the tarsal strip. The
tarsal strip procedure is well suited to the
more senescent patient in whom lower
lid and tarsal stretching has created F Commissuroplasty
relative redundancy in this structure. E Trim excess skin and/or orbicularis muscle

39
 A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

A B

C D

E F
Figure 3-6 A, This patient is undergoing lateral canthotomy by spreading lids apart and transecting skin laterally from the commissure,
exposing the lateral retinacular elements. A scissors may be introduced to complete the transection, or one may simply use a scalpel.
B, Cantholysis is completed with scissors. All the lateral retinacular components are lysed with complete mobilization of the lower eyelid. Note
how high the lid can be displaced. A back-cut is created in the mobilized lateral lid just below the tarsal plate margin. C, Beginning with skin,
circumferential de-epithelialization of the tarsal strip is undertaken with scissor dissection. Care should be taken to maintain the integrity of the
tarsus. D, The skin (anterior) and lashes (superior) have already been removed, with posterior de-epithelialization being completed by removing
conjunctiva. E, Wide exposure to the orbital rim is gained laterally with traction, and the periosteum is scored at the lateral rim. F, An internal
orbital periosteal flap is elevated medially into the orbit at the level of Whitnall’s tubercle. Continued

40
 EYELID MALPOSITIONS

G H

I J
Figure 3-6 Continued G, Tarsal strip is engaged with a suture. I prefer double-armed 4-0 nonabsorbable suture on a semicircular rigid needle.
H, The internal orbital rim periosteal flap is engaged and tied down. In this photograph both arms of the sutures have been passed through
the periosteum at Whitnall’s tubercle and the lower lid has only been partially pulled into appropriate position. This allows visualization of
de-epithelialized tarsus, orbital rim (blackened by cautery use) sutures, and the lower lid being pulled cephalad and posterior. Orbicularis
muscle and skin may be repaired following this step. I, Preoperative photograph of patient with lower lid laxity, scleral show, and ectropion.
J, Postoperative photograph shows good lower lid position lying above limbus and ectropion corrected. Lateral canthotomy incision is barely
perceptible.

41
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

A B
Figure 3-7 A, Defect in the upper eyelid of a young patient after malignant melanoma was resected. The tumor was resected, and the patient
was left with only one third to one half of the lateral eyelid. Note the tarsal plate evident beyond the skin margin on the lateral resected side.
B, Upper eyelid canthal elements along with lateral levator extension are lysed to mobilize the lateral lid medially. Note the hook in the upper
medial lid providing traction. Continued

42
 EYELID MALPOSITIONS

C D
Figure 3-7 Continued C, A periosteal flap is elevated off the lateral external orbital wall surface raised over the rim and into the internal
orbital surface with a skin hook providing traction. D, The periosteal flap serves as a replacement canthal tendon and is sutured to the lateral
extent of the tarsus within the remnant of upper lid that has been mobilized. A new commissure can be created, followed by muscle and skin
repair.

43
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
Another method of tightening the lower eyelid
without division of the lateral canthal tendon or its
inferior crus is to plicate or tuck the lateral aspect of the
tarsal plate. This can be performed transcutaneously
and may be performed alone or in combination with
other procedures (Fig. 3-8). It is effective only in mild
degrees of lower lid laxity and in youthful patients who
do not have attenuation of the lateral canthal complex.
44
This subgroup of patients will tolerate increased forces
across the lower lid without foreshortening the inter-
commissure distance and other problems associated
with procedures that do not suspend the lateral canthal
complex. In the face of significant horizontal lower lid
laxity, the tarsal plication will produce a buckled lower
eyelid that does not appropriately appose the ocular
surface.
 EYELID MALPOSITIONS

FAT REDISTRIBUTION AND TARSAL TUCK

Access incision–common canthopexy

Depressions that may be filled with
orbital fat

Figure 3-8 The transcutaneous

approach to the lower eyelid affords
access to the inferior crus of the Closeup of tarsal tuck
lateral canthal tendon and lateral
Access incision–tarsal tuck
tarsus. In mild cases of lower lid
laxity, plication of the inferior crus
can be performed (tarsal tuck).
Because the lower eyelid is not
shortened, buckling is created Fat redistribution
(central insert) in the lower eyelid, from lateral pocket
which can create spatial orientation
problems in the lower eyelid (e.g.,
ectropion, anterior displacement from
the globe). Therefore, it is only
applicable in very mild cases of Fat redistribution
laxity. Fat may be transposed over from medial pocket
the orbital rim. I prefer a
supraperiosteal tunnel with
transcutaneous fixation sutures. The
access may be transcutaneous or
transconjunctival. The amount of
viable filler available is limited in all
pedicled fat transposition procedures
and usually promises more than is
deliverable. The inserts depict the
subtle changes in the lower lid that
may be achieved with a tarsal tuck
and fat transposition. Completed canthopexy

45
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
An effective alternative approach to the inferior can-
thal or common canthal complex is by way of an upper
lid approach. Access to the lateral canthal complex can
always be achieved by way of an upper lateral eyelid
incision, whether for cosmetic or reconstructive pur-
poses. Through this route, the common canthal tendon
may be suspended and anchored to the internal orbital
rim periosteum in a method analogous to the tarsal
strip procedure described previously. Again, cephalic
and lateral pull or tension is the key to achieving satis-
factory results. Using this route, I favor disinsertion of
the entire lateral canthal tendon complex along with
the inferolateral aspect of the lower lid retractors and
orbital septum. This should allow complete mobiliza-
tion of the entire lateral lid complex, including the
lower eyelid. Significant degrees of elevation can be
achieved without tension, and the entire complex can
be anchored to the internal orbital rim at an appro-
priate position.
This procedure enables the surgeon to effectively
increase the intercommissure distance, as well as
significantly alter the angle of inclination of the lateral
canthus relative to the medial canthus. Should
inadequate periosteum or soft tissue be present for
suspension, as in secondary or tertiary procedures, then
a drill hole through the orbital rim at an appropriate
level will suffice. In using this approach, care must be
taken to avoid entrapping the lateral horn of the levator
muscle in the suspension suture because lateral upper
eyelid closure problems can result in this instance.
Overelevation of the lateral canthus can create an un-
acceptable cosmetic appearance and/or impingement
on the pupillary axis by the elevated lower eyelid. When
this occurs, patients complain of obstruction of their
vision in down gaze, for example when reading.
The upper lateral eyelid access incision may be used
to approach the mid face for suspension procedures,
but with slightly more difficulty than in approaching
the mid face from the lower eyelid incision. I believe
46
that canthal and midface suspension is more easily and
accurately achieved and the appropriate vector is more
easily engendered with an upper lid approach. Because
the surgeon is farther away from the structures to be
addressed, he or she may be less comfortable initially.
I do not recommend lower eyelid incisions combined
with upper lateral eyelid incisions for approaching the
canthal complex when division, lysis, and suspension
are to be performed. Generally, this requires significant
dissection, and the small bipedicle bridge tends to be
surgically compromised, leaving the lateral canthal soft
tissue elements with at least an appearance of having
had a surgical procedure and sometimes with severe
contraction bands that are difficult to correct. Therefore,
the ideal use for the upper lateral eyelid access incision
to the lateral canthal complex is one in which there is
complete lateral canthal dystopia and the surgeon
would like to reposition the entire complex or in the
case in which a lower eyelid incision will not be used
other than a transconjunctival route, thereby avoiding
compromise of skin and soft tissue bridges. In all these
patients, the mid face may be effectively approached
through this route should the surgeon choose not to
utilize a preauricular facialplasty incision to access the
mid face (Fig. 3-9).
The lateral canthopexy and canthoplasty can then be
applied in a number of scenarios either alone or in
consort with other procedures. I view canthal suspen-
sion as a procedure that should be liberally applied as a
primary procedure for patients with frank lower lid
laxity whether or not other procedures are being per-
formed concomitantly. It should also be liberally
applied when a patient has a tendency toward lower lid
laxity, that is, he or she has normal or near-normal
lower eyelid position and appearance but is undergoing
a primary cosmetic or reconstructive procedure in
which increased distraction forces will be applied to the
lower eyelid, thereby tipping the balance of forces
toward lower eyelid malposition.
 EYELID MALPOSITIONS

A Eyelid droop due to lateral canthal

tendon attenuation

Line of division
of lateral retinaculum
for common canthoplasty

B Common canthal tendon is retracted laterally

and superiorly then anchored to periosteum

Closeup of common canthopexy

C Effect of completed repair

Figure 3-9 A, Laxity in the lateral lid support structures is largely attributed to common canthal
attenuation and stretching. These changes occur in other components of lid support, including the
tarsal plate itself. A more direct anatomic approach to lateral canthal laxity and canthal dystopia is
what I term the common canthoplasty. B, Here the entire common lateral canthal tendon is mobilized
and fixed to periosteum in a cephalic posterior position. In distinction to other procedures that simply
“pexy” or suture-fixate the tendon to periosteum or fascia, this procedure requires complete mobilization
of the lateral canthus with lysis of the lateral septum and other components of the retinaculum. This
allows transposition of the entire commissure en bloc into an anatomic and cosmetically pleasing
position. The central insert (box) depicts how the canthus is fixed and the changes invoked by this
maneuver are seen in A and B, respectively.

47
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
CICATRICIAL ECTROPION AND
ENTROPION
Contractures in the anterior lamella of the eyelid can
cause cicatricial ectropion. These conditions can be seen
secondary to chemical or thermal injuries, secondary
to deficiencies or devascularization after surgery or
trauma, after severe outbreaks of herpes zoster, or iatro-
genically after aggressive lower eyelid laser procedures.
The surgeon should not be beguiled into believing that
a lateral canthal procedure will suffice in correcting
ectropion and/or scleral show when there is a true
deficiency in any of the lamellae of the lower lid, in-
cluding skin. Traction on the lower eyelid in a cephalo-
lateral direction, while observing the lower lid and
cheek, is a reasonable test to assess the extent of external
lamella deficiency. Generally, if elevation of the lower
A B
C D
48
eyelid produces traction and notable movement in the
cheek region, then a canthopexy alone will usually not
suffice. In mild-to-moderate cases of anterior lamellar
deficiency, a cheek or midface suspension, either by
means of a lateral upper, lateral lower lid, or a pre-
auricular facelift incision, may suffice. A free skin graft
or transpositional flap (i.e., Trippier, Fricke) will be
necessary when the external lamella deficiency exceeds
the amount correctable by simply elevating the malar
soft tissue. Free full-thickness skin grafts from donor
sites that are as close to the lower lid as possible
(i.e., upper eyelid) are quite satisfactory in the long run
and look as good as transpositional upper lid flaps. Free
skin grafts also avoid the distortion in the lateral canthal
region that occurs with transpositional flaps. The key
point in grafting the external lamellae of the lower
eyelid is to re-create the defect and place the lower
eyelid on cephalic traction, thereby overcorrecting the
defect significantly (Fig. 3-10).
Continued
 EYELID MALPOSITIONS

E F

G H
Figure 3-10 Continued The upper lid approach to the lateral canthal tendon and midface. A, The lateral canthal tendon is held in the forceps,
and the bony orbit lies beneath the retractor. B, Note that with the lateral retinacular elements lysed, the lateral canthus and the entire lateral
commissure can be transposed along an arc delineated by the lateral orbital rim. C, Viewed from the upper lid down, the dissection can be
carried inferiorly to approach the mid face and any plane of preference (e.g., subperiosteal, suborbicularis) may be accessed. A suture (green) is
engaged to the lateral canthal tendon, and the supraperiosteal plane over the zygoma is visualized. D, The suture engaged to the lateral canthus
is then passed through the periosteum of the orbit at a desired level. Note a second amber suture is visible at the edge of the retractor and onto
the skin surface. This suture passes through the malar fat pad. E, Canthal suspension suture now engaging both the tendon and the periosteum
of the orbit is ready to be tied down. The midface structures have been suspended, and the entire lateral canthus and commissure will be
translocated cephalad and laterally. F, Contralateral procedure on the same patient with the lateral canthus engaged by the suspension suture
and all elements of the lateral retinaculum freed. Exposure to the infraorbital and midface region is demonstrated with the use of a retractor.
G, Patient who had a previous blepharoplasty and now has midface ptosis and a relative deficiency of lower lid skin. She has scleral show,
bowing of the lower lids laterally, especially on the right, and wide lateral commissure angles. H, The same patient as in G after a lateral
common canthoplasty and midface suspension (as seen in operative views) now demonstrates obliteration of the preoperative scleral show, loss
of lateral lid bowing, acuteness to the lateral commissure angles, and midface elevation.

49
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Cicatricial entropion usually presents as the opposite
rotation of the eyelid margin as found in ectropion and
is caused by foreshortening of the internal aspect or
posterior lamellar eyelid structures. The etiology may
include chemical burns, iatrogenic or surgical injuries,
ocular pemphigoid, Stevens-Johnson syndrome, and
other scarifying processes. As in ectropion, replacement
of the lamella deficiency with a free graft (mucous
membrane or composite) is the treatment of choice.
This may be combined with a lateral canthotomy and
cantholysis or division of the inferior crus of the lateral
canthal tendon. This allows access to the entire fornix of
the lower lid. A canthopexy to further suspend the lower
eyelid may be performed after grafting is complete
(Figs. 3-11 and 3-12).

A B

C D
Figure 3-11 A, A 51-year-old woman presented with bilateral cicatricial ectropion from an external lamellar deficiency. She has had a number
of past surgical procedures by other surgeons, including a lower lid blepharoplasty at 44 years of age (7 years before presentation) and an
endoscopic browlift and lower lid blepharoplasty 4 months before presentation. Approximately 1 month before presentation she underwent a
lower lid suspension procedure (type unknown) that did not correct her problem. She presents with significant signs and symptoms of corneal
exposure, including corneal edema and decreased visual acuity. Note the scleral show and ectropion of the lower lid, especially on the right side.
B, On close-up view of the patient’s eyes, note lateral lower lid bowing, scleral show, ectropion, and conjunctival injection, especially in the
temporal quadrant of the right eye. C and D, Lateral view of the left and right eyes, respectively, demonstrating displacement of the lower lid
away from the globe in two planes (vertical and horizontal) and the resulting signs of an eye that is not well covered and wet (i.e., conjunctival
injection).

50
 EYELID MALPOSITIONS

A B
Figure 3-12 A and B, Front and right lateral views of same patient after bilateral lower eyelid full thickness
grafts obtained from the retroauricular sulci along with a canthoplasty. Note bowing in the lateral third of
each lid with almost normal central lower lid position. On both views the ectropion is completely corrected.
Note also there remains midface ptosis, and on the lateral view the orbital rim is visualized in relief owing to
excess orbital fat resection in the past and midface ptosis. Her symptoms were relieved and her corneal edema
and epithelial problems resolved with a corrective procedure. Subsequently, a midface suspension was
performed to address the orbital rim and midface junction as well as to provide additional external lamella
tissue for the lower lid. These postoperative photos are shown to demonstrate the potency of external lamella
replacement by way of skin graft.

51
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
INVOLUTIONAL ENTROPION
The causes of senile or involutional entropion are often
analogous to those of senescent ectropion, with the
dominant common cause being significant horizontal
eyelid laxity. There is an associated net attenuation of
the inferior lid retractors along with an override of the
more loosely attached preseptal orbicularis muscles
over the pretarsal orbicularis muscle. In most cases there
is relaxation of the medial and lateral canthal tendons
along with a secondary redundancy of the lateral orbital
septum with pseudoherniation of orbital fat. The
dehiscence of the lower lid retractors is analogous to
levator aponeurotic dehiscence in the upper lid, which
will be discussed in Chapter 8. The classic presentation
of patients with involutional entropion is the patient
who presents in the sixth or seventh decade of life with
an inturning of the lower eyelid, especially on aggressive
or forced closure. This repetitive turning in of the lid can
cause corneal irritation and even breakdown, leading to
significant morbidity and debilitation. Although a
number of procedures have been described for the
correction of involutional entropion, I have found them
to be either insufficient, associated with a high recur-
rence rate of the entropion, or overly aggressive, in-
curring a significant amount of unnecessary surgery.
Simply stated, these solutions are either too little or too
much. My recommendation for correction of involu-
tional entropion uses a few basic techniques already
described in this text. The principle is to first address the
lower lid laxity and second to address the preseptal
orbicularis override. This procedure can be performed
quickly, reproducibly, and safely with the patient under
52
local anesthesia and with or without sedation. A lateral
canthotomy and cantholysis of the inferior crus of the
lateral canthal tendon is performed. The lower eyelid is
mobilized with a subtarsal dissection lysing the lateral
inferior lid retractors. A suborbicularis preseptal
dissection is performed in the potential space between
the orbicularis muscle and the orbital septum, along
with a subcutaneous or preorbicularis dissection (see
Figs. 1-1 and 1-2). This dissection is carried out from the
lateral canthus to the medial canthus, eliminating
muscular override by creating fibrosis. The canthoplasty
is then completed as previously described utilizing the
denuded tarsal strip (see Fig. 3-5). The lower lid
retractors are allowed to spontaneously adhere to the
newly elevated lid position. In my experience, this
definitive and simple procedure can be nearly 100%
successful with limited or no morbidity (Fig. 3-13).
SCLERAL SHOW OR LOWER LID
RETRACTION
In severe cases of lower lid retraction or pseudoretrac-
tion, as in mild exophthalmos or proptosis secondary to
Graves’ disease, the lower lid may be elevated with a
combination of canthopexy and middle and internal
lamellar spacer grafts to provide rigidity and support.
This is especially the case when an external lamella or
skin deficiency does not exist. The atonic lower eyelid
found in facial paralysis is another example of an
appropriate indication for this procedure.
 EYELID MALPOSITIONS

A B

C D
Figure 3-13 A, A 71-year-old patient presented with involutional entropion of the left lower lid. She also has chronic exotropia of
her eye and ptosis of her upper lid with amblyopia. Note her left lower lid lash line is barely visible as the lid rolls in on lid closure
and is exposed with upper lid retraction. Note also the contralateral right lower lid margin with lash line properly directed. This
patient suffered from corneal erosion. B, Close-up view of the left lower eyelid involutional entropion. Note the distinct rolling in of
the eyelid associated with lower lid laxity, orbicularis muscle override, and other factors (see text). C and D, Distant and close-up
photographs of patient approximately 6 months later with left lower lid in good anatomic position with lash line everted away
from the ocular surface. The underlying pathophysiology is addressed by tightening the lower eyelid with a canthoplasty,
preorbicularis and postorbicularis undermining, and muscular stabilization.

53
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

I prefer palatal mucoperiosteum as an interposition
graft between the tarsal plate and lower lid retractors. A
lateral canthotomy and inferior cantholysis is again
performed, and the lower lid retractors are divided by
way of a transmucosal approach. I prefer an insulated
electrocautery to achieve this exposure. Easy access to
the lower lid retractors and the inferior tarsal plate
border is obtained with the lower eyelid mobilized and
turned outward. The interposition graft is sutured into
place apposing deeper structures (eyelid retractors) and
then mucosa separately. The lower eyelid is then
suspended again with a canthopexy by way of the tarsal
strip or other procedure (Figs. 3-14 and 3-15). A similar
interposition type graft can be employed in upper lid
retraction as in Graves’ disease and is described in
Chapter 8. The difference in the case of the upper lid is
that the graft need not provide rigidity nor mucosa
unless there is an internal lamellar deficiency.

Figure 3-14 A 61-year old woman

presented with symptomatic left lower
lid retraction and atonicity caused by
facial nerve paralysis and multiple
attempts to suspend the left face and
lower lid in the past. Note lateralization
of the lower lid punctum, scleral show,
slight ectropion, a thinned lower eyelid
compared with the normal right side
caused by orbicularis atrophy, and left
facial ptosis from resection of the
seventh nerve on both far (A) and close-
up (B) views.
B

54
 EYELID MALPOSITIONS

SPACER GRAFT FOR CONTRACTED LOWER LID

Mucoperiosteum

Lower lid retraction

A Harvest hard palate graft

Lower border
of tarsal plate

B Conjunctiva divided and lower lid retractors

disinserted

C Graft sutured to lower edge of tarsal plate

and lower lid retractors

Figure 3-15 This patient has middle internal lamella deficiencies that will not respond to canthoplasty
alone or in combination with a midface support procedure. Patients with these types of deficiencies
usually have had several previously failed procedures. On examination, digital elevation of the cheek
and canthus fails to correct the lower lid malposition; and in these cases a spacer graft, which also
provides some central vertical support, is needed. The procedure requires a transconjunctival lysis of the
lower lid retractors below the tarsal plate and the interposition of a palatal mucoperiosteal graft. The
lower lid retraction is severe in this figure. A, Hard palate mucoperiosteum is harvested. B, The
conjunctiva and lower lid retractors are incised and recessed. C, The space between the retractors and
tarsal plate is grafted with free mucoperiosteum using a fine absorbable suture (i.e., 6-0). A lateral
cantholysis (not shown) is usually helpful but not necessary for access and insetting the graft and adds
little time and no morbidity. In most cases in which a spacer graft is used some type of canthal
suspension should be performed.

55
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
P E A R LS A N D P I T FA L LS
1. All lower eyelid malpositions (refraction, entropion, ectropion)
should be identified and then addressed by their patho-
physiology.
2. Involutional lower eyelid malpositions are the most common
and are associated with lateral canthal laxity.
3. Descent of the lateral canthus leads to intercommissure
shortening and septal laxity.
4. Involutional entropion shares all the contributing components
with involutional ectropion, but also has retractor dehiscence.
5. Lower lid shortening procedures should be avoided in the
treatment of lower lid laxity.
6. Canthoplasty and canthopexy are different procedures, and
each may be subdivided into one that applies to a single crus
or to the common element.
7. The lower eyelid can be fully mobilized only when the lateral
retinacular components (i.e., orbital septum, lid retractors)
are lysed.
8. A commissuroplasty is important for proper alignment of the
upper and lower eyelids when completing a tarsal strip
procedure.
56
9. Tarsal plication is effective only in mild lower lid laxity and,
when employed in more severe cases, can lead to buckling of
the lower eyelid.
10. The lateral horn of the levator may be entrapped during a
lateral canthal suspension, leading to upper lid retraction or
lagophthalmos.
11. Overelevation of the lateral canthus can produce an un-
acceptable appearance and impinge on the visual axis.
12. Lateral canthal suspension procedures alone will not correct a
significant lamella deficiency of the lower eyelid.
13. One should consider midfacial suspension or even grafts in
treating significant anterior lamella deficiencies.
14. The ideal treatment for involutional entropion is to tighten
the lower lid and prevent orbicularis override.
15. Spacer grafts of the middle and inner lamella of the lower lid
are ideal in providing central support and can be combined
with canthal and midface suspension.

References
Aldave AJ, Maus M, Rubin PA: Advances in the management of
lower eyelid retraction. Facial Plast Surg 15:213-224, 1999.
Caldato R, Lauande-Pimentel R. Sabrosa NA, et al: Role of
reinsertion of the lower eyelid retractor on involutional
entropion. Br J Ophthalmol 84:606-608, 2000.
Dagum AB, Antonyshyn O, Hearn T: Medial canthopexy: An
experimental and biomechanical study. Ann Plast Surg
35:262-265, 1995.
Glatt HJ: Follow-up methods and the apparent success of
entropion surgery. Ophthalmic Plast Reconstr Surg 15:396-
400, 1999.
Kim JW, Kikkawa DO, Lemke BN: Donor site complications of
hard palate mucosal grafting. Ophthalmic Plast Reconstr
Surg 13:36-39, 1997.
Lemke BN, Cook BE Jr, Lucarelli MJ: Canthus sparing
ectropion repair. Ophthalmic Plast Reconstr Surg 17:161-
168, 2001.
Lisman R, Campbell J: Tarsal suspension canthoplasty.
Aesthetic Surg J 19:412-424, 1999.
Matsuo K: Stretching of the Mueller muscle results in
EYELID MALPOSITIONS
involuntary contraction of the levator muscle. Ophthalmic
Plast Reconstr Surg 18:79-83, 2002.
Mommaerts MY, De Riu G: Prevention of lid retraction after
lower lid blepharoplasties: An overview. J Cranio-
maxillofacial Surg 28:189-200, 2000.
Olver JM, Barnes JA: Effective small-incision surgery for
involutional lower eyelid entropion. Ophthalmology
107:1982-1988, 2000.
Patel BC, Patipa M, Anderson RL, McLeish W: Management of
postblepharoplasty lower eyelid retraction with hard palate
grafts and lateral tarsal strip. Plast Reconstr Surg 99:1251-
1260, 1997.
Patipa M: The evaluation and management of lower eyelid
retraction following cosmetic surgery. Plast Reconstr Surg
106:438-453; discussion 454-459, 2000.
Rougraff PM, Tse DT, Johnson TE, Feuer W: Involutional
entropion repair with fornix sutures and lateral tarsal strip
procedure. Ophthalmic Plast Reconstr Surg 17:281-287,
2001.
Yip CC, Choo CT: The correction of oriental lower lid
involutional entropion using the combined procedure. Ann
Acad Med Singapore 29:463-466, 2000.
57

Upper Lid Blepharoplasty
Blepharoplasty has become one of the more common
aesthetic surgical procedures performed today. Pre-
operative evaluation should include a number of im-
portant factors, none the least of which is the patient’s
own assessment in a mirror of what he or she finds
bothersome. As mentioned in Chapter 2, the pre-
operative evaluation should include a complete exami-
nation including a detailed history concerning dry eyes,
recurrent herpes zoster or simplex infections, and
thyroid disease. The physical examination should
include a Schirmer test, tear film break-up time, visual
acuity with and without correction, and so on. Fine
examination of the lid margin for chronic blepharitis,
evidence for lid retraction or laxity, and signs of asso-
ciated systemic disease such as thyroid disease or other
problems should be assessed. Although the surgical
approaches may be the same, an appreciation of the
difference between blepharochalasis and dermato-
chalasis, that is, the etiology for the redundant upper
eyelid tissue, should be understood. I like to define
blepharochalasis as redundant upper lid tissue secondary
to underlying pathophysiology such as recurrent edema
as found in renal failure, cardiac disease, or angio-
neurotic edema. Dermatochalasis is the commonly
found redundancy of upper eyelid tissue secondary to
58
CHAPTER FOUR
the senescent process with or without ptotic eyebrow
changes.
An important concept in appreciating upper eyelid
functional and cosmetic surgery is illustrated by con-
trasting nuances in the anatomy and pathophysiology
between racial and age groups. For example, the upper
eyelid crease lies 6 to 8 mm from the lid margin in the
young Caucasian. The lid fold is created by extensions
of the levator to the lid skin. This lid fold is significantly
elevated in the deep-set eye or an eyelid in which levator
dehiscence has occurred. In both instances, preapo-
neurotic fat is retracted or located more cephalad. In the
senescent or “baggy” Caucasian upper eyelid, septal
laxity and tissue relaxation allow preaponeurotic fat to
prolapse anteriorly, lowering the eyelid fold and
moving it closer to the lid margin. This age-related
pathophysiology is analogous to the normal anatomy
found in the youthful Asian upper eyelid. Here the
eyelid fold is low and variably closer to the lid margin,
with fullness created above it owing to prolapsed
preaponeurotic fat extending to the insertion of the
levator aponeurotic elements on the overriding lid skin.
Therefore, the aged Occidental upper lid resembles the
youthful Asian lid (Figs. 4-1 and 4-2).
 UPPER LID BLEPHAROPLA S T Y

6 – 8 mm.
A Occidental

8 – 13 mm.
B Deep Set
(levator dehiscence)

0 to minimum
C Baggy Eyelid

0 to minimum
D Asian

Figure 4-1 The anatomic variations in the upper eyelid displayed by different ethnic groups and the changes associated with senescence within
each group allow for a convergence of anatomy. Many of these ethnic differences are erased by aging and/or attenuation of structures, allowing
for what I like to call a unified upper lid concept. A, The normal youthful Occidental upper eyelid has levator extensions inserting onto the skin
surface to define a lid fold that averages 6 to 8 mm above the lid margin. Note the orbital septum coalescing with the levator aponeurosis creating
the fat-containing preaponeurotic space. The position of the levator-skin linkage and the anteroposterior relationship of the preaponeurotic fat
determine lid fold height and degree of sulcus concavity or convexity (as shown on the right half of each anatomic depiction). B, In the deep-set
eyelid or in the case of levator dehiscence from the tarsal plate, the upper lid crease is displaced superiorly. The orbital septum and
preaponeurotic fat linked to the levator are displaced superiorly and posteriorly. These anatomic changes create a high lid crease, a deep superior
sulcus, and, in the case of levator dehiscence, eyelid ptosis. C, In the aging or baggy eyelid, the septum becomes attenuated and stretches. The
preaponeurotic fat attachments loosen, and this allows orbital fat to prolapse forward and slide over the levator into an anterior and inferior
position. The net result is an inferior displacement of the levator skin attachments and a low and anterior position of the preaponeurotic fat pad.
Clinically, this results in a low lid crease that is only a few millimeters from the lid margin and may not be visible owing to the overhanging lid.
D, The youthful Asian eyelid anatomically resembles the baggy or senescent upper lid with a low levator skin zone of adhesion and inferior and
anteriorly located preaponeurotic fat. The characteristic, but variable, low eyelid crease and convex upper eyelid and sulcus are classic.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
In the patient undergoing upper lid blepharoplasty, it
is extremely important to assess eyebrow position and
note the presence or absence of ptosis. The eyebrow
hairline and sub-brow fat pad should be evaluated in
relationship to the upper orbital rim. The surgeon may
have to consider direct eyebrow elevation through the
upper lid incision or an indirect approach by means of
a temporal incision to be included in the facelift, an
endoscopic route, or a classic coronal route when signi-
ficant eyebrow ptosis is present. The surgeon who
attempts to correct significant eyebrow ptosis by means
of an upper lid blepharoplasty alone will meet with
unsatisfactory results and usually have a dissatisfied
patient. This approach usually leads to a blending of the
very thin eyelid skin with the thicker eyebrow skin and
sub-brow fat pad with an appearance of the eyelids
being sutured directly to the eyebrows. In my experi-
ence, it is the lateral one third of the eyebrow that is
most important from a cosmetic standpoint; and this
has been corroborated in other studies. Redundancy
in the lateral one third of the upper eyelid presents as
a hooding that can only be eliminated in two ways.
Either the surgeon may elevate the lateral one third of
the eyebrow and then perform a more conservative
blepharoplasty, or a very aggressive lateral blepharo-
60
plasty extending beyond the orbital rim is necessary in
addressing this hooding. The constraint for the surgeon
is that incisions that extend beyond the lateral orbital
rim become proportionately more noticeable the more
laterally they extend. Therefore, the surgeon must
balance the extent of lateral hooding against the desire
to minimize lateralization of the upper lid blepharo-
plasty scar. Based on each patient, the extent of
lateralization necessary and other factors, the surgeon
and patient may choose to add an adjuvant procedure
such as a lateral browlift to the planned blepharoplasty.
This becomes an easier decision when a facelift is
planned, because the lateral one third of the brow can
be elevated in a plane over the deep temporal fascia
extending over the lateral orbital rim. This is readily
accessed by way of an extension of the facelift incision
into the scalp. A direct brow suspension by way of the
upper lid is another satisfactory approach that requires
a significant amount of dissection, which can result in
more postoperative swelling and a prolonged recovery
for a blepharoplasty. This latter approach is especially
useful in balding men and in limiting surgery and
incisions in women. These procedures are described in
more detail in Chapter 10.
 UPPER LID BLEPHAROPLA S T Y

A B

C D
Figure 4-2 A to D, Clinical photographs that correspond to graphic representation as delineated in Figure 4-1.
Note: A young non-Asian (A) is compared with the deep-set sulcus and preaponeurotic fat retraction associated
with levator dehiscence (B), the baggy upper eyelid seen in septal laxity and fat prolapse associated with aging
(C), and the Asian upper eyelid (D) with its low septal attachment and anteroinferior fat position analogous to
the aging Occidental upper eyelid.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The amount of horizontal skin laxity of the eyelids
themselves, that is with the eyebrow fat pad held in an
anatomic position and eliminating its contribution to
skin redundancy, is another important factor that
should be appreciated preoperatively. The presence or
absence of lid lag or lagophthalmos should be noted
and measured because asymptomatic lagophthalmos
can easily be converted to the symptomatic variety with
even small amounts of skin resection. Some patients
may not tolerate brow suspension procedures (i.e.,
along with a skin resection in the upper eyelid,
especially in the medial two thirds of the eyebrow).
Elevation of the lateral one third of the brow is less
likely to produce untoward sequelae even in patients
with upper lid skin deficiencies. Therefore, the surgeon
should assess “relative” dermatochalasis, that is, skin
redundancy as contributed from the eyelid versus the
eyebrow. Then the surgeon and patient can choose the
appropriate technique based on the pathophysiology
and the patient’s desires (Fig. 4-3). Because upper lid
blepharoplasty basically involves removal of redundant
or excessive skin of the upper eyelids along with
excision of some portion of the orbicularis muscle and
preaponeurotic fat with violation of the orbital septum,
there are a few salient points that predicate a well-
executed procedure. The first important anatomic
location is the upper lid eyelid crease. In Occidentals,
this lies 6 to 10 mm above the eyelid margin and is
generally higher in females. It is important to remember
that one is not bound by a particular eyelid crease
height; however, the endogenous lid crease is usually
the most appropriate for the patient. In Oriental or
Asian eyelids the lid crease may be considerably lower
than in Occidentals (see Figs. 4-1 through 4-3). Some
Asian patients may request an Occidentalization or
elevation of the endogenous upper eyelid fold. One
may even encounter patients with asymmetric upper
eyelid folds, and the surgeon should be comfortable
with adjusting and repositioning eyelid folds as is
discussed in Chapter 8 on the technique of supratarsal
fixation. Once the upper eyelid fold is defined and
marked with a surgical marking pen, the extent of upper
eyelid skin excision is determined by a pinch test. The
design of the upper and lower limbs of the incision
lines should be curvilinear, with the medial aspect
being convex superiorly and the lateral aspect being
convex inferiorly. Attempts should be made to place the
lateral aspect of the lower incision line within a skin
crease, and this is upwardly inclined to meet the upper
limb of the incision, which is extended laterally. In my
mind, the importance of curving the lateral aspect of the
upper incision is twofold: (1) to extend the upper eyelid
62
incision away from any potential lower eyelid incisions
and, therefore, obviate a narrow skin bridge that is
usually neurovascularly compromised in some fashion
and (2) to curve the incision upward, allowing the
lower limb to be longer than the upper limb and
thereby effectively creating a Burow’s triangle resection
of the potential dog-ear. An atraumatic forceps is used
to pinch the skin between the delineated upper eyelid
fold and the desired excision line superiorly, and I
prefer to induce a small amount of upper eyelash ever-
sion as a determinant of the proper amount of skin
resection. Remember, brow positioning is important
and should a brow elevation procedure be entertained,
then suspension of the brow digitally before delinea-
tion of the extent of upper eyelid skin excision should
be performed. Positioning the brow digitally before
marking the upper eyelid allows the surgeon to address
the upper eyelid first without risking overresection,
independent of which procedure is chosen for brow
elevation and independent of the order in which
the surgeon chooses to perform the procedures (see
Fig. 4-3). I find it very cumbersome to resect skin after
the brow is suspended, especially in the transblepharo-
plasty brow elevation procedure, because this usually
results in irregularities in the upper eyelid incision line.
Local anesthetic with epinephrine is infiltrated and
adequate time for hemostasis is allowed to elapse.
Upper and lower lid eyelid incisions are made in a
medial to lateral direction through skin and orbicularis
muscle (Fig. 4-4). The skin muscle flap is elevated from
the lateral to medial direction with digital retraction
laterally. The orbital septum is tented with a forceps
unroofed from lateral to medial, utilizing a sharp
scissor or needle-tip cautery at the level of the upper
extent of the eyelid incision. Tentative dissection by
some surgeons occurs at this juncture owing to concern
over creating iatrogenic damage to underlying structures
at or behind the orbital septum (e.g., levator apo-
neurosis, tarsal plate). This can be obviated by opening
the orbital septum as cephalad as possible where the
levator aponeurosis lies most posteriorly away from the
orbital septum and the buffer of preaponeurotic fat is
interposed (Fig. 4-5). In Chapter 1, I pointed out that
the levator aponeurosis and orbital septum fuse at the
level of the upper tarsal plate and diverge as one moves
superiorly, with the levator aponeurosis converting
from an inferosuperior to an anteroposterior orienta-
tion as one moves cephalad from the tarsal plate (see
figures in Chapter 1). Preaponeurotic fat (medial and
central fat pads) can then be appropriately resected if
desired. It is useful to use a fine hemostat with light
digital pressure on the globe to tease the fat free of
 UPPER LID BLEPHAROPLA S T Y

Lid crease marks

lower limb of incision

Lateral browlift

Upper limb of incision is

defined when lashes evert
A B
Figure 4-3 The keypoints in planning and executing the upper lid blepharoplasty are as follows:
A, Determination of the endogenous lid crease or height at which to create a new lid crease (if different
than the existing crease). The latter would require supratarsal fixation. The level of this crease will serve as
the lower limb of the blepharoplasty incision and the height of supratarsal fixation, should that be
necessary. The width or extent of skin excision is determined by pinching the lid skin between forceps using
slight lash line eversion as the end point. This superior point will determine the location for the superior
limb of the skin incision (left). B, Determination of the extent of lateral eyebrow ptosis and, hence, the
amount of lateral upper eyelid hooding. The degree of lateral hooding will dictate the point of the lateral
extension needed to treat the hooding. The greater the hooding the more lateral the extent of the incision
(top, dark to lighter shades of color). In general, incisions that extend beyond the orbital rim are not well
tolerated (middle). The unequal lengths of the upper and lower limbs are effectively Burow’s triangles to
eliminate dog-ears and must be exaggerated as one widens the lateral skin excision. Also a brow that lacks
stability may be pulled down by tension induced by a wide lateral excision. Here a balance must be made
between the extent of lateral hooding and the drive to maintain incision lines within the confines of the
orbital rim. Once the lateral extent of the incision becomes excessive then a lateral brow suspension
should be entertained.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

septal adhesions and allow it to prolapse spontane-
ously. Fat may be resected by any technique; however, I
find it preferable to use an insulated needle cautery. By
using light inferior traction on the upper lid, one
should be able to visualize the levator aponeurosis and
Whitnall’s ligament. It is easy to obtain complete access
to the anterior one third of the orbit above the levator
muscle using these simple technical maneuvers (see
Fig. 4-5).

UPPER LID BLEPHAROPLASTY

A Incision

Figure 4-4 In practice the upper lid

blepharoplasty can be efficiently
performed using a few technical
manipulations consistent with the
anatomy. Digital traction and light Levator aponeurosis
pressure by the surgeon and/or
assistant allow smooth quick skin Orbital septum
incisions. A, Slightly more pressure
must be exerted on the scalpel
laterally as the skin thickens around
and lateral to the orbital rim. B, The Central fat pad B Skin and orbicularis muscle resection
(preaponeurotic)
skin may be elevated with the on levator aponeurosis
orbicularis muscle in one maneuver
using an instrument on the skin-
muscle section to be resected and
pulling this superonasally while
providing digital traction laterally. I
find a needle-tipped insulated
cautery to be most advantageous in
this and other succeeding steps,
especially in avoiding any delaying
hemostasis problems. The orbital Pressure on globe
septum is then widely opened, causes medial
exposing the preaponeurotic space. fat pad to bulge
C, The underlying levator aponeurosis
is protected by opening the septum as
cephalad as possible, because the
levator and septum diverge as one
moves superiorly. C Orbital septum incised Continued

64
 UPPER LID BLEPHAROPLA S T Y

Whitnall's ligament

Levator aponeurosis

D Medial fat pad removed

Figure 4-4 Continued D, The medial fat

pad may require some digital pressure to
expose and grasp; however, care should be
taken not to overly resect fat when using
digital pressure techniques. Excessive
traction and manipulation of fat could
cause a deep orbital hemorrhage and
should, therefore, be avoided. E, Closure
may then be performed and I prefer Interrupted sutures Intracuticular
6-0 nylon interrupted sutures laterally and running stuture
5-0 nylon intracuticular sutures medially. E Closure

65
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

B C

D
Figure 4-5 A, An upper lid blepharoplasty is delineated with marking ink. Slight upper lid lash line eversion delineates the extent of the skin
excision. This can be ascertained by pinching the upper and lower limbs of the central aspect of the incision lines together with an instrument.
B, An upper lid skin excision leaving the orbicularis muscle behind. The muscle is thin, and the underlying orbital septum is visualized in the
vertical traction line lying between the upper and lower hooks. C, An incision line is made with a scalpel, and the skin flap is elevated with a
cautery. I prefer to remove central orbicularis muscle beneath the skin and avoid a second step as well as hemostasis problems, leaving the
orbital septum intact. D, The orbital septum is then incised at its more superior extent. The septum may be stabbed or widely incised with a
needle-tip cautery. Fat will prolapse spontaneously or with light digital pressure. The medial fat (held in forceps) is whiter and lies medial to the
superior oblique muscle, which can be visualized if desired. The central or preaponeurotic fat (pulled laterally by suction cannula) is darker, less
fibrous, and loosely but definitively adherent to the levator aponeurosis. Continued

66
 UPPER LID BLEPHAROPLA S T Y

Figure 4-5 Continued E, Contralateral upper eyelid shows

preaponeurotic fat lying lateral to the superior oblique muscle
and visualized more anatomically as a thin yellowish fan-shaped
layer attached to the levator aponeurosis. The medial fat is
separate, isolated between the medial orbit and the superior
oblique muscle. After fat resection, closure may be performed as
shown in Figure 4-4. F, Close-up photograph of an upper lid
blepharoplasty demonstrating some important anatomic and
clinical features. Here the lower forceps is indenting the levator
aponeurosis and the upper forceps is retracting part of the
preaponeurotic fat. Just lateral to the visualized preaponeurotic
fat, the orbital septum remains intact. Note that the orbital
septum must be violated to gain access to the superior orbit, the
levator, and the preaponeurotic fat. Also note that the whiter F
medial orbital fat is spontaneously prolapsing anteriorly and the
more central preaponeurotic fat is loosely attached to the
underlying levator mechanism. G, The upper lid is placed on
moderate traction, and the preaponeurotic fat is partially
divided with a cautery and retracted nasally with forceps. Just
above the skin traction hook one can see the tarsal plate with
overlying orbicularis muscle (white); above that, a blue band
corresponds to a levator dehiscence from the tarsal plate, and
superior to that the levator aponeurosis is viewed as a white flat
fan. Whitnall’s ligament is seen as a white thin band lateral to
the cut end of the preaponeurotic fat. Just above Whitnall’s
ligament is the blackened (cauterized) cut end of the orbital
septum, and just below Whitnall’s ligament is the levator
palpebrae superioris muscle, which is pale yellow and
vascularized compared with the white aponeurosis distally.
Modifications in the levator or at the levator tarsal junction can
be easily performed with this exposure. G

67
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The levator aponeurosis may be modified at this
juncture if so desired. It may be freed from the tarsal
plate and advanced as in a formal levator advancement
procedure for ptosis. Alternatively, the levator may be
plicated or tucked in mild degrees of ptosis (Fig. 4-6).
This is described in Chapter 8. Closure is then per-
formed, and I find the preferable method is to utilize an
intracuticular suture extending from the medial canthal
region to just medial to the lateral canthal region. I pre-
fer a 5-0 nonabsorbable monofilament suture. Laterally,
I prefer a 6-0 interrupted monofilament suture. Eversion
of skin lateral to the canthus helps in eliminating a
depressed incision line, which can be unsightly espe-
cially in women. I have seen some longer-lasting
absorbable sutures produce unsightly tracts. Suture re-
moval can be performed at 5 to 10 days as deemed
appropriate by the treating surgeon. The medial aspect
of the intracuticular suture that is transcutaneous tends
to be prone to purulent inclusion cysts, and the surgeon
may wish to trim this at the level of the skin at surgery
or earlier than the scheduled complete suture removal.
Supratarsal fixation refers to creating a controlled
adhesion between the levator aponeurosis and the
P E A R LS A N D P I T FA L LS
1. Age and race dictate the position of the upper eyelid fold, with
a convergence in anatomy occurring between the aging
Caucasian and youthful Asian.
2. Eyebrow and eyelid ptosis are important factors to be noted in
planning the upper lid blepharoplasty, and their presence or
absence will affect the final procedure of choice.
3. Lateral eyebrow ptosis contributes to lateral upper lid
hooding. The surgeon will meet with unacceptable results
should he or she attempt to correct either one, using the
other.
4. The endogenous or selected position for the upper lid
fold is the first key step in designing an upper lid
blepharoplasty.
5. When planning a brow elevation procedure, the brow should
be digitally suspended prior to delineation of the extent of
upper eyelid skin excision.
6. Iatrogenic injury to the levator aponeurosis can be avoided by
opening the orbital septum as high as possible where the
aponeurosis moves posteriorly.
68
overlying skin. An endogenous lid fold of variable
height, based on ethnic origin and other factors, exists
owing to extensions between the levator aponeurosis
and the dermal surface of the lid (as previously
described). During the blepharoplasty, the surgeon may
choose to either more definitely refine the location of
an existing endogenous lid crease or he or she may
choose to alter its height accordingly. This can be
facilitated by passing sutures from the lower margin of
the skin incision through the levator aponeurosis and
then through the upper margin of the skin incision. The
level at which the levator aponeurosis is engaged will
determine the level of the upper eyelid fold. This
technique is especially useful in creating a lid fold in the
patient with congenital ptosis as well as in the typical
cosmetic patient. I find it to be a necessity in the Asian
patient who desires not to be Occidentalized. I prefer to
use three or four interrupted small absorbable sutures
such as 5-0 or 6-0 Vicryl or chromic catgut sutures to
achieve supertarsal fixation. Cutaneous closure may be
performed as described earlier should these fixation
sutures not be adequate (see Fig. 4-4).
7. Careful skin eversion lateral to the canthus is important to
avoid a depressed incision line.
8. Supratarsal fixation is a potent technique that may be
employed in every upper lid blepharoplasty. It allows the
creation of an upper lid fold based on skin fixation to the
underlying levator aponeurosis.
9. The transconjunctival blepharoplasty and the transcutaneous
blepharoplasty are equally effective in approaching fat but
the former has some shortcomings vis-a-vis the mid face and
in addressing significant skin redundancy.
10. The decision to utilize the transconjunctival versus the
transcutaneous route should be predicated on the amount of
skin redundancy and whether a canthal tightening procedure
is indicated.
11. When fat resection is employed it should be conservative to
avoid a hollowed-out appearance.
12. Skin should be redraped, with the line between the nasojugal
groove and the lateral canthus kept in mind, that is, inducing
a lateral cephalic vector.
 UPPER LID BLEPHAROPLA S T Y

LEVATOR MODIFICATIONS

Orbital septum
and underlying
(preaponeurotic) fat

Levator
aponeurosis

or

Supratarsal
fixation

Levator
plication

A
Figure 4-6 A, Once the upper lid skin is incised or excised, the levator may be modified (shortened/lengthened) without mobilization in a
number of ways. The skin edges may also be incorporated in these modifications so as to accentuate or move a lid crease. These changes may be
performed alone or in combination and may be utilized freely with the standard upper lid blepharoplasty as already depicted (see Figs. 4-4 and
4-5). The orbital septum in the lower two drawings is shown to be intact to render a clear distinction in anatomic structures. Clinically, the
septum may be left intact when the septum fuses with the aponeurosis above the level at which a modification will be performed; however, the
septum may be liberally opened and Whitnall's ligament visualized in all cases. Continued

69
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

B C

D E
Figure 4-6 Continued B, In the upper lid the skin and orbicularis muscle have been removed from the underlying orbital septum. Forceps
provide traction on the septum, demonstrating its rigidity and its insertion onto the bony orbit. The preaponeurotic fat is visible superiorly
beneath the septum. C, Once the septum is incised, free access is gained to the superior orbit. The upper lid is on traction, and the levator
aponeurosis and more superior levator muscle is seen. D, The levator may be modified in a number of ways without complete disinsertion from
the tarsal plate. Several variations include plicating the levator muscle alone, removing a strip and apposing the cut ends, or plicating and
removing the excess levator above the suture line. Here a strip of levator is removed. The underlying cornea is visible through conjunctiva and
Müller’s muscle. The suture is placed through the two cut ends and left loose for demonstration purposes before being tied down. E, Supratarsal
fixation is a powerful tool for creating, preserving, or altering the height of the upper lid fold. I prefer to use a small absorbable suture. Here the
suture is passed from the lower skin margin, through the levator aponeurosis, and then through the upper skin margin. Once tied down, the two
skin edges are apposed at the desired level onto the levator aponeurosis, thereby simulating the normal mechanism for eyelid crease formation.

70

References
Berman M: Rejuvenation of the upper eyelid complex with
autologous fat transplantation. Dermatol Surg 26:1113-
1116, 2000.
Castro E, Foster JA: Upper lid blepharoplasty. Facial Plast Surg
15:173-181, 1999.
Friedland JA, Jacobsen WM, Terkonda S: Safety and efficacy of
combined upper blepharoplasties and open coronal
browlift: A consecutive series of 600 patients. Aesthetic Plast
Surg 20:453-462, 1996.
Guyuron B, Knize DM: Corrugator supercilii resection
through blepharoplasty incision. Plastic Reconstr Surg
107:606-607, 2001.
Lee Y, Lee E, Park WJ: Anchor epicanthoplasty combined with
out-fold type double eyelidplasty for Asians: Do we have to
make an additional scar to correct the Asian epicanthal
fold? Plast Reconstr Surg 105:1872-1880, 2000.
UPPER LID BLEPHAROPLA S T Y
Januszkiewicz JS, Nahai F, Zarem HA: Transconjunctival upper
blepharoplasty. Plast Reconstr Surg 103:1015-1019, 1999.
Kim JW, Lee JO: Asian blepharoplasty with a short-pulsed
contract Nd-YAG laser: Limited-incision resectable laser
double fold with internal medial and lateral functional
epicanthoplasty. Aesthetic Plast Surg 22:433-438, 1998.
Lee Y, Kwon S, Hwang K: Correction of sunken and/or
multiply folded upper eyelid by fascia-fat graft. Plast
Reconstr Surg 107:15-19, 2001.
Lee Y, Lee E, Park WJ: Anchor epicanthoplasty combined with
out-fold type double eyelidplasty for Asians: Do we have to
make an additional scar to correct the Asian epicanthal
fold? Plast Reconstr Surg 105:1872-1880, 2000.
Ullmann Y, Levi Y, Ben-Izhak O, et al: The surgical anatomy of
the fat in the upper eyelid medial compartment. Plast
Reconstr Surg 99:658-661, 1997.
Weber PJ, Wulc AE, Foster J: Transconjunctival upper
blepharoplasty. Plast Reconstr Surg 104:2333-2334, 1999.
71

Lower Lid Blepharoplasty
The lower lid blepharoplasty has been viewed by many,
especially the less experienced, as being technically
more difficult to perform than the upper lid blepharo-
plasty. The perception of difficulty likely lies more in
the numerous decision-making processes the surgeon
and patient are forced to undergo to achieve a satis-
factory lower lid result. Once evaluation of the patient
is complete, the surgeon has many more choices as to
how to approach the lower lid blepharoplasty and less
margin for error. In examining the patient, the surgeon
is faced with concerns over such things as the degree of
horizontal lid laxity, position of the lateral and medial
canthal angles, conditions such as scleral show, entro-
pion and ectropion, or other underlying pathologic
processes. As in the case of the upper eyelid, the surgeon
should obtain a thorough history. I find it is always
helpful to have the patient look in a mirror and delin-
eate, articulate, and specifically demonstrate what are
his or her cosmetic concerns. Then the surgeon has a
plethora of procedures available with which to address
these concerns. These include whether to perform a
transcutaneous or transconjunctival approach, whether
to perform a canthal procedure such as a tarsal tuck or
tarsal strip procedure, or even whether to reposition the
entire lateral canthus (common canthoplasty). Deci-
sions as to how to address skin and/or fat are equally
numerous. The surgeon is faced with whether to address
the skin and, if so, whether to perform a skin trim pro-
cedure, laser resurface the skin, or address the skin
element in some other fashion. Fat can be addressed
with resection, redistribution, or both. An appreciation
of midface position is as important in lower lid ble-
pharoplasty as is appreciation of brow position in upper
lid blepharoplasty. Here with regard to the mid face, the
surgeon has a choice as to whether he or she wishes to
address it at all, whether to approach it by way of the
72
CHAPTER FIVE
lateral extent of the upper or lower lid incision, or
whether to approach it by means of a preauricular
facelift incision. Of course, the approach depends on
the underlying pathologic process and what the patient
and surgeon perceive as the underlying cosmetic and/or
functional abnormality. The surgeon should be familiar
and well versed and comfortable with all techniques
and approaches to the lower eyelid and attempt to
adjust the operation to the patient and not the other
way around.
TRANSCUTANEOUS LOWER LID
BLEPHAROPLASTY
The transcutaneous lower lid blepharoplasty is a
powerful technique for addressing lower lid cosmetic
abnormalities. It allows a number of adjuvant proce-
dures to be performed easily and more accurately than
the transconjunctival route. Its disadvantages include
greater technical demands, more time, more extensive
dissection, and, hence, greater secondary fibrosis; and
it has an inherently greater margin for error (i.e., over-
resection or changes in forces on the lower lid engen-
dering scleral show and/or ectropion). It is, however,
more powerful in that one can address fat alone (resect
or redistribute), address skin and/or muscle separately,
and approach lower lid tightening by way of a direct
approach to the lateral lower lid tarsus or inferior crus
of the lateral canthal tendon.
Although there have been descriptions of the use of
cutaneous flaps as an approach to fine skin rhytids of
 LO W E R L I D B L E P H A R O P L A S T Y

the lower eyelid, I do not recommend them. These were
originally described as a means of addressing fine
rhytids separately from other more gross irregularities.
The lower eyelid skin is extremely thin, and any attempt
to raise a skin flap independently of the underlying
orbicularis muscle likely leads to a poorly vascularized
cutaneous segment that is prone to secondary con-
tracture and other complications. In distinction, the
myocutaneous flap is extremely hardy and, given the
number of other modalities available to the surgeon
today for addressing fine rhytids of the lower eyelid, the
argument for a cutaneous flap independently of the
muscle segment, in my opinion, is tenuous. The deci-
sion to use the transcutaneous route versus a trans-
conjunctival route should be predicated on the amount
of skin redundancy and whether a canthal tightening
procedure is indicated. The transcutaneous or trans-
conjunctival routes are equally effective in addressing
fat (resection and/or redistribution). Should one wish
to address the mid face (cheek suspension), then an
access incision either by way of the lateral lower eyelid,
lateral upper eyelid, or facelift approach is usually
necessary. The transconjunctival route alone does not in
general provide adequate exposure to the mid face and
does not allow appropriate cephalic and lateral eleva-
tion of the cheek unit. It may, however, be used to subtly
elevate the medial cheek at the nasolabial junction.
Midface access by way of a preauricular or lateral upper
eyelid incision may force the surgeon to perform a
second lower eyelid transcutaneous incision should he
or she wish to achieve anything more than a canthopexy
or common canthoplasty to the lower eyelid (Fig. 5-1).
The lower eyelid may be delineated for blepharo-
plasty by drawing an incision line extending from the
lateral canthus posteriorly in a natural skinfold. This is
usually subtly declined inferiorly to appear more
natural and avoid encroaching on the upper lid. As in
the upper lid blepharoplasty, one would prefer to mini-
mize the lateral extent of the incision line, and I choose
to make a limited incision that is extended if necessary
for skin and muscle redraping and/or suspension. The
incision line will extend medial to the lateral canthus in
a natural fold below the lower eyelid. One would prefer
to leave a cuff of pretarsal orbicularis below the lash
margin, which is theoretically responsible for eyelash
orientation (Riolan's muscle).

A B
Figure 5-1 A and B, The patient who has midface ptosis along with significant lower lid dermatochalasis that is not correctable with a canthal
elevation procedure and/or laser alone is one in whom the surgeon should perform a transcutaneous lower lid blepharoplasty in conjunction
with the midface suspension. Here is a patient who has facial ptosis, good lower eyelid position, significant dermatochalasis of the eyelids, and
brow ptosis. The lower eyelid skin redundancy will not respond to lateral canthal elevation alone, and when the mid face is suspended, the
redundancy will be exacerbated. In this case a reasonable choice would be to elevate the mid face either with a preauricular facialplasty
approach or through the lateral upper eyelid. The lower eyelid may then be addressed with a transcutaneous blepharoplasty to adequately
redrape the lower lid skin.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
Local anesthetic of choice (lidocaine with epinephrine)
is infiltrated, and adequate time for hemostasis is
allowed to elapse. An incision is made in the lateral
extent of the delineated incision through skin and
orbicularis muscle. A curved sharp tenotomy or Steven’s
scissor is inserted in the postorbicularis/preseptal plane.
This is the potential space just anterior to the orbital
septum, which has been described in Chapter 1 (see
Fig. 1-2). As one enters the potential space from lateral
to medially, the scissor is opened gently and a true space
is developed extending from the preseptal to the pre-
tarsal suborbicularis regions. The scissor is withdrawn
and a fine small sharp scissor (iris scissor) is reinserted
with one limb of the scissor in the incision and the
other overlying the skin of the lower lid. The marginal
aspect of the incision is then made just below the lash
line margin of the lid with the scissor beveled inferiorly
(lower limb inferior) (Fig. 5-2). The incision should
extend up to a point lateral to the medial punctum. The
lower eyelid is then placed on cephalic traction with an
eyelid hook, and with countertraction on the skin
muscle flap the myocutaneous flap is elevated to the
level of the orbital rim inferiorly. I recommend that the
lower eyelid hook be placed on the conjunctival side of
the lower eyelid so as to avoid corneal or eyeball injury
should one choose not to use a protective eye shield
or contact lens. Once the myocutaneous flap is elevated
to the orbital rim, the orbital septum will be easily
visualized and may be incised to address orbital fat
when appropriate.
I prefer to incise the orbital septum and visualize all
three fat pads along with the inferior oblique muscle.
The fat may then be resected, preferably with a needle
cautery technique. In resecting lower lid fat, conser-
vation is strongly recommended, because overresection
usually leads to a concavity or “sickly appearance” to
the lower lid and inferior orbital region. Fat redis-
tribution techniques may be used alone or in com-
bination with fat resection depending on which
compartment is thought to be prominent or deficient.
In general, in approaching resection only, only fat that
spontaneously herniates with light digital pressure to
the globe should be removed and the amputation point
should not extend within the orbital rim. Special care
should be taken to directly observe the lateral fat
compartment because this is most frequently missed or
inappropriately treated (see Fig. 5-2).
Once fat has been addressed and the surgeon sus-
pends the lower lid and/or mid face if appropriate, then
74
the skin muscle flap is redraped and adjusted. Every
attempt should be made to elevate the skin muscle flap
cephalad and laterally so as to create a vector force that
runs superiorly from the nasojugal groove through the
lateral canthal area. This orientation is important in
eliminating the line of force that links the lower eyelid
directly to the malar tissue in one plane. This technique,
however, may be slightly less advantageous in elimi-
nating lower eyelid skin rhytids. The flap may be back-
cut at the point of insertion to the lateral canthal region,
and skin may be trimmed from lateral to medial as a
tapered wedge so that very little, if any, skin is resected
from the level of the pupillary axis to the medial can-
thus. The area of skin muscle flap that lies lateral to the
lateral canthus can be appropriately resected without
tension with the possibility of extending the incision
line temporarily depending on the amount of redun-
dancy or dog-ear created. A separate closure of the
muscular layer may be performed when a larger amount
of myocutaneous resection is employed.
A single absorbable suture through the orbicularis
muscle that engenders cephalic lateral suspension
forces can be useful in not only eliminating or reducing
tension on the skin closure but also further supporting
the lower lid against distraction forces. This is especially
useful when one performs a formal lower lid tightening
procedure whether it be a tarsal tuck, tarsal strip, or
other canthopexy procedure. In fact, muscular suspen-
sion should be viewed as the simplest but least effective
method of increasing lower lid support. Orbicularis
repair may be achieved with a small (5-0) absorbable
suture (i.e., Vicryl). Before skin closure one may con-
sider resecting a small cuff (2 to 3 mm) of orbicularis
muscle from the undersurface of the myocutaneous flap
extending from the lateral canthal region medially.
Although this usually creates an annoying hemostasis
problem near the end of the procedure, it is useful in
eliminating or avoiding orbicularis bulge inferior to the
lid margin, which in many patients is noted as a
preoperative cosmetic concern.
Finally, skin closure is performed and I prefer to
utilize a running 6-0 silk suture from medial to the
lateral canthus and interrupted 6-0 nylon sutures lateral
to that. Only the nylon sutures are tied down (see
Fig. 5-2). This enables the silk to be easily removed early
in the postoperative period, that is, 3 to 5 days.
 LO W E R L I D B L E P H A R O P L A S T Y

LOWER LID BLEPHAROPLASTY (TRANSCUTANEOUS)

A Primary incision

B Undermining in the preseptal sub-orbicularis potential space

Orbicularis
muscle

C Secondary incision

Orbital
septum

Figure 5-2 As with the upper lid, the successful completion of the lower lid blepharoplasty requires a few technical steps that will simplify and
speed its execution. The anatomy of the lower eyelid can be advantageous to the surgeon in properly performing these steps. A, The primary
incision should be in a desired fold or potential fold at and lateral to the lateral canthus. The incision should be limited but be able to admit a
small curved scissor. The scissor should be passed through the incision into the suborbicularis preseptal space. B, This plane is developed from
lateral to medial while gently pushing and spreading the scissor. Once this plane is developed, the myocutaneous flap can be mobilized with
ease. The scissors are withdrawn and only one limb is inserted into the preseptal postorbicularis plane, with the other over the skin surface. The
scissors may be beveled toward the eyeball (less skin, more muscle). C, The second incision is completed lateral to medial with the assistance of
inferior digital traction, ending just lateral to the lower lid punctum. The flap should be mobilized to the orbital rim without violating the
septum. This is best achieved with a combination of digital cheek traction inferiorly and instrument elevation of the myocutaneous flap.
Continued

75
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Lower lid, retracted superiorly (conjunctival surface)

D Incised orbital septum

Orbital rim

Medial fat pad

E Remove medial and
central fat pads

Central fat pad

Inferior oblique
muscle

F Pressure on upper lid

causes lateral orbital fat pad
to bulge anteriorly

Lateral fat pad

Orbital rim

Figure 5-2 Continued D, The septum may then be opened either widely or with stab incisions. E, In
either case the inferior oblique muscle should be visualized and protected. I usually identify the oblique
muscle before resection or repositioning fat. The muscle is most anterior medially, adjacent to the medial
fat pad, and this is the best place to identify it using an instrument to spread or probe while
concomitantly applying light digital pressure. F, Remember overresection of fat, especially the lateral
compartment, can lead to less than acceptable cosmetic results. Skin resection should be conservative
and invoke lateral and cephalic vectors. Continued

76
 LO W E R L I D B L E P H A R O P L A S T Y

Patient looks up with mouth open for skin

redraping and excision

G Redrape skin (cephalic

and lateral) and trim excess

Line of excision

H Closure including interrupted sutures

laterally and running suture medial
to lateral

Figure 5-2 Continued G, This will render the most tension under the canthus and the least distraction
force in the mid lower lid. I find it helpful to have the patient look up and open his or her mouth to add
conservation to the skin excision step (inset). Before closure, it is sometimes helpful to resect a few
millimeters of orbicularis muscle at the superior aspect of the flap. This does not affect function and
avoids the annoying post-blepharoplasty bulge or roll. H, Closure is completed after hemostasis is
controlled. I prefer running 6-0 silk medially and interrupted nylon laterally.

77
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

A B

C D
Figure 5-3 The transcutaneous blepharoplasty can be a powerful technique yet easily executed, provided a few points are kept in mind. The
only incision line I design is the lateral extent beyond the canthus. This is usually inferiorly declined and mirrors an existing skin crease. In the
more youthful patient, the incision may only extend a few millimeters lateral to the canthus; and in the older patient, one may extend it much
farther. A, The myocutaneous flap is developed first with an incision lateral to the lash line. Curved Stevens’ scissors are introduced, and the
preseptal postorbicularis plane is developed to a point just short of the punctum. The scissors are withdrawn and one blade reintroduced and
the cut made with a bevel, leaving orbicularis muscle on the lid. The myocutaneous flap is then developed to the orbital rim margin. The trick
here is to provide superior lid traction with a small hook. I prefer to place this on the conjunctival side of the eyelid. Countertraction should be
provided with an insulated Desmarres retractor after digital traction is first used. In this photograph one can see the developed myocutaneous
flap to the inferior orbital margin. The lower lid is placed on superior traction, and the orbital septum is left intact. B, Orbital fat is visible
through the thinned septum just above the orbital rim. Note orbicularis muscle left on the superior lid margin (below the superior traction
hook). The mid face may be approached through this route using the inferior orbital rim as an anatomic point of dissection and fixation. The
orbital septum may be incised and fat addressed. C, A lateral oblique view of the dissection shows how wide exposure can be gained with
appropriate traction. The inferior lid retractors are pulled superiorly and indented by scissors. The open edge of the septum is pulled with medial
orbital fat anteriorly. Just to the lower left of this retracted fat the inferior oblique muscle is visualized. D, Orbit fat may be repositioned
throughout or in selected pockets and combined with resection techniques depending on the needs of a patient. In this patient the lateral fat
pad was deficient and there was early midface ptosis, which the patient did not want to address. This caused a concavity in the lateral inferior
lower eyelid/orbital rim junction, with the rim visible in relief. The lateral fat pad was advanced onto the orbital rim.

78

Various techniques to assist the surgeon in avoiding
overexcision of skin have been described, and these may
be useful but not entirely dependable. The amount of
skin resected and the degree of cephalic lateral sus-
pension should be judged on the patient's history,
physical examination, and appearance. That is, most of
the decision making is made preoperatively. In patients
who have minimal tolerance for overresection based on
these parameters, one might want to evoke distraction
tests, such as forcibly opening the patient's mouth
and/or have the patient look up, before finally
trimming the skin muscle flap (see Figs. 5-2 and 5-3).
References
Alster TS, Lupton JR: An overview of cutaneous laser
resurfacing. Clin Plast Surg 28:37-52, 2001.
Bernardi C, Dura S, Amata PL: Treatment of orbicularis oculi
muscle hypertrophy in lower lid blepharoplasty. Aesthetic
Plast Surg 22:349-351, 1998.
Castro E, Foster JA: Upper lid blepharoplasty. Facial Plast Surg
15:173-181, 1999.
LO W E R L I D B L E P H A R O P L A S T Y
P E A R LS A N D P I T FA L LS
1. The key anatomic plane in any of the techniques for lower
lid blepharoplasty is the preaponeurotic post-orbicularis
space.
2. Orbicularis muscle (i.e., orbicularis muscle at the lid
margin) should be preserved when raising a skin muscle
flap.
3. Orbicularis muscle suspension through the transcutaneous
access route is the simplest but least effective method of
increasing lower lid support.
Codner MA: Reduction of lower palpebral bulge by plicating
attenuated orbital septa: A technical modification in
cosmetic blepharoplasty. Plast Reconstr Surg 105:2559-
2560, 2000.
Mommaerts MY, DeRiu G: Prevention of lid retraction after
lower lid blepharoplasties: An overview. J Cranio-
maxillofacial Surg 28:189-200, 2000.
Nguyen XC: Guidelines to avoid lid retraction following lower
transcutaneous blepharoplasty. Int J Cosmetic Surg
Aesthetic Dermatol 2:231-233, 2000.
79

Transconjunctival Lower
Lid Blepharoplasty
The ideal candidate for a transconjunctival lower lid
blepharoplasty is the youthful patient who has no or
only a small amount of skin redundancy but has promi-
nent orbital fat pads that are of concern to the patient.
These patients may also have depressions in the naso-
jugal and/or lateral orbital rim region that one may
want to address with orbital fat repositioning or
redraping. Patients in this category who have mild skin
rhytids, pigmentary disturbances, or other irregularities
may have these addressed by means of a simple skin
excision at the lid margin with cephalic lateral redraping
or by laser resurfacing techniques, and so on. The other
category of patients in whom the transconjunctival
route is most useful is the older individual who is
usually thin, has minimal skin redundancy with or
without fine rhytids, and does not have lower eyelid
malposition and/or lower lid laxity that can be ad-
dressed with a common canthoplasty through the
upper eyelid. These patients may or may not be under-
going other procedures, such as a facelift. Less time and
fewer risks are involved in the transconjunctival
approach to the fat pads, and again the fine rhytids may
be addressed with either a marginal skin trim or a laser
procedure. The surgeon should appreciate the relatively
increased efficacy of the transconjunctival route in the
younger individual versus the older patient. The
convexity of the lower eyelid produced by herniated
80
CHAPTER SIX
orbital fat in the younger individual is converted to a
coplanar or slightly concave lower eyelid more easily
than in an older individual. This is likely due to greater
skin elasticity in the younger versus older patient.
Therefore, when utilizing the transconjunctival route in
older individuals, the surgeon should expect less effect
on the skin and one should readily entertain procedures
for addressing skin redundancy to achieve optimal
aesthetic results (Figs. 6-1 and 6-2). These techniques
for the treatment of skin rhytids or mild redundancy
can include a simple rhytidectomy with orbicularis sus-
pension without raising a cutaneous or myocutaneous
flap. The technique is similar to that initially used in
the full transcutaneous blepharoplasty (see Fig. 5-2).
Lateral cephalic resection and suspension are the key
elements in this technique. I use muscular suspension
with 5-0 Vicryl and cutaneous repair with 6-0 nylon
and silk.
This technique can be employed in combination with
a facialplasty or midface, transconjunctival, or any other
procedure. I have used it frequently to supplant lower
lid laser procedures, especially in those patients who are
not candidates or are unwilling to undergo lower lid
laser resurfacing procedures. I find this approach to be
more powerful and associated with fewer complications
than aggressive laser techniques.
 T R A N S C O N J U N C T I VA L LO W E R L I D B L E P H A R O P L A S T Y

RHYTIDECTOMY – LOWER LID

E
Figure 6-1 Rhytidectomy of the lower lid may be achieved without raising a cutaneous or
myocutaneous flap. A, An incision is first placed in a lateral fold or potential fold. B, The incision is
completed lateral to medial, and I prefer to develop the inferior aspect of the pretarsal postorbicularis
in continuity with the superior aspect of the preseptal space. C, Lateral and cephalic traction is applied
to the orbicularis muscle near its raphe, and a wedge resection is performed. D, The cut edges of the
muscle are approximated with sutures. E, Skin is separately addressed, again invoking the lateral and
superior vectors as shown previously.

81
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

A
Figure 6-2 A, The ideal candidate for transconjunctival blepharoplasty is the youthful person without midface ptosis; and, therefore, the
orbital rim is not visualized in relief. The orbital septum is convex, but there is not sufficient skin redundancy to require skin redraping. Small
skin changes may be involved with a trim or laser. A 38-year-old woman presented with upper and lower lid age-related changes. Her mid face is
in relatively good position, and the lower lid skin changes are subtle enough not to require a major redraping. She underwent a conservative
transconjunctival blepharoplasty and erbium laser procedure of her lower lids. A standard upper lid blepharoplasty was performed
(preoperative view—left; postoperative view at 1 year—right). Continued

82
 T R A N S C O N J U N C T I VA L LO W E R L I D B L E P H A R O P L A S T Y

C
Figure 6-2 Continued B, A younger woman presented with herniated fat and Graves' disease. She had no appreciable midface ptosis but a
prominent convexity to her lower lids with skin changes. She underwent a lower transconjunctival blepharoplasty without any skin procedures
(i.e., laser, trim) and an upper lid blepharoplasty (preoperative view—left; postoperative view—right). C, This is in distinction to the case in
which there is a convexity to the orbital septum but with significant rhytids and redundancy of the lower lid skin. This is usually associated with
some degree of midface ptosis. Although fat may be removed or repositioned in these cases by the transconjunctival route, the skin and muscle
are in need of redraping and positional reorientation (lateral cephalic vector) especially when the midface unit is suspended (preoperative
view—left; postoperative view—right).

83
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
SURGICAL TECHNIQUE
The well-executed transconjunctival blepharoplasty, like
the transcutaneous lower lid blepharoplasty, requires a
few key steps that are predicated on anatomic points
already discussed. The procedure does not require de-
lineated surgical markings.
Once the patient is appropriately sedated, topical
anesthetic (tetracaine) may be instilled into the
conjunctival sac. A protective contact lens may then be
placed, or the surgeon may choose to use an autologous
contact lens created by the elevated conjunctival flap. In
the latter case, care must be taken at the initial part of
the procedure to protect the cornea and eyeball during
local anesthesia infiltration and the initial dissection.
Local anesthetic of choice containing epinephrine
may be infiltrated with a small needle (27 to 30 gauge)
preferably by way of the transconjunctival route with
the lower lid either everted with slight digital pressure
placed on the inferior tarsus or with light traction with
an instrument such as a Desmarres retractor.
Once adequate time for hemostasis is allowed to
elapse, the conjunctiva and lower lid retractors are
grasped near the central cul-de-sac or fornix with a
tooth forceps and engaged with a traction suture. I
prefer to use a 5-0 fast absorbing catgut suture that will
be recycled for conjunctival closure at the end of the
84
procedure. The lower lid is everted with a small eyelid
hook, and a transconjunctival incision is made just
below the tarsal plate with the conjunctiva and lower lid
placed on cephalic traction. I prefer to use a needle
cautery throughout this procedure and do not use
scissors or scalpels.
Once the lower lid retractors are disinserted from the
tarsal plate, the eyelid hook is removed and a Desmarres
retractor inserted to engage the lower edge of the tarsal
plate. I prefer an insulated or plastic instrument to dimi-
nish the possibility of cautery burn injuries. Traction is
placed cephalad and anteriorly, and dissection is carried
out in front of the orbital septum, in the preseptal post-
orbicularis plane, down to the orbital rim. This is exact-
ly the plane that is developed in the transcutaneous
blepharoplasty, but it is accessed differently. At this
juncture, the surgeon should be able to visualize an
intact orbital septum, orbital rim, and suborbital tis-
sues, including the malar fat pad, and so on. Dissection
may be carried out inferiorly either in a supraperiosteal
or subperiosteal plane should the surgeon desire to
execute other adjuvant procedures or effect change in
other areas of the face.
The orbital septum may then be incised by a wide
transverse midseptal incision, or three distinct openings
in the orbital septum may be created to access
underlying fat compartments (Fig. 6-3). In either case,
the inferior oblique muscle should be visualized

and protected, lying between the medial and central
fat pads.
A total transverse septal incision is preferred,
especially in fat redraping, to avoid tethering or
strangulation of the fat pedicle through a narrowed
orbital septal opening. In fat resection, conservative
resection of spontaneously herniated tissue is most
appropriate, and, again, special attention should be
directed toward the lateral fat compartment, which is
usually under or inappropriately addressed. These are
concepts that are shared with the transcutaneous route
and have already been described.
Hemostasis is usually spontaneous and complete
when this procedure is executed appropriately. Closure
requires only cutting the traction suture and allowing
the conjunctival flap, which was cephalically draped
over the cornea or contact lens surface, to spontane-
ously retract. The conjunctiva may then be apposed
with a single interrupted small absorbable suture (5-0
fast absorbing catgut suture) lateral to the corneal sur-
face (Fig. 6-4). Care should be taken to engage only the
conjunctiva and not the underlying Tenon capsule,
because this may lead to postoperative pyogenic
granulomas. I prefer to approximate the conjunctiva
because this eliminates Tenon cysts or pyogenic
granulomas in my hands. The surgeon may then initiate
T R A N S C O N J U N C T I VA L LO W E R L I D B L E P H A R O P L A S T Y
a skin tightening procedure such as laser or marginal
skin trim.
I find it advantageous to use a topical antibiotic
drop containing a corticosteroid (e.g., Tobra-
Dex [dexamethasone/tobramycin/chlorobutanol] or
Blephamide [prednisolone/sulfacetamide]) in the
postoperative period when not contraindicated by
corticosteroid-responsive glaucoma or other conditions.
Low-dose corticosteroid-containing drops and oint-
ments tend to lessen the postoperative chemosis or
conjunctival edema and appear to shorten the recovery
process.
P E A R LS A N D P I T FA L LS
1. A cephalic traction suture on the conjunctiva allows easy
access to the post-orbicularis space.
2. The orbital septum should be visualized to the orbital rim
and the inferior oblique muscle should be seen and
preserved after the septum is incised.
3. Access to the lower fat pads requires disinsertion of the
lower lid retractors.
4. Steroid-containing eyedrops postoperatively can be useful
in lessening chemosis.
5. Topical steroids can raise intraocular pressure significantly.
Lower concentrations (0.1%) of fluorinated preparations
(i.e., FML) are least likely to do so.
85
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

TRANSCONJUNCTIVAL SURGICAL APPROACHES

Retroseptal Approach
Preseptal (suborbicularis) Approach

Nonconductive retractor

A Conjunctiva is tented Nasal

and secured with a
stay suture

B Conjunctiva is divided
longitudinally just
below tarsal plate Orbital septum

Inferior
tarsal plate

Figure 6-3 The transconjunctival approach to the retroseptal space may be in one of two ways: preseptal or retroseptal (top). By far the most
controlled and anatomically consistent is the preseptal route. In either case an insulated retractor (e.g., Desmarres) is extremely useful. The
retroseptal route entails simply incising the conjunctiva and cutting through the lower lid retractors into the postseptal space (dotted lines). The
preseptal route requires entry into the postorbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum. This
will allow direct visualization of the septum, and each fat pad can be addressed separately in a controlled fashion. To expediently achieve this,
a few simple steps are necessary. A protective lens may be used. A, A conjunctival stay suture is placed deep in the fornix and traction is applied
superiorly while the lid margin is everted. This causes the inferior edge of the tarsal plate to rise toward the surgeon. B, The conjunctiva and
lower lid retractors are incised just below the tarsal plate entering the postorbicularis preseptal space. This plane is developed to the orbital rim
with the assistance of the traction suture and a nonconductive instrument. Continued

86
 T R A N S C O N J U N C T I VA L LO W E R L I D B L E P H A R O P L A S T Y

Inferior
oblique muscle Conjunctiva
retracted superiorly

Nasal

C Orbital septum
opened

Lateral, central and

medial fat pads
(left to right)

D1 Remove fat pads D2 Reposition fat pads

if they bulge transconjunctivally

E One internal suture

in conjunctiva
lateral to cornea

Figure 6-3 Continued C, The orbital septum may then be widely incised or punctured and the inferior oblique muscle identified and preserved.
D1 and D2, The fat pads may be addressed individually in keeping with preoperative plans with either resection, repositioning, conservation,
or any combination of these techniques. In repositioning, I prefer a supraperiosteal tunnel with a temporary transcutaneous stay suture to
maintain the proper location. E, A single absorbable closure suture is useful in avoiding Tenon inclusion cysts. It should be placed laterally to
avoid postoperative complaints of corneal irritation.

87
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

A B
Figure 6-4 The surgical sequence for transconjunctival access to the retroseptal space requires appropriate traction and exposure and can be
applied for fat resection, repositioning, and in medial midface exposure. The technique is also useful for bone exposure in trauma and/or elective
osteotomies. When the procedure is properly executed, the preseptal postorbicularis plane may be rapidly exposed to the orbital rim and the
surgeon may then perform whatever procedure is deemed necessary. A, Lid eversion with wand traction using a small hook (I prefer double to
avoid traction injury to the lid margin) allows exposure of the conjunctival fornix. A traction suture is placed here (plain gut). B, Needle-tip
cautery is used to dissect the preseptal postorbicularis plane down to the orbital rim. Note: the orbital septum is left intact with fat pads
visualized. Continued

88
 T R A N S C O N J U N C T I VA L LO W E R L I D B L E P H A R O P L A S T Y

C D

E
Figure 6-4 Continued C, The orbital septum may then be selectively incised and fat addressed, or the orbital rim may serve as a juncture point
for midface adjustments. Here the medial fat pad is delineated by a curved hemostat. The fat pad is seen lying on the insulated retractor as it is
teased anteriorly. This may be used for redraping in a fat preservation procedure. D, The inferior oblique muscle should be identified and
preserved as it divides the medial from the central fat pads. E, Conjunctiva is closed with a single interrupted plain gut suture placed lateral to
the cornea. Skin may be addressed with a rhytidectomy or other procedure (see Fig. 6-1).

References

Eremia S, Newman N: Use of an insulated ultrafine-point
electrocautery for transconjunctival blepharoplasty of the
lower eyelids. Dermatol Surg 27:1052-1054, 2001.
Ghabrial R, Lisman RD, Kane MA, et al: Diplopia following
transconjunctival blepharoplasty. Plast Reconstr Surg
102:1219-1225, 1998.
Kavouni A, Stanek JJ: Lower eyelid cysts following trans-
conjunctival blepharoplasty. Plast Reconstr Surg 109:400-
401, 2002.
Seckel BR, Kovanda CJ, Cetrulo CL Jr, et al: Laser blepharo-
plasty with transconjunctival orbicularis muscle/septum
tightening and periocular skin resurfacing: A safe and
advantageous technique. Plast Reconstr Surg 106:1127-1141,
2000.
Zarem HA, Resnick JI, Stuzin JM: Expanded applications for
transconjunctival lower lid blepharoplasty. Plast Reconstr
Surg 103:1041-1045, 1999.

89

Tarsal Tuck and Fat
Redistribution
As mentioned in Chapter 3, horizontal laxity of the
lower eyelid may be addressed with plication of the
lateral tarsus or the lateral canthal tendinous complex.
This is best approached by means of a transcutaneous
approach and is only useful in addressing milder
degrees of lower lid laxity. In addition to this limitation,
it can produce canthal rounding and anterior displace-
ment of the commissure and lateral lower eyelid, unless
stable fixation to orbital periosteum is achieved. Distri-
bution of the lower lid redundancy against a fixed upper
lid and canthus becomes difficult and tedious. There-
fore, it is only useful in mild degrees of laxity and
should be considered in the same category as any pro-
cedure that does not mobilize the lateral canthus, such
as cephalic lateral orbicularis suspension or trans-
blepharoplasty canthal suspension (canthopexy) with-
out lysis and mobilization of the lateral retinaculum
(see Fig. 3-8).
Fat redistribution is a more useful adjuvant procedure
in blepharoplasty. This is a powerful technique that
addresses the atrophy and ptosis associated with age-
related changes or senescence along the orbital malar
junction. Specifically, the malar fat pad becomes ptotic
and there is an associated fat atrophy with nasojugal
and orbital malar depressions (medial and lateral),
resulting in prominence of the orbital rim and visuali-
zation of that structure in relief. Although there is
associated pseudoherniation of orbital fat owing to
septal laxity, simply resecting orbital fat only serves to
further accentuate the orbital malar discrepancy instead
of rejuvenating the patient's appearance. Some younger
individuals present with accentuated atrophy along the
orbital malar and nasojugal region without significant
orbital fat prominence. These persons have early cheek
ptosis and are not yet candidates for midface elevation
by facialplasty or other routes, but they may be good
candidates for orbital fat repositioning (Fig. 7-1).
90
CHAPTER SEVEN
ORBITAL FAT REPOSITIONING
TECHNIQUE
Orbital fat repositioning requires atraumatic anterior
translocation of postseptal orbital fat. Orbital fat is
accessed by either the transcutaneous or the transcon-
junctival route, depending on predetermined factors.
Once the orbital septum and orbital rim margin is
exposed, supraperiosteal dissection is carried out over
the areas for fat deposition. These areas should be de-
lineated with a surgical marking pen while the patient is
awake and standing or sitting. Once the orbital rim is
exposed, limited soft tissue exposure is preferred so as
not to further destabilize malar support and warrant
formal suspension. Suborbicularis, subcutaneous, or
supraperiosteal dissection is carried out by creating a
tunnel with a small scissor or hemostat. The tunnel and
pocket that is created should be limited only to the
extent of fat that must be passed and the defect that one
intends to fill. I prefer the plane of dissection to convert
from suborbicularis to supraperiosteal at the arcus
marginalis. The septal opening and tunnel should be of
adequate size to obviate ischemic necrosis. The orbital
fat is teased from its respective compartment (usually
the medial and lateral) and by means of a transcutane-
ous suture engaged and fixed into position. I prefer to
place the transcutaneous suture through the skin into
the dissection plane where the orbital fat is dissected,
engage the desired fat for repositioning, and then pass
the suture back through the cutaneous surface to be
loosely tied. This technique is similar to cutaneously
fixing cartilage grafts, and so on, onto the dorsal nasal
surface. The temporary suture is left in place approxi-
mately 1 week and then removed. Alternatively, the fat
may be fixed to the orbital or malar periosteal surface;
 TA R S A L T U C K A N D FA T R E D I S T R I B U T I O N

B
Figure 7-1 A, A 39-year-old woman presented with complaints of lower lid cheek junction
depressions (nasojugal, orbital malar). She also complained of lower lid darkness or
pigment. She does not have significant orbital fat prominence. B, Appearance 1 year post-
operatively after orbital fat repositioning over the orbital rim by way of a transconjunctival
route and erbium laser treatment. Note the subtle improvement in depressions and
decreased pigment to the lower eyelid. The inferior orbital rim is less visualized in relief.

however, more extensive soft tissue dissection is usually
necessary and exact positioning of the fat within the
area of intended filling is less optimal. Fat may be redis-
tributed in one compartment and selectively removed
in another in any combination deemed appropriate for
each patient. The incisions are closed as described in
Chapter 5. Skin may be addressed with either a margi-
nal trim or laser procedure, which is another reason for
limiting the extent of subcutaneous tunneling or
dissection (i.e., devascularization and compromise)
(see Fig. 3-8).

P E A R LS A N D P I T FA L LS
1. The tarsal tuck procedure is only useful in mild lid
redundancy and can produce a buckled lower lid. It is,
however, readily accessible as a procedure in lower lid
transcutaneous blepharoplasty.
2. Orbital fat repositioning can be useful in addressing
depressions along the orbit–mid face junction; however,
there are volumetric limitations.
3. Various planes for fat repositioning may be chosen, but I
prefer the suborbicularis to the supraperiosteal plane,
converting at the arcus marginalis.
4. The septal opening and tunnel need to be large enough to
obviate ischemic necrosis.
References
Anderson RL, Jordan DR: The tarsal tuck procedure: Avoiding
eyelid retraction after lower blepharoplasty. Plast Reconstr
Surg 104:284-285; discussion 286, 1999.
Coleman SR: Structural fat grafts: The ideal filler? Clin Plast
Surg 28:111-119, 2001.
Goldberg RA: Transconjunctival orbital fat repositioning:
Transposition of orbital fat pedicles into subperiosteal
pocket. Plast Reconstr Surg 105:743-748; discussion 749-
751, 2000.
Turk JB, Goldman A: SOOF lift and lateral retinacular
canthoplasty. Facial Plastic Surg 17:37-48, 2001.
Von Heimburg D, Pallua N: Two-year histological outcome of
facial lipofilling. Ann Plast Surg 46:644-646, 2001.

91

Ptosis and Upper Eyelid
Retraction
The evaluation and management of the patient with
eyelid ptosis requires an especially careful history and
repeated examinations to corroborate the extent of
levator function and the degree of ptosis. One should
possess facile knowledge of common conditions that
may present as the ptotic eyelid and various methods
for addressing them. For the purpose of simplicity and
practicality, I will attempt to present the more com-
monly encountered entities that present as ptosis and a
logical way of reliably approaching them. For the pur-
pose of understanding this chapter and logically
applying this information to patients, ptosis is defined as
an abnormal drooping of the upper eyelid so that it lies
below the normal anatomic position when secondary
compensatory muscular action is not initiated. This
may occur as a component of a syndrome or as an
isolated finding secondary to a mechanical, neurogenic,
or other disorder.
EVALUATION OF THE PATIENT
WITH PTOSIS
Eyelid ptosis, when present in syndromes, usually occurs
with concomitant neurologic findings, including dys-
phagia, diplopia, or facial myoneuropathies, such as
myasthenia gravis or other conditions. Ptosis associated
with pupillary miosis or constricted pupil and anhi-
drosis suggests a sympathetic lesion associated with
Horner’s syndrome. Ptosis associated with mydriasis or
a dilated pupil along with diplopia suggests a palsy of
the third cranial nerve. Ptosis associated with proptosis
of the globe suggests an orbital tumor or infiltrating
disease of the orbit. Multiple congenital syndromes,
such as the blepharophimosis syndrome, which is asso-
92
CHAPTER EIGHT
ciated with bilateral ptosis, blepharophimosis, telecan-
thus, epicanthus inversus, and lower lid ectropion,
are rare.
True ptosis as an intrinsic isolated entity should
be discriminated from pseudoptosis. The latter is a
mechanical condition other than impairment of the
upper eyelid retractor complex (levator palpebrae supe-
rioris muscle and Müller’s muscle) and can be confused
with the former, especially when the patient is exam-
ined in a cursory fashion. Conditions that can mimic
ptosis but that are mechanical include severe dermato-
chalasis with or without associated brow ptosis,
hypertropia (elevation of the eyeball), blepharospasm
or increased hemifacial tone, and enophthalmos, in
which the affected eyeball is retrodisplaced with the
upper eyelid draping over the anterior corneal surface in
a lower position compared with the contralateral side.
This is frequently seen in post-traumatic orbital fractures
or in erosive lesions of the bony orbit that effectively
increase orbital volume. Small degrees of pseudoptosis
caused by orbital volume discrepancies may be
addressed in a similar fashion to that of isolated true
ptosis; however, the surgeon should understand that
this is a “masking procedure” and with this approach
the underlying pathophysiology is not specifically
addressed. In severe cases of enophthalmos, procedures
that alter orbital volume are indicated and are described
in Chapter 11 (Fig. 8-1).
Once the ptosis is determined to be an isolated in-
trinsic condition related to impairment of the upper
eyelid retractor system, it should then be classified as to
whether it is acquired or congenital. It is helpful to
obtain a detailed history and view old photographs in
making this determination. A history of trauma, a com-
plicated or forceps delivery, an episode or repeated
episodes of intense orbital swelling, and even cataract
surgery are usually salient and indicate the cause of
ptosis to be levator aponeurotic dehiscence.
 P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N

Figure 8-1 The cause of ptosis of

the upper eyelid is frequently
ascertained by examination
alone. A and B, The signs of
levator dehiscence including a
superior sulcus deformity, high or
absent lid crease, and good
levator function are typical in
older individuals or those who
A B
have sustained trauma. The man
shown here underwent a previous
left cataract extraction. The
woman has left greater than right
levator dehiscence with
compensatory eyebrow elevation.
The etiology is likely age-related
attenuation of the levator
insertion. Sometimes
blepharochalasis and fat
herniation can mask the classic
signs of levator dehiscence.
C and D, Congenital ptosis usually
presents as an absent lid fold and
lid lag (lagophthalmos). This
18-month-old boy has moderate
left congenital ptosis and no lid
fold and on down gaze
demonstrates lid lag. E and F,
Enophthalmos may cause C D
pseudoptosis. In this case a
previous zygoma and orbital
fracture has created
enophthalmos, with the upper
eyelid draping over the eye in a
more inferior location. The
computed tomographic scan
demonstrates a malpositioned left
zygoma and disproportionately
large orbital volume compared
with the contralateral right side.
The lower lid on the left is pulled
inferiorly by septal attachments to
the malpositioned zygoma.
Similarly, the left lateral canthus
shows inferior dystopia.
Appropriate correction of this
ptosis requires osteotomies and
repositioning of the zygoma. In
small degrees of ptosis secondary
to enophthalmos, a soft tissue
masking procedure may suffice. E F

93
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
Congenital ptosis is caused by poor development of
the levator palpebrae superioris muscle. The patient
presents with a long-term history of ptosis associated
with lid lag on down gaze caused by fibrotic replace-
ment of levator muscle fibers. Acquired ptosis may be
mechanical, myopathic, or neurogenic, but by far the
most common cause of acquired ptosis is disinsertion
or dehiscence of the levator aponeurosis from the tarsal
plate. This may occur as a senescent or age-related
change or after intense swelling, surgery for cataracts, or
blunt or penetrating injuries.
As in all areas of the body, gross observation and
careful physical examination are paramount in diag-
nosing and treating the patient correctly. This can be
performed quickly and accurately as time and experi-
ence are accrued. Initially, the presence or absence of
ptosis should be noted on gross examination. A
comparison should be made between each side con-
cerning the upper lid position vis-à-vis the iris and
pupillary aperture. Obviously, to properly make this
comparison, the pupillary aperture should be the same
and pupils should react similarly to light. In third nerve
palsies and Horner’s syndrome this is not the case.
Several gross but reliable modalities for assessing upper
lid ptosis have been described. These include the
corneal light reflex distance, which is defined as the
distance between the corneal light reflex and the upper
lid margin at its mid position. This distance usually is
between 3.0 and 4.5 mm. Another useful test is to
examine the position of the upper lid vis-à-vis the
limbus or corneoscleral junction and the pupillary aper-
ture. A normal upper eyelid should bisect the distance
between the limbus and the pupillary aperture. The
distance between the upper and lower lids or the vertical
interpalpebral distance in the mid position is the least
useful tool. This assessment can be influenced by lower
lid position and is generally not a true measure of upper
lid position. Bear in mind that proper assessment of
upper lid position using these tools requires that both
eyeballs are in alignment (e.g., absence of hypertropia).
Ocular malalignment distorts the pupillary eyelid
relationship, which is the backbone of most of these
assessment tools.
94
The key point is to examine the patient and appre-
ciate gross topographic differences or surface deviations
from normal before embarking on a detailed and
intricate analysis. For instance, look for symmetry or
absence of symmetry between the two upper eyelids and
the presence and degree of prominence of the lid crease
and its relationship to the eyelid margin. The upper
eyelid crease is usually 7 to 9 mm above the lash line
and an elevated and/or ill-defined eyelid crease usually
suggests disinsertion of the levator aponeurosis. A
superior sulcus deformity or asymmetry in the lid fold
and sulcus usually indicates differences in the position
of the preaponeurotic fat pad. This occurs because the
preaponeurotic fat pad is loosely but definitively tethered
to the anterior surface of the levator aponeurosis.
Disinsertion of the levator aponeurosis and retraction
from the tarsal plate causes the preaponeurotic fat pad
to ride posteriorly within the orbital rim along with the
retracted levator aponeurosis. This results in creation of
a superior sulcus deformity or diminution in the upper
eyelid fold. These findings are characteristic of invo-
lutional ptosis or post-traumatic levator dehiscence. The
presence of lid lag or lagophthalmos may be noted by
having the patient look up and down. Inability to com-
pletely cover the globe in down gaze, despite inade-
quate lid elevation on primary gaze, is associated with
congenital ptosis. Unilateral lagophthalmos is more
easily discernible than bilateral lid lag on attempted
closure. The patient should demonstrate adequate
orbicularis motor function by forcibly closing his or
her eyes against resistance. Significant weakness in the
orbicularis muscle may suggest a myopathic problem
and, more importantly, these patients are very poor
candidates for ptosis correction because their ptotic
eyelid is protective and necessary to achieve adequate
corneal coverage and wetting. Any attempt at elevation
of their ptotic eyelids may produce severe lagophthal-
mos or an inability to completely cover their corneas.
These patients can develop significant postoperative
problems, and the lid lag is difficult to correct. Always
have the patient perform ocular versions by looking up,
down, left, and right and obliquely up and down.
Changes in lid position with extraocular motion suggest

aberrant regeneration of the third cranial nerve. Chronic
external ophthalmoplegia presents as limitation of
extraocular muscle activity or versions. Have the patient
open and close the mouth and sublux the jaw laterally
looking for eyelid position. Marcus-Gunn jaw-winking
phenomenon or aberrant regeneration of the facial
nerve may be discriminated from isolated impairment
of the upper eyelid retractor system using this method.
A Schirmer test is indicated in all patients in whom a
ptosis procedure is planned. A significant compromise
in tear production can militate against performing a
surgical lid elevation, or a ptosis procedure may have to
be modified to obviate excessive evaporative tear loss.
Adequate eyeball wetting is not only dependent on tear
production and tear quality but also on ambient
evaporative loss. The amount of evaporative tear loss
will increase with ptosis correction owing to greater
ambient eyeball exposure, yet tear production will
remain the same. This may tip the patient over into a
dry eye syndrome, with its attendant symptoms and
complications.
Once a diagnosis in surgically appropriate patients is
identified by way of an organized screening process,
then a more detailed examination of levator function
should be undertaken. I will discuss this in more detail
to simplify the evaluation and describe several
appropriate procedures that can be logically applied.
MEASUREMENT OF LEVATOR
FUNCTION
Once a mechanical or isolated ptosis has been diag-
nosed then the most important determinant of which
procedure to perform depends on two factors: (1)
degree of ptosis and (2) amount of levator function. I
prefer to evaluate the degree of ptosis based on it being
mild, moderate, or severe. Mild ptosis is less than 2 to
3 mm, moderate ptosis is 3 to 5 mm, and ptosis of
5 mm or more is severe. An even more important factor
in deciding on the best procedure is the assessment of
P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N
levator function. Levator function determines which, if
any, upper eyelid retractor complex tightening proce-
dures will work. These include levator advancement,
levator tuck, levator resection, müllerectomy, and tarsal
conjunctival müllerectomy (Fasanella-Servat proce-
dures). It becomes necessary to utilize exogenous lid
elevators such as the frontalis sling procedure when
levator function is poor. These procedures incorporate
or utilize muscles other than the primary upper eyelid
retractor system to serve as upper lid elevators.
ASSESSING LEVATOR FUNCTION
Levator function is the single most important deter-
minant of the likely cause for eyelid ptosis (i.e., neuro-
muscular vs. involutional or senescent) and the
appropriate surgical approach for its correction. Because
levator function may vary temporally, based on
circulating catecholamines and other factors, it is best to
evaluate levator function on at least two separate
occasions to corroborate the initial findings. Levator
function is established by measuring excursion of the
upper eyelid as it moves from down gaze to complete
up gaze with the eyebrow fixed by the examiner to
prevent any transmission of forces from the frontalis
muscle to the upper eyelid. The patient may be asked to
look straight ahead with the brow fixed so that primary
lid aperture is established. The lid aperture is then
measured in extreme up gaze followed by down gaze.
The difference in the lid aperture between extreme up
gaze and extreme down gaze with the brows fixed is a
measure of levator excursion or function and is usually
greater than 12 mm in the normal individual. Levator
excursion or function can usually be divided into poor,
fair, and good categories, with less than 5 mm being
poor, 6 to 9 being fair, and 10 to 15 mm being good.
Analogously, as already described, the degree of ptosis
may be assessed and divided into three categories: mild
(1 to 2 mm), moderate (3 to 5 mm), and severe (greater
than 5 mm) (Figs. 8-2 and 8-3).
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ASSESSING LEVATOR FUNCTION

Primary Gaze

Levator aperture

Degree of ptosis:
mild/moderate/severe

Clear
ruler

Levator
Excursion Up Gaze

Levator aperture

Down Gaze

Levator aperture

Figure 8-2 Levator function can be assessed through the measurement of upper eyelid excursion. That combined with a measurement of the
degree or extent of ptosis allows the surgeon to choose the best procedure for each patient. The degree of ptosis is best noted using a clear ruler
held in front of the eyelid to be assessed. The measurement in millimeters while in primary gaze will give the aperture of the affected eye, and
this may be compared with the unaffected side. The difference is the amount of ptosis, and this may be classified as mild, moderate, or severe.
Grossly, one may assess the degree of ptosis by noting the position of the upper eyelid in relation to the iris and pupil. The upper lid margin is
normally at the level of a line that bisects the distance between the upper aspect of the pupillary aperture and the iris. One can assess the
number of millimeters the ptotic eyelid lies below that line, with mild being 1 to 2 mm, moderate 3 to 5 mm, and severe greater than 5 mm.
Levator function, as measured by eyelid excursion, is then recorded by having the patient look up and then down. The difference between the
apertures in extreme up gaze and down gaze indicates the extent of levator function. A significant aperture in down gaze (lagophthalmos) may
be an indication of infiltrative disease (i.e., Graves’ disease) or a fibrotic process (i.e., congenital). In all measurements of aperture and levator
function, the eyebrow should be immobilized by the examiner to eliminate compensatory brow contribution to upper eyelid elevation (note the
examiner’s finger over brow in drawing).

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C
Figure 8-3 Clinical example of levator function assessment. The lid
aperture is measured in primary gaze (A). The aperture is measured
in up gaze (B) and then down gaze (C). The aperture in primary gaze,
in this case 12 mm, can be compared with the opposite side and is a
measure of the degree of ptosis. The difference between up gaze (14
mm) and down gaze (2 mm) is a measure of levator excursion and
function.

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CHOICE OF PROCEDURE
The surgeon may then choose an appropriate procedure
based on these two key assessments: levator excursion
or function and the degree of ptosis. Any upper lid
retractor tightening procedure (i.e., levator advance-
ment, levator resection, levator tuck, müllerectomy, or a
tarsal conjunctival müllerectomy [Fasanella-Servat]) are
all appropriate procedures when levator function is
good. Levator advancement is by far the most powerful
technique for correcting larger degrees of ptosis. All
other procedures have limitations and, when applied to
larger degrees of ptosis, result in untoward sequelae.
Therefore, posterior lamella shortening (i.e., müller-
ectomy, Fasanella-Servat) and other procedures are indi-
cated only in mild degrees of ptosis. In the case of the
müllerectomy procedure alone, the best candidates are
those with good to excellent levator function, those
with mild degrees of ptosis, and those who respond to
topical instillation of phenylephrine. The Fasanella-
Servat operation is also indicated in mild degrees of
ptosis, and this operation effectively shortens the entire
posterior lamella of the upper lid by resecting Müller’s
muscle, superior tarsal plate, and conjunctiva. It has
similar indications to the müllerectomy alone and, in
my opinion, is a more powerful technique for correcting
ptosis. It does, however, have greater disadvantages,
including an inability to provide graduated tension on
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the lid retractors. It decreases wetting surface over the
cornea and may produce corneal irritation secondary to
exposed sutures. In addition, symmetric upper lid
contour may be distorted by this procedure. Therefore,
although I will describe the procedure for tarsal con-
junctival müllerectomy (Fasanella-Servat), I recom-
mend that all surgeons become familiar with levator
aponeurosis plication or tuck, with or without resec-
tion, as well as levator advancement procedures. All of
these techniques may be performed alone or in com-
bination with various cosmetic procedures, especially
upper lid blepharoplasty.
The just-mentioned procedures are all indicated in
patients who have an intact endogenous lid elevator
mechanism. In cases in which levator function is ex-
tremely poor or absent, use of exogenous muscles, such
as the frontalis muscle sling procedures, is of most
benefit. Patients with congenital ptosis usually present
with significant degrees of ptosis, poor to absent levator
function, and significant lid lag on down gaze. These
patients have a fibrotic contraction of a relatively atonic
levator muscle and have the characteristic combination
of significant ptosis associated with significant lid lag or
corneal exposure on down gaze. As always, one should
be cognizant of the patient’s ability to adequately wet
their corneal surface. Elevation of the lid with ptosis
correction will produce increased evaporative tear loss,
and this could therefore serve to trade one symptom
(ptosis) for another (dry eye syndrome). Of course, in

cases in which profound symptomatic ptosis is present
in combination with borderline or frank dry eyes,
obliteration or limitation of tear drainage with punctal
occlusion or plugs can be considered at the time of
ptosis correction. The ptosis should be undercorrected
in an attempt to diminish the loss of tears by way of
evaporation.
PTOSIS PROCEDURES
Tarsal Conjunctival Müllerectomy
(Fasanella-Servat Operation)
The Fasanella-Servat procedure is a simple posterior
approach to mild degrees of ptosis. It is important to
achieve proper anesthesia without soft tissue distortion.
Topical ophthalmic anesthetic (i.e., tetracaine) is in-
stilled, local anesthetic is infiltrated, and adequate time
for hemostasis is allowed to elapse. The upper eyelid is
everted, and the tarsal plate along with the overlying
conjunctiva and Müller’s muscle is engaged with a
forceps. The everted tarsal plate and associated soft
tissue are clamped at its most superior extent utilizing
two identical curved clamps. A cuff of 3 to 4 mm of
tarsal plate is left above the clamps. It is important to
visualize the sweeping contour of the upper lid and
P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N
mimic this contour with clamp placement, adjusting
the “heel and toe” of each clamp accordingly. Once this
is accomplished, a monofilament nonabsorbable suture
(i.e., 4-0 or 5-0 Prolene) is brought through the skin
surface at the lateral external eyelid crease. The suture is
brought into the conjunctival surface of the everted
eyelid and woven from lateral to medial beneath the
clamps in a horizontal mattress fashion. Once the su-
ture is brought to the most medial extent of the
clamped tarsal surface, it is brought back out through
the skin surface. The soft tissue above the clamps (tarsus,
conjunctiva, and Müller’s muscle) can be removed with
a scissor or scalpel and the eyelid reverted. The lateral
medial elements of the suture may be tied to each other
loosely, and it is helpful to smooth the undersurface of
the eyelid with a blunt instrument to diminish post-
operative corneal irritation. No other closure is neces-
sary, and the suture may remain in place for 1 to 2
weeks. In cases in which slight undercorrection has
been achieved, it is useful to leave the suture in place for
longer than 2 weeks, and the reverse is true in slight
overcorrection. Early removal of the suture, frequent
massage, and downward traction on the upper eyelid
may also serve to improve slight overcorrection in this
procedure. Because the wetting surface of the eyelid is
decreased in this procedure, patients with dry eye
syndrome or decreased tear production may be better
served by direct levator procedures (Figs. 8-4 and 8-5).
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TARSAL CONJUNCTIVAL MÜLLERECTOMY

Mild upper lid ptosis, 1-2 mm.

Figure 8-4 The tarsal conjunctival

müllerectomy or Fasanella-Servat
procedure is one of the more simple
procedures that reliably corrects mild
to lesser degrees of moderate ptosis
(i.e., 1 to 2 mm). The procedure
shortens the entire posterior lamella of
the upper lid, including the tarsal Cross section of suture placement
plate, Müller’s muscle, and
conjunctiva. A, After topical anesthetic A Running suture (full thickness)
is applied and local anesthetic is behind clamps, lateral to medial
infiltrated, the upper eyelid is everted.
Small curved identical clamps are used
to engage the tarsal complex. A
monofilament suture is passed from
the skin onto the conjunctival surface
and woven below the clamps from
lateral to medial. It is helpful to
manipulate the clamps as a unit,
without disengaging the tarsal complex
(toward the surgeon when passing the
needle from posterior to anterior and
away from the surgeon when passing
in the other direction [insert]). B, The
excess tissue above the suture line may
then be resected with or without the
clamps in place, after the suture is
B Trim excess
clamped tissue
passed back onto the skin surface of
the medial lid. C, Its suture ends are
tied to each other after the eyelid is
reverted. Slack should be left in the
suture to prevent cheese wiring, and I
like to apply a Steri-strip to prevent the
suture from falling onto the eyeball C Closure – suture tied on skin surface
when the patient ambulates. Although and covered with Steri-Strip
the procedure is straightforward from
a technical standpoint, the selection of
clamps (i.e., degree of curvature),
clamp positioning (i.e., amount of
tarsus engaged), and the clamp
angulation (tip-to-heel angulation) all
play an important role in determining
the results achieved in the tarsal
conjunctival müllerectomy.

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A B
Figure 8-5 The proper execution of the relatively straightforward tarsal conjunctival müllerectomy (Fasanella-Servat) requires choosing the
correct patient to begin with. This is one with good levator function and mild ptosis. After topical and local anesthetics are utilized, the ptotic
upper lid is everted with a Desmarres retractor or other atraumatic instrument. The proximal edge of the tarsal plate now lies superior or distal.
I prefer to stabilize the middle superior aspect of the tarsus with a tooth forceps (A) and then precisely place two matching curved clamps (one
nasal and one temporal) across the tarsal plate, Müller’s muscle, and conjunctiva (B). The clamps, whose tips meet in the midline of the tarsus,
should engender a soft sweeping curve, because this will eventually be the shape of the corrected upper eyelid. A single suture is then woven
below the clamps entering and exiting the skin surface at entry and exit points, before amputations of the tissue above the clamps. The
procedure is rapid and less daunting compared with levator procedures; however, great care and artful placement of the clamps is necessary to
achieve a satisfactory result. Contour irregularities and overcorrections are difficult to correct. (In this patient, the upper lid was also used for a
skin graft donor site.)

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Levator Tuck with or without Resection
In mild to smaller degrees of moderate ptosis with
good-to-excellent levator function, one may use a sim-
ple anterior approach to the levator aponeurosis that
does not require extensive dissection. The redundant
aponeurotic tissue is plicated or tucked. The redundant
tissue above the suture line may be resected to avoid
subcutaneous bulk. The procedure is carried out by per-
forming an anterior cutaneous lid incision along the
desired eyelid crease after local anesthetic with epi-
nephrine is infiltrated and adequate time for hemostasis
is allowed to elapse. Dissection is carried down to the
levator aponeurosis after skin and orbicularis muscle is
incised. The dissection should be carried cephalad
along the levator aponeurosis, and the orbital septum
should be incised, allowing visualization of the pre-
aponeurotic fat pad. Distally, dissection is carried down
to the superior border of the tarsal plate. The levator
aponeurosis may be plicated at a level cephalad to the
tarsal plate with an absorbable suture (i.e., 5-0 Vicryl).
Generally, one chooses the medial aspect of the pupil as
the apex of eyelid curvature and a plication suture is
placed at this point. Two other plication sutures may be
placed medially and laterally to this central suture,
visualizing the anatomic sweep of the upper eyelid.
Closure may be performed as in an upper lid blepharo-
plasty. Alternatively, the cuff of levator aponeurosis left
after plication or tuck may be resected, being careful to
leave the suture line intact. This is especially useful
when larger cuffs are created in the treatment of larger
degrees of ptosis. Larger cuffs may leave a cosmetically
visible and palpable firmness to the upper lid behind,
and these tend to obscure upper sulcus definition. Care
should be taken to firmly and reliably plicate the
underlying levator aponeurosis before resection of the
overlying cuff to avoid dehiscence and postoperative
ptosis. A one-to-one millimeter plication for the degree
of ptosis is generally ideal. The patient may be seated
upright for assessment of levator excursion and
adequacy of ptosis correction before the levator
aponeurosis is resected above the suture line. One must
remember that the epinephrine that is infiltrated will
cause some correction of ptosis by way of stimulation of
Müller’s muscle (see Fig. 4-6).
Levator Advancement
The levator advancement procedure is by far the most
powerful technique for the correction of ptosis in
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patients who have good-to-excellent levator function no
matter how severe their ptosis. This technique may be
applied in congenital ptosis when there is fair-to-good
levator function. In distinction to levator plication with
or without resection, this procedure involves more
extensive dissection with complete mobilization of the
levator aponeurosis from the tarsal plate, lysis of both
the medial and lateral levator excursions (horns), and
dissection carried cephalad into the orbit behind the
septum. In this procedure the distal aponeurosis is
resected after appropriate advancement and fixation to
the superior tarsal plate. In cases of disinsertion of the
levator aponeurosis or involutional ptosis (senescent
ptosis) the levator aponeurosis may be freed from its
other tethering points (as described earlier) and simply
advanced without resection of the distal aponeurosis. In
cases in which the lid crease is not well defined or
deficient (i.e., involutional ptosis or congenital ptosis
with adequate levator function), the lid crease may be
defined at an appropriately chosen level with supra-
tarsal fixation, which will be further delineated and has
already been mentioned. I prefer the patient to be
lightly sedated whenever possible to maintain his or her
cooperation. Local anesthetic infiltration should be
minimized to avoid soft tissue distortion and compro-
mise of levator function. It is best that the patient
become maximally cooperative once the adjustment
stage of the procedure is performed. Skin resection may
be performed as in an upper lid blepharoplasty, and the
degree of skin excision is chosen as described in
Chapter 4. Residual excess skin after the correction of
ptosis can result in a prominent lid fold, distortion of
eyelashes, and, in extreme cases, the creation of entro-
pion. In cases of mild skin excess after a lid elevation
procedure, a secondary skin resection can be performed
later after swelling dissipates. I always try to defer signi-
ficant skin resections after a ptosis correction, especially
in secondary or tertiary cases, until a later date. This
affords a maximal cosmetic and functional result.
Levator Advancement Technique
Local anesthetic is infiltrated once the upper eyelid
crease is delineated with a marking pen. Adequate time
is allowed to elapse for vasoconstriction to occur. The
incision is carried down through the skin and orbi-
cularis muscle, exposing the levator aponeurosis. I pre-
fer to perform all dissection after the initial incision
with an insulated needlepoint cautery. Skin is retracted
cephalad, and the dissection is carried cephalad
through the orbital septum and along the levator
aponeurosis. Preaponeurotic fat is exposed and left in

place unless concomitant cosmetic improvement of her-
niated fat and so on is desired. In levator dehiscence,
preaponeurotic fat will be retracted into the orbit along
with the levator to which it is loosely attached. Levator
advancement will reposition this fat, and resection is
not necessary in routine cases. Attention is then brought
to the superior tarsal plate and with the pretarsal
orbicularis and skin retracted the levator aponeurosis is
dissected off the tarsal plate in a caudal to cephalic
fashion. Müller’s muscle may be carried with the over-
lying levator aponeurosis, leaving conjunctiva behind as
dissection is carried superiorly. It is preferable, but not
always possible, to leave Müller’s muscle behind. A
corneal protector may be placed before this surgery
because conjunctiva alone may not serve as an adequate
corneal protector for some surgeons. It is important to
carry out the dissection as cephalad as possible so that
the entire levator aponeurosis is freed and adequate
advancement may be performed. The medial and lateral
horns of the levator muscle are similarly severed with
cautery or other dissection. Needle-point cautery is pref-
erable because difficult bleeding can be encountered,
especially laterally near the lacrimal gland during lateral
horn interruption. Medial and lateral horn division is
an important step, because untethered levator advance-
ment is impossible without it. The levator aponeurosis
is then advanced and reinserted into the upper one
third of the tarsal plate. I prefer to use a double-armed
absorbable suture such as 5-0 Vicryl. This may be
temporarily tied so that the degree of advancement and
correction may be assessed in the operating room,
demonstrating lid position and excursion after reposi-
tioning the patient. This is achieved by removing the
protective contact lens, decreasing the ambient light,
and sitting the patient as upright as possible. High-
intensity light will cause the patient to squint and alter
the accuracy of the intraoperative assessment. Should
the advancement be too little or too much, the patient
may be placed in a recumbent position and the suture
may be adjusted until the desired lid height is achieved.
Once the appropriate degree of lid height and ptosis
correction is obtained, the suture may be permanently
tied down and the excess levator aponeurosis resected.
A second or even third simple interrupted suture may be
placed medially and laterally to fixate the distal levator
aponeurosis to the tarsal plate and ensure stabilization
without distortion. The key central suture should lie
P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N
along a vertical line that intersects with the nasal pupil-
lary margin. This usually corresponds to the highest
point of the lid. Should the high point on the contra-
lateral side differ, then one may adjust the location of
the key central suture during the repair of the ptotic
eyelid (Fig. 8-6). An appropriate lid fold may then be
accentuated with supratarsal fixation by attaching the
upper and lower skin margins to the levator aponeurosis
at an appropriately chosen height with several spaced
absorbable sutures (i.e., 5-0 Vicryl). Skin may be closed
as in the upper lid blepharoplasty procedure with intra-
cuticular or other preferred technique as previously
described in Chapter 4 (Figs. 4.4 and 8-6). Although
supratarsal fixation or lid crease sutures may be applied
to any upper lid procedure, I usually find it necessary
only in congenital ptosis and in rare instances of
involutional ptosis (see Figs. 4-6 and 8-1).
In cases of congenital ptosis with fair-to-good levator
function in which levator aponeurotic advancement
is used, much larger degrees of levator advancement
are necessary to effect a change in the degree of ptosis
(Fig. 8-7). This is because of the relatively atonic levator
and part of the congenital abnormality. Significant
levator advancement and resection in congenital ptosis
cases leads to significant degrees of lid lag, but this is
invariably well tolerated in the pediatric population.
The surgeon also has the significant disadvantage in the
pediatric population of not having a cooperative patient
in whom to adjust levator advancement and resection
in a dynamic fashion at surgery. In cases of congenital
ptosis, 2 to 3 mm of advancement and resection for
each millimeter of ptosis is usually necessary. In dis-
tinction, much lesser degrees of advancement and resec-
tion are necessary in cases of noncongenital ptosis. I
prefer to avoid relying on any formulas to determine the
amount of levator advancement necessary at surgery.
These formulas may serve as rough guidelines for pre-
operative planning but are usually not accurate enough
by themselves to be relied on to determine a specific
advancement. This is because of the large number of
variables involved with ptosis correction, including
preoperative and postoperative nuances in levator func-
tion and lid position, as well as the induced intra-
operative variables, such as swelling and changes in
neuromuscular activity introduced by local anesthetic
and other agents (Fig. 8-8).
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LEVATOR ADVANCEMENT

A Lid is incised through orbicularis muscle

Figure 8-6 The levator may be

advanced onto the tarsal plate in a
controlled fashion for correction of
B Skin retracted exposing levator aponeurosis,
significant degrees of ptosis provided cut edge of orbital septum, and
the muscle has adequate function. preaponeurotic fat
The initial steps are those required for
an upper lid blepharoplasty. A, After
local anesthetic is conservatively
infiltrated, a curvilinear incision is
made in the upper eyelid crease or in
a line where a new lid crease will be
created. A suborbicularis dissection is
carried out superiorly, exposing the
Tarsal plate
orbital septum, which is then opened.
B, The preaponeurotic space is C Levator aponeurosis is freed from upper
margin of tarsal plate
exposed, and both fat and levator
aponeurosis are visualized. C, The
superior tarsal plate is exposed with
inferior suborbicularis dissection.
Care should be taken to avoid distal
tarsal exposure, because hair follicles
may be damaged. D, The levator
aponeurosis is then freed from the
tarsal plate and dissected superiorly. D Levator aponeurosis dissected cephalad
Continued

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Figure 8-6 Continued E, The medial

and lateral extensions (horns) of the
levator are lysed, and the levator
muscle may then be freely advanced.
At this point the patient may be
asked to look down and then up and
the free distal levator should move
superiorly under the orbital rim and E Medial and lateral horns divided freeing
superior aspect of levator aponeurosis
roof (anterior skull base). F, The
levator may then be advanced onto
the tarsal plate and temporarily
suture-secured. The patient can sit
upright with or without the help of
an operating table, and the eyelid
height and excursions from down
gaze to up gaze can be assessed. The
process can be repeated with
repositioning of the temporary
suture until the surgeon is satisfied.
G, Permanent sutures may then be F Advance levator aponeurosis and
substituted and excess levator may be suture to tarsal plate
removed distal to the suture fixation.
H, Skin closure may be performed as
in a blepharoplasty, or supratarsal
fixation may be used where the lid
fold needs to be accentuated or its
height changed (i.e., congenital
ptosis). The surgeon should minimize G Trim excess levator aponeurosis
the amount and depth of local
anesthetic used because this may
affect levator function and
compromise intraoperative
assessment. One should also
remember that epinephrine can
stimulate Müller’s muscle and this
may “artificially” elevate the eyelid,
resulting in undercorrection. However,
slight undercorrection is always a
better problem than overcorrection of H Intracuticular running suture medial to lateral
ptosis.

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A B

C D
Figure 8-7 The levator advancement procedure is a very powerful and reliable procedure that when properly employed and executed produces
excellent results. I prefer to perform this procedure with sedation and minimal local anesthetic because I like to adjust the correction on the
operating table by allowing the sedative to dissipate after the dissection phase of the surgery is completed. A limited upper blepharoplasty
incision is all that is needed for access. The orbital septum is incised superiorly and dissection is carried cephalad anterior to the levator.
Whitnall’s ligament is visualized, and for full advancement procedures dissection is carried more superiorly beneath the orbital rim and roof.
Distally, the tarsal plate is exposed in a suborbicularis dissection. This dissection should remain superior to the last few millimeters of the tarsus,
because very distal dissection can damage specialized orbicularis muscle and hair follicles, resulting in distichiasis and/or loss of eyelashes. The
levator is then disinserted from the tarsal plate, and both medial and lateral horns are lysed. The patient may then be asked to look up and
down, and the levator should freely and spontaneously excurse, retracting under the superior orbital rim. The levator is then advanced onto the
tarsal plate and temporarily fixed with a suture. I prefer a 5-0 double-armed absorbable suture (i.e., Vicryl). The temporarily tied suture may
then be adjusted as the patient is sat upright and lid position and function is assessed. Once the surgeon is satisfied, the suture may be
permanently tied. A second more lateral suture may be placed in more significant corrections to avoid lateral lid ptosis and an unnatural lid
sweep. In milder cases, the medial and lateral horns may be left intact and the levator advanced onto the tarsal plate and sutured as described
in Figure 8-6. Skin closure is achieved as in the upper lid blepharoplasty. A, In the first view, Whitnall’s ligament is visualized after the orbital
septum is opened. A forceps delineates the lateral extent of the ligament near the lacrimal fossa. B, The upper aspect of the tarsal plate is
exposed, with forceps again pointing to the tarsus. C, A double-armed suture is passed between the tarsal plate and the free edge of the levator
aponeurosis. D, The suture is in place at the level of the medial pupillary margin. Continued

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G
Figure 8-7 Continued E, The suture is tied down, advancing the levator onto the tarsal plate
and correcting the ptosis. F, Preoperative view. Note the left lid ptosis and compensatory left
brow elevation. G, The same patient at 1 year postoperatively.

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A B

C
Figure 8-8 An 18-month-old child with left congenital ptosis had undergone previous surgery by another surgeon at 14 months of age. He
presents with residual ptosis and lid lag (lagophthalmos) and asymmetric lid folds. The low fold on the congenitally ptotic side is caused by the
low incision line initially used. Preoperative examination showed enough levator function to perform a ptosis repair using the levator muscle by
way of an advancement procedure. Elevation of the lid fold would be necessary to achieve external lid symmetry independent of eyelid height
(ptosis correction). I chose to perform a distal and proximal dissection over the tarsal plate with supratarsal fixation at the desired height along
with a levator advancement procedure to address his lid fold asymmetry and eyelid ptosis, respectively. Because of his age, the procedure
required general anesthesia. A, Photograph of the child before his initial surgery taken by another surgeon. Note the ptotic eyelid on the left side
and absent lid fold. B, The patient at consultation with me. Note the ptosis in primary gaze. C, Despite ptosis in primary gaze there is lid lag on
down gaze as well as asymmetric eyelid creases which the primary surgeon created. Continued

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D E

F G

H I
Figure 8-8 Continued D, The incision line chosen is at the correct or matching height from the lash line as on the contralateral side. Wide
distal and proximal undermining was performed in the suborbicularis plane. E, The levator was freed from the tarsal plate, the medial and
lateral horns completely lysed, and the levator, along with loosely attached preaponeurotic fat, was advanced. Note the fibrotic and pale nature
of the soft tissues. F, The levator was then reattached to the tarsal plate and excess levator aponeurosis amputated. G, Supratarsal fixation was
used to create a lid fold at the appropriate height by apposing skin to levator aponeurosis on both sides of the incision. H, The skin closure was
completed using the supratarsal fixation technique. I, The patient at approximately 3 months after the procedure.

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Ptosis Correction Using Exogenous Muscle
Action (Frontalis Sling)
Some of the more unsatisfying procedures for ptosis
correction are the use of muscles outside the lid to serve
as a lid elevator. These are, unfortunately, the only
viable options when intrinsic levator function is not
adequate. The more important of these procedures is
the frontalis sling procedure, which uses a static linkage
between the upper eyelid and the overlying brow. Lid
elevation is achieved with contraction of the frontalis by
way of eyebrow elevation. The procedure produces sig-
nificant lid lag and corneal exposure, and it is important
to preoperatively assess the presence or absence and
degree of Bell’s phenomenon in addition to all of the
other parameters that are routinely assessed in ptosis
evaluation. There are a plethora of materials that have
been described as appropriate in performing these sling
procedures. These include Silastic tubing, Superamid
and other alloplastic materials, as well as preserved
fascia and autogenous fascia. Autologous tissue such as
fascia lata or palmaris longus tendon tend to have the
longest duration, most stable correction, and least
complications associated with them.
A number of configurations of the frontalis sling have
been proposed and include single rhomboids, double
rhomboids, and various permutations of triangles. Each
of these may be satisfactory, but none of them is ideal,
given the underlying conceptual and practical limita-
tions of this procedure.
The frontalis sling with a double rhomboid is per-
formed by marking areas medially, centrally, and
laterally at the superior border of the eyebrow hairs. The
lower surgical incisions are delineated across the tarsal
plate approximately 3 mm superior to the lash line.
Local anesthetic with epinephrine is infiltrated, and
110
adequate time for hemostasis is allowed to elapse. Stab
incisions are made at each of these marks extending
down to the periosteum in the brow region and to the
tarsal plate in the lid. A long curved or straight needle
(i.e., Wright) is used to pass two separate pieces of
fixation material (i.e., fascia) from the medial and
lateral brow incisions, respectively. Each piece of fascia
or other material is passed deep to the orbicularis
muscle from the brow through the pretarsal area and
back to the brow area. Locking sutures such as 4-0 Vicryl
may be used to reinforce the sling ties, and it is generally
useful to slide the knots through the subcutaneous
tunnels away from the incision lines to obviate extru-
sion. The undersurface of the upper eyelid should be
everted before tying any knots on these slings to
ascertain whether there is any exposure or conjunctival
penetration, because this will lead to corneal irritation
and breakdown. Fascia or other material that is exposed
should be removed and repassed. This procedure is
generally performed with the patient under sedation or
general anesthesia and with infiltration of local
anesthetic with epinephrine. These agents limit frontalis
muscle action and the ability of the surgeon to assess
appropriate elevator action to the sling. It is helpful to
tighten the sling so that the upper lid either pulls away
from the globe or reaches the superior limbus or
corneoscleral junction. The upper eyelid should be set
at a lower level if the patient has a poor Bell reflex or
poor seventh cranial nerve or orbicularis function. The
greater the patient’s inability to forcibly close his or her
eyes, the closer one should set the upper lid to the visual
axis. Skin closure can then be performed in layers, and
a temporary tarsorrhaphy to protect the cornea in the
immediate postoperative period may be used, especially
when compensatory mechanisms for corneal coverage
are weak or compromised (Fig. 8-9).
 P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N

FRONTALIS FIXATION (no levator function)

Subcutaneous placement
of suspension material
to create a static sling

Protective
contact lens

B
A

Figure 8-9 The frontalis sling, like all other static eyelid procedures, depends on exogenous forces to elevate the upper lid. In this case, the
eyebrow is the primary provider and this, like all other static procedures, is nonanatomic with obvious pitfalls. Illustrated here is a double
suspension technique in which fascia is used to connect the eyelid to the eyebrow. Three incisions are located approximately 3 mm above the
lash line and three above the eyebrow (top). The upper incisions extend to the periosteum and the lower to the tarsal surface. A long curved
needle (i.e., Wright) is used to pass two separate pieces of fascia from the preperiosteal to the pretarsal planes and back. Care must be taken to
avoid passing the fascia through the conjunctival surface (bottom). Although a number of permutations for fascial linkage and placement
exist, the technique used in this drawing requires linking the fascial strands together both with knots and a reinforcing absorbable suture
(insert). The upper lid height should be set at the limbus for patients with good Bell’s and lid protractor function. For those with poorer
protective mechanisms, the lid should be set at a lower level. Skin incisions can then be closed in layers, and a temporary tarsorrhaphy is
sometimes necessary in those patients who are not capable of protecting their eyes initially.

111
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
Upper Eyelid Retraction
Upper eyelid retraction usually occurs as a sequela of
previous trauma or surgery. Upper lid retraction results
from compromise, shortening, or fibrosis of the under-
lying eyelid elevator system and should be distinguished
from seventh cranial nerve paralysis or orbicularis
muscle dysfunction in which there is adequate uncom-
promised “slack” in the lid elevator system but the
inability to close the eye is caused by failure neuro-
logically or mechanically to initiate or complete the
closure reflex. This is a distinctly different entity from
true eyelid retraction, in which there is infiltrative, post-
112
traumatic, or surgical tethering of the upper eyelid at the
middle lamella level. This may occur in Graves’ disease
or in other infiltrative phenomena. It may also occur in
the case of overcorrection of ptosis, especially with leva-
tor advancement or Fasanella-Servat procedures. In the
case of a deficiency of both the middle and internal
lamella (conjunctiva), a composite graft such as a
mucoperiosteal palatal graft may be used as an inter-
position between the levator/conjunctival surface and
the superior border of the tarsal plate. This is similar to
the procedure described for lower lid retraction, with
the exposure and dissection similar to that used in
ptosis correction (Fig. 8-10).
 P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N

Figure 8-10 A patient with eyelid retraction after overcorrection of acquired ptosis by
another surgeon. Note the involuntary eyebrow asymmetry as the patient attempts to
compensate for the condition. Another interesting and even more important compensatory
mechanism is contralateral upper lid ptosis. This is caused by the concept of equal and
opposite innervation to both eyelids. In the case of eyelid retraction, the brain will send
less elevational drive to the retracted eyelid and, because of an inability to innervate each
lid differently, the relaxation will be mirrored in the contralateral normal eyelid, resulting
in relative ptosis on that side. The converse is true in primary ptosis cases, and this
produces eyelid retraction on the contralateral normal side.

113
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
A deficiency in the middle lamella either from Graves’
disease or iatrogenically after a previous ptosis proce-
dure is more common. In these instances, I prefer
autogenous deep temporal fascia as an interposition
graft, although the ophthalmic literature is filled with
other suggestions (e.g., banked scleral, banked fascia).
In general, allografts are plagued by unpredictable long-
term results. In cases of orbicularis or facial nerve
compromise, simply weighing down the upper lid may
serve as either a temporary or permanent solution, and
this can be achieved with a pretarsal gold weight inser-
tion. In these cases, providing additional upper lid
weight is all that is needed to lower the upper lid and
provide adequate corneal coverage on attempted clo-
sure. Preoperatively, with the patient awake, an appro-
priate weight may be taped to the outside of the eyelid
to achieve the desired lid height. Basically, a minimal
weight may be chosen from a trial kit that allows the
upper eyelid to drape and move most appropriately. At
surgery, an upper lid crease incision is made and dis-
section is carried down distally, raising an orbicularis
myocutaneous flap. The underlying tarsal plate should
be exposed and care should be taken not to carry the
dissection distally to the hair follicle margin. This will
result in loss of lid cilia and/or distichiasis. The
appropriate gold weight is then fixed to the anterior
tarsal plate, being careful not to place the weight above
the superior margin of the tarsus. This is a common
etiology for postoperative sulcus obliteration, lid
malposition, or underutilization of the mass engen-
dered by the gold weight. Temporary suture fixation
above and below, utilizing an absorbable suture (i.e.,
5.0 Vicryl), is all that is necessary, and skin closure is
performed as described in Chapter 4. I have never had a
malpositioned gold weight or one dislodge after an
appropriate pretarsal pocket is made, and temporary
immobilization is performed as described earlier.
Lid retraction due to fibrosis, trauma, previous ptosis
surgery, or infiltrative disease such as Graves’ disease is
114
best corrected with recession of the levator and Müller’s
muscle complex with placement of an interposition
autogenous graft. The patient is appropriately sedated,
and an upper lid crease incision is designed. Local
anesthetic containing epinephrine is infiltrated, and
adequate time for hemostasis is allowed to elapse.
Dissection is carried down through skin and orbicularis,
and with the use of an insulated needle cautery the
levator aponeurosis and tarsal plate are exposed as in
the description for correction of ptosis. It is necessary to
free the levator and Müller muscle complex from the
underlying conjunctival surface by a similar dissection
as described previously. The entire complex is dis-
inserted from the tarsus, and the medial and lateral
horns of the levator aponeurosis are severed, with a
dissection carried out posterior to the orbital septum.
Deep temporal fascia is harvested with a small incision
in the coronal plane below the palpable temporal line
of the skull. An appropriate amount of deep temporal
fascia can easily be harvested in minutes, and the scalp
may be closed with staples or sutures as the surgeon
desires. I prefer to use a few deep absorbable sutures
followed by staples or a running 3-0 absorbable suture.
The fascia is then interposed between the free edge of
the levator aponeurosis and the superior edge of the
tarsal plate and sutured into place. Approximately a 2:1
ratio of fascia to degree of retraction is necessary to
appropriately lengthen the lid. Several interrupted
absorbable sutures (5-0 Vicryl) on both the distal and
proximal ends of the interposition graft are all that is
necessary for stabilization and fixation. Skin closure is
performed as described in Chapter 4, and the lid crease
may be created with supratarsal fixation when appro-
priate (see Fig. 4-6). Temporary tarsorrhaphy or Frost
sutures are especially useful in these procedures in the
immediate postoperative period. These provide immo-
bilization of the graft, adequate maintenance of length,
and general patient comfort (Figs. 8-11 and 8-12).
 P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N

LEVATOR SPACER FOR LID RETRACTION

A Lid is incised through orbicularis muscle

B Skin and orbicularis muscle are retracted

exposing levator aponeurosis, cut edge of
orbital septum, and preaponeurotic fat

C Upper margin of tarsal plate is dissected free

Figure 8-11 The levator muscle may

be recessed instead of advanced;
however, a spacer is needed when
recession is above the level of the D Levator aponeurosis dissected cephalad
superior tarsal border. The procedure
entails the same technique and
maneuvers as used in levator
advancement until the recession step.
A, An upper lid incision is made.
B, The levator aponeurosis and
levator muscle are exposed
transseptally. C, The tarsal plate is
exposed distally in the suborbicularis
plane. D, The levator is freed in a
distal-to-proximal dissection. E, The E Medial and lateral horns are divided freeing
medial and lateral horns of the superior aspect of levator aponeurosis
levator are divided. Continued

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Figure 8-11 Continued F, An

incision is made in the coronal
plane overlying the temporalis
muscle. The donor site can be
made inconspicuous by beveling
the incision according to the
direction of hair growth,
approximating the temporal line F Deep temporal fascia (DTF) harvest
superiorly and curving it well
behind the anterior hair line. It is
helpful to delineate the incision
preoperatively by having the
patient masticate and palpating
the underlying anatomy of the
temporalis muscle. I harvest a large
section of fascia and then split or G Graft sutured to tarsal plate
contour it according to the
requirements of the recipient site
or sites. Despite the sequence
depicted here, I usually harvest the
graft first and close the donor site
before beginning the eyelid aspect
of the procedure. I find this speeds
the entire procedure and obviates
head movement after the eyelid
has been incised. G and H, The
deep temporal fascial graft is then
used as a spacer between the
levator aponeurosis and the tarsal
plate. I find it easier to first suture
the graft to the tarsal plate and
then contour or trim the graft and
H DTF graft sutured to free end
appose the levator aponeurosis to of levator aponeurosis
the superior edge of the graft;
however, either way is acceptable.
I, Finally skin is approximated and
whenever possible I use a
temporary tarsorrhaphy I Closure - intracuticular running suture medial
postoperatively. to lateral

116
 P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N

A B

C D

E F
Figure 8-12 The clinical sequence for autogenous facial upper lid interposition lengthening requires only a few additional techniques beyond
what has already been described for levator surgery in the case of ptosis. A, The deep temporal fascia is harvested with a small incision in the
hairline below the temporal line. Closure without drains may be performed as described in the text. B, The levator is completely freed distal to
the tarsal plate as well as medially and laterally. Remember the lateral horn of the levator divides the lacrimal gland. In this case, with
significant previous surgery by others, there is a great deal of fibrosis and the right forceps overlies a small segment of exposed lacrimal gland.
Note the thickened and whitened fibrotic tissue of the levator distracted by the left forceps. C, Fascial graft is interposed between the levator and
tarsal plate. Here a lateral view shows the width of the temporal fascial graft, which is tented by the two forceps as it is being inset. D, Another
patient with the facial graft already sutured to the tarsal plate and inset on the left side (nasal) to the levator after the desired length and width
is created. The forceps is engaging the temporal side in preparation for the placement of a stabilizing suture. E, Same patient as seen in D
preoperatively. F, Same patient postoperatively as in the previous two photographs (D, E). This is approximately 1.5 years after the lengthening
procedure. Note the relative symmetry of eyelid position; however, there remains a modest superior sulcus deformity on the treated left side.
Continued

117
A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Figure 8-12 Continued G, Milder forms of upper lid

retraction without a soft tissue deficiency may be passively
corrected by weighing down the upper eyelid with a surgically
inserted gold weight. Usually these patients have an
imbalance between the eyelid elevators (levator, Müller’s) and
the eyelid depressors (orbicularis). This patient suffers from a
left facial palsy since birth and presents with complaints and
a physical examination consistent with corneal exposure from
G
a combination of upper lid retraction, lagophthalmos on
closure, and lower lid ptosis. Note his inferior scleral show
and cheek ptosis compared with the contralateral right side.
H, Here this patient is being assessed for an appropriate-size
gold weight preoperatively. The patient’s youth and
professional demands required that we achieve maximal
corneal coverage but leave him as cosmetically symmetric as
possible. As is always the case, the correction of lid retraction
should be maximal without interfering with the pupillary axis
and functional vision. I find it helpful in an office setting to H
try various weights that are adhered to the upper lid with a
topical adhesive (i.e., Mastisol or Steri-strip). Then the patient
can be evaluated through lid excursions. The weight chosen
leaves him with some residual scleral, but not corneal, show.
The weight should be placed beneath the pretarsal orbicularis
muscle and fixed to the tarsal plate. Access is through a
standard blepharoplasty incision. I, Here the patient is shown
approximately 3 months postoperatively after having
undergone an upper eyelid gold weight insertion, a lateral
canthoplasty of the lower eyelid, and a midface suspension
through the eyelid. I

P E A R LS A N D P I T FA L LS
1. True eyelid ptosis must be discriminated from pseudoptosis
before one embarks on a treatment plan.
2. Orbital volume discrepancies (enophthalmos or proptosis) can
produce pseudoptosis or pseudo retraction of the eyelids.
3. A high lid fold and superior sulcus deformity suggest levator
aponeurosis dehiscence.
4. Elevation of the upper eyelid will always cause higher
ambient evaporative tear loss and sometimes lid lag.
Preoperative evaluation should assess tolerance for these
sequelae.
5. The degree of ptosis and the level of levator function are the
two most important factors in determining which procedure
to perform.
6. The difference in lid aperture between extreme up gaze and
down gaze is a measurement of levator function.
7. Congenital ptosis consists of the triad of significant lid
malposition, poor-to-absent levator function, and significant
lid lag on down gaze. These characteristics are due to an
atonic and fibrotic levator muscle.
8. The tarsal conjunctival müllerectomy (TCM) (Fasanella-Servat)
is a posterior approach to mild ptosis.
9. In performing the TCM procedure, extreme care must be used
in cross-clamping and resection so as to induce a clean-
sweeping, arched, and not a peaked or retracted eyelid.
10. The levator tuck is an anterior approach to mild or small
degrees of moderate ptosis in the setting of good to excellent
levator function.
11. The levator advancement procedure is the most powerful
technique for ptosis correction, no matter how severe the
ptosis, provided levator function is good.
12. Complete levator advancement requires adequate cephalic
dissection along with lysis of the medial and lateral horns of
the levator.
13. The central suture in the advanced levator should lie at the
vertical meridian of the nasal pupillary margin.
14. A second suture laterally is helpful in avoiding too rapid a
decline in the upper eyelid height as it approaches the lateral
canthus.
15. Significant levator advancement and resection can be
employed in cases of congenital ptosis, provided enough
levator function exists.
16. In the absence of adequate levator function, exogenous
muscle must be employed to correct the ptosis (i.e., frontalis
sling).
17. The upper eyelid should be set at a lower level than normally
chosen in the presence of a poor Bell’s reflex or compromised
VII cranial nerve or orbicularis function.
18. Upper eyelid retraction must be distinguished from VII cranial
nerve or orbicularis muscle dysfunction.
19. A true deficiency in the middle lamella of the upper eyelid
requires a spacer for correction, whereas a nerve or muscular
compromise requires only a weighing down of the upper
eyelid.
20. The dissection for levator recession with interpositional
grafting (temporalis fascia) is the same as that for levator
advancement.

118

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Abdul-Rahim AS: Determination of resting upper eyelid
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Bartkowski SB, Zapala J, Wyszynska-Pawelec, G, Krzystkowa
KM: Marcus Gunn jaw-winking phenomenon: Management
and results of treatment in 19 patients. J Craniomaxillofac
Surg 27:25-29, 1999.
Bartley GB, Lowry JC, Hodge DO, et al: Results of levator-
advancement blepharoptosis repair using a standard
protocol: Effect of epinephrine-induced eyelid position
change. Trans Am Ophthalmol Soc 94:165-177, 1996.
Bradley EA, Bartley GB, Chapman KL, Waller RR: Surgical
correction of blepharoptosis in patients with myasthenia
gravis. Ophthalmic Plast Reconstr Surg 17:103-110, 2001.
Chen TH, Yang JY, Chen YR: Refined frontalis fascial sling with
proper lid crease formation for blepharoptosis. Plast
Reconstr Surg 99:34-40, 1997.
Dinces EA, Mauriello JA Jr, Kwartler JA, Franklin M:
Complications of gold weight eyelid implants for treatment
of fifth and seventh nerve paralysis. Laryngoscope 107(12 pt
1):1617-1622, 1997.
Harris WA, Dortzback RK: Levator tuck: A simplified
blepharoptosis procedure. Ann Ophthalmol 7:873-878,
1975.
Khan JA, Garden V, Faghihi M, Parvin M: Surgical method and
results of levator aponeurosis transposition for Graves’
eyelid retraction. Ophthalmic Surg Lasers 33:79-82, 2002.
Lim KH, Lee SY, Hwang JM: Primary levator synkinesis
associated with eye movement. J Pediatr Ophthalmol
Strabismus 38:179-180, 2001.
Mauriello JA Jr: Modified levator aponeurotic advancement
with delayed postoperative office revision. Ophthalmic
Plast Reconstr Surg 14:266-270, 1998.
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Mauriello JA Jr, Abdelsalam A: Modified levator aponeurotic
advancement with delayed postoperative office revision.
Ophthalmic Plast Reconstr Surg 14:266-270, 1998.
Mercandetti M, Putterman AM, Cohen ME, et al: Internal
levator advancement by Müller’s muscle-conjunctival
resection: Technique and review. Arch Facial Plast Surg
3:104-110, 2001.
Mulvihill A, O’Keefe M: Classification, assessment, and
management of childhood ptosis. Ophthalmol Clin North
Am 14:447, 2001.
Saeed M, Usama U, Aziz TM: Recession of levator in the
management of retracted upper lid. J Coll Physicians Surg
Pakistan 10:451-453, 2000.
Signorini M, Baruffaldi-Preis FW, Campiglio GL, Marsili MT:
Treatment of congenital and acquired upper eyelid ptosis:
Report of 131 consecutive cases. Eur J Plast Surg 23:349-
355, 2000.
Tellioglu AT, Saray A, Ergin A: Frontalis sling operation with
deep temporal fascial graft in blepharoptosis repair. Plast
Reconstr Surg 109:243-248, 2002.
Tezel E, Numanoglu A: Readjustment of the degree of lift
following frontalis sling operation in ptosis: A new and
simple method. Plast Reconstr Surg 104:587-588, 1999.
Tsa CC, Li TM, La CS, Li SD: Use of orbicularis oculi muscle
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frontalis suspension. Br J Plast Surg 53:473-476, 2000.
Tucker SM: Stabilization of eyelid height after aponeurotic
ptosis repair. Ophthalmology 106:517-522, 1999.
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aponeurotic ptosis repair. Ophthalmology 106:517-522,
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119

The Mid Face and Lateral
Canthus
ANATOMY AND
PATHOPHYSIOLOGY
There has been an evolution in the conceptualization
and the technical approaches to the periocular region
and mid face. In the past, surgeons have focused either
on the periocular region within the confines of the
orbital rim or on the face and brow outside the orbital
rim. These two areas were traditionally treated as
discrete entities. Classical thinking encouraged surgeons
to address either the eyelids alone, the face alone, or the
eyelids and face in combination, with the orbital rims
being not only a conceptual but also a technical
boundary in the amalgamation of a unified concept for
addressing anatomic and technical concerns in reju-
venative surgery of the face. As alluded to earlier in this
text, the lower eyelid, canthal structures, and mid face or
soft tissues overlying the zygoma should be thought of
as codependent anatomic and surgical regions. That is,
one must consider the lateral canthus, the lower eyelid,
and the cheek as three independent variables in the
equation we view as the mid face.
Anatomically, the lower eyelid fat pads are held
posteriorly and within the orbit by the orbital septum,
which effectively links the periosteum and periorbita to
the inferior tarsal plate. The arcus marginalis can be
viewed as a confluence of the periorbita, periosteum,
and orbital septum at or near the orbital rim. The
orbital malar ligament extends inferiorly and anteriorly
from the arcus marginalis. The orbital malar ligament
essentially links the orbital rim confluence or arcus
marginalis to the overlying malar soft tissue, including
skin. This is accomplished by way of its course through
the preorbital orbicularis muscle and malar fat pad. In
the youthful and aesthetically pleasing lower eyelid and
mid face, the distance between the superior edge of the
120
CHAPTER NINE
lower eyelid and the junction of the cheek is only
approximately 10 mm. This transition area is coplanar
or even slightly concave in youth. Senescence and
attenuation of the lateral canthal tendon allows the
lateral canthus to drift inferiorly and medially, short-
ening the intercommissure distance and changing the
normal lateral canthal inclination of 10 to 15 degrees
compared with the medial canthal position. Analo-
gously, the orbital malar ligament attenuates with age
and the soft tissues of the cheek or mid face undergo an
inferior medial ptosis. The distance from the upper
margin of the lower eyelid to cheek effectively lengthens,
extending well beyond the orbital rim inferiorly, as the
orbital malar ligament fails. This usually occurs con-
comitantly with lateral canthal tendon laxity so that all
three elements of the mid face equation are anatomi-
cally incorrect and connote the aged periocular look.
This consists of an inferior inclination to the lateral
canthus, lower lid ptosis with scleral show with or
without laxity, midface ptosis, and deepening of the
nasolabial fold. Further aging changes associated with
soft tissue and fat atrophy produce grooving in the
nasojugal region, the tear trough deformity, and depres-
sions along the lateral orbit (Figs. 9-1 and 9-2).
It is therefore important in the more youthful patient,
whose only complaint may be confined to cosmetic con-
cerns within the orbital rims, to address cosmetic con-
cerns while keeping in mind the eventual aging changes
that will occur at the orbital malar junction. We have all
seen patients who have had early aggressive fat resection
during blepharoplasty only to have a hollowed out or
concave inferior eyelid with malar ptosis and an orbital
rim viewed in relief 10 years after the original procedure.
It is these more youthful patients in whom conservative
resections, repositioning, and support procedures as
well as fat conservation, repositioning, and augmenta-
tion procedures should be considered and imple-
mented whenever possible and where indicated.
 T H E M I D FA C E A N D L A T E R A L C A N T H U S

CANTHOPEXY vs MIDFACE SUSPENSION w/CANTHOPEXY

Good cheek support Cheek support

is lacking

Figure 9-1 The mid face should be viewed as an amalgamation of the lateral canthus, lower eyelid, and cheek. These three elements should be
assessed independently and collectively in deciding which procedure is best suited for the patient. The left half of the drawing depicts lower lid
laxity, scleral show, and a coplanar medial-to-lateral canthal position with only slight shortening of the intercommissure distance. There is only
a modest descent of the malar soft tissues, as evidenced by the relatively short distance between the lower lid margin and the cheek. This patient
would be treatable with a canthopexy alone. In distinction, the patient on the right side demonstrates more significant scleral show, an inferiorly
placed lateral commissure compared with the medial, a significant distance between the lower eyelid and cheek soft tissues (despite eyelid
descent), and a depression between the lower eyelid and cheek, with the bony orbit rim clearly visualized in relief. This patient is not treatable
by a canthal procedure alone but needs midface suspension along with a canthal procedure. Patient assessment may be simplified into an
appreciation of the amount of cheek support present and then how one will support it, if necessary.

Figure 9-2 This patient demonstrates the point illustrated in the

drawing in Figure 9-1. Here the aging process is exaggerated by the
right facial paralysis secondary to a malignant parotid tumor
resection, and this allows us to view a single patient with two
distinct sides. The right side has significant midface ptosis as well as
lower eyelid ptosis with significant scleral show. The left side has
milder lower lid ptosis with a small amount of scleral show.
Although the left side demonstrates some midface ptosis for her age,
the lower eyelid position can be normalized with a canthal
procedure alone with midface suspension. The contralateral right
side is not correctable with a canthal procedure alone. A suspension
of the mid face is necessary along with a canthal procedure. Finally,
relative to Figure 8-12, this patient had a right upper eyelid gold
weight inserted at the time of her parotid resection by her original
surgeons. Notice the oblique, low, and superficial location of the
gold weight. This can usually be avoided by defining a limited
pretarsal suborbicularis pocket, positioning the weight in the
midtarsus, and stabilizing it in at least two distinct points to obviate
rotation in all planes.

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INDICATIONS FOR MIDFACE
SUSPENSION
The indications for addressing the mid face specifically
are the appearance described earlier in which the lower
lid to cheek distance is significantly elongated and the
orbital rim is visible with a concavity between the
pseudoherniated inferior and medial orbital fat and the
ptotic or inferiorly displaced malar fat pad. Other asso-
ciated abnormalities such as increased or deepening of
the nasolabial fold, tear trough deformity, and scleral
show may also be present. It is important to note that,
as has been previously mentioned, scleral show or lower
lid laxity in patients who have moderate or severe mid-
face ptosis are generally not well served by canthopexy
or canthoplasty alone. In fact, to reiterate an important
point, the lower eyelid cannot support the cheek.
Therefore, patients who present with significant mid-
face ptosis and lower eyelid dystopia are candidates for
midface suspension along with canthopexy or cantho-
plasty. At this juncture, clarification of canthopexy
versus canthoplasty should be repeated. The canthopexy
is a supportive procedure of the canthus in which the
lateral canthal crura are not divided, shortened, or
interrupted in any way. Generally, the common canthal
tendon is fixed cephalad and laterally to provide
minimal to moderate support. The canthoplasty should
be defined as a canthal support procedure in which the
inferior crus of the lateral canthal tendon is usually
divided; tarsal elements then serve as a neocanthal
tendon, should the lower lid require shortening, and
122
the lateral canthus is attached to the lateral orbital rim
in some fashion, as described in Chapter 3. A com-
missuroplasty or reconstruction of the lateral canthus is
then required; however, most surgeons should not find
this learning curve overly steep. There is a third canthal
support procedure that does divide the lateral canthal
tendon and does not require commissuroplasty. This
should be called a canthopexy with disinsertion of the
canthal tendon or, more appropriately, a common
canthoplasty. This procedure requires mobilization of
the entire lateral canthus and lateral retinaculum at the
periosteal junction and reinsertion cephalad at an
appropriate and desired level. Careful positioning of the
suspension suture through the soft tissue avoids dis-
tortion and extrusion postoperatively. In my experience
it provides the most latitude in repositioning the
canthus, and, with correct dissection, the lateral canthus
may be positioned as high as the eyebrow. The indi-
cation for this procedure should be the patient with
severe lateral tendon laxity in whom the entire lateral
canthus has drifted inferiorly and medially, presenting
with lower lid laxity, scleral show, and a dystopic
canthus declined (negatively inclined) by at least 15 to
20 degrees. These patients invariably demonstrate all of
the anatomic elements of midface ptosis. They also are
not especially well served with a lower lid canthoplasty
because shortening the lower eyelid does not serve to
reposition the superior crus of the lateral canthal
tendon and correct the inferior drift of the upper lateral
eyelid. Disinsertion of the lateral canthal tendon with
canthopexy is merely a modification and an evolution
of procedures familiar to surgeons with backgrounds in
craniofacial procedures (Fig. 9-3).
 T H E M I D FA C E A N D L A T E R A L C A N T H U S

A B

Figure 9-3 The common canthoplasty is

illustrated in these intraoperative photographs.
Unlike the common canthopexy, this procedure
requires complete disinsertion of the lateral
canthal tendon and lysis of the structures
stabilizing the lateral canthus, namely, the lateral
retinacular elements. This allows complete
mobilization and repositioning of the lateral
canthus. This is a very powerful technique. A, The
common canthal tendon has been isolated and
disinserted from its bony fixation point. The lateral
retinacular elements have been lysed, and the
canthus is free to be repositioned. Access is by way
of an upper lid blepharoplasty incision. The forceps
is holding the distal aspect of the common tendon.
B, External view demonstrating how the common
canthal tendon can be repositioned at any level
with the forceps holding the structure. C, A suture
engaging the tendon will then be fixed to
periosteum at a desired level around the arc of the
lateral orbit. The lateral insertion point may even
be altered should one prefer to elongate the
intercommissure distance. C

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
APPROACHES TO THE MID FACE
The midface or malar soft tissues may be addressed in a
number of ways, and the choice depends on the
patient's age, the degree of deformity, the objectives,
and the desires of the patient.
One may choose a transeyelid or canthal approach in
a patient who is younger (30s to 40s) and who has early
senescent changes and ptosis of the mid face but is not
quite ready for a full facialplasty and its associated
incision lines. It may also be chosen in the older patient
with significant facial aging changes whose complaints
are solely focused around the periocular region. These
patients are frequently symptomatic from lower lid and
canthal laxity but are usually unwilling to undergo a
more extensive facelift procedure. The surgeon is forced
to utilize a periocular incision to suspend the mid face
along with eyelid and canthal procedures, when the
preauricular incision is not available as access to
suspend the mid face.
The approach to the mid face familiar to most cos-
metic surgeons is the preauricular approach, as is typical
in a facelift procedure. The facelift incision should
extend somewhat into the temporal scalp either at or
posterior to the hairline. This should give the surgeon
adequate exposure to the deep temporal fascia, orbital
rim region, and the body and arch of the zygoma. With
the use of a needle-tip cautery, dissection is carried
down from the outer one third of the orbit laterally at
the level of the orbital rim. The dissection is carried
124
superiorly as one moves laterally, mimicking the
inclination of the orbital rim from medial to lateral.
Dissection is carried out over the face and body of the
zygoma parallel to the superior aspect of the zygomatic
arch. The exposure need only be carried out laterally to
the junction of the body and arch of the zygoma, and
then inferior dissection is completed lysing the orbital
malar ligament and exposing the suborbicularis oculi
fat (SOOF) pad. The dissection is carried out superficial
to the periosteum throughout the procedure, and the
soft tissues can then be fixed cephalad and laterally to
the underlying periosteum of the body of the zygoma
and zygomatic arch. Laterally along the arch I prefer to
plicate the superficial musculoaponeurotic system
(SMAS) from medial to lateral approaching the ear.
Following this, a canthopexy or canthoplasty may be
performed, after the facialplasty flaps have been
positioned. It is important for lower eyelid skin to be
conserved, and any resection should engender lateral
and cephalic tension. I prefer this approach whenever a
facelift is part of the planned procedure or in patients
who are not amenable to extended eyelid incisions or
whose cosmetic concerns far outweigh their functional
problems. In my experience, the facialplasty or pre-
auricular approach is a slightly less powerful technique
compared with the more direct transeyelid approach;
however, it is associated with a notably lessened com-
plication and revision rate. The appropriate lateral
cephalic vector is always easier to create by a direct
periocular approach to the mid face (Figs. 9-4 and 9-5).
 T H E M I D FA C E A N D L A T E R A L C A N T H U S

Facelift
incision

Malar fat pad

SMAS

SMAS sutured to zygomatic

periosteum

SOOF and malar fat pad sutured to deep temporal fascia

Figure 9-4 The cheek may be supported in a number of ways. The facelift incision (limited or
classic) may be used to gain access to the SMAS and SOOF. Patients with significant malar bulk are
more important and easier to suspend. The vector invoked in the lift is the key to eliminating or
softening the eyelid-to-cheek discrepancy as described earlier in the text (Chapters 1 to 3). The
facialplasty or facelift approach to the mid face can be satisfactory for suspension of the soft tissue
components that compose the infraorbital soft tissue structures. The correct vector must be induced
by the suspension. I find this technique alone to be less powerful than the direct periocular approach.
The advantage is that it avoids any extended periocular incisions and allows a total skin redraping
and rejuvenation.

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A B
Figure 9-5 In this patient a standard preauricular facialplasty incision was made and subcutaneous dissection carried to and over the orbital
rim. The lateral third to half of the orbital rim and septum are palpated through this route. The SOOF and malar fat pad are sutured to either
lateral zygomatic arch periosteum and/or deep temporal fascia. This approach is limited in that it does not practically allow the execution of a
suture suspension in the vertical plane as in the transeyelid midface suspension (see Fig. 9-6). A, Fiberoptic retractor view of a standard
facialplasty incision with a subcutaneous flap elevated. In the upper left is the deeper plane directly on the deep temporal fascia and a
transition leash of more superficial structures (superficial temporal vessels, facial nerve) delineating the two planes. The malar soft tissue is just
beyond and to the left of the center of the retractor. B, This is a close-up of A. The pre-orbital orbicularis muscle is reflected superiorly with the
flap, and the malar fat pad is directly in front of the retractor. Continued

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 T H E M I D FA C E A N D L A T E R A L C A N T H U S

C D
Figure 9-5 Continued C, A clear monofilament suture has already been passed through the malar soft tissue pad for suspension to more stable
lateral and cephalic structures. D, In distinction to malar suspension, the more lateral SMAS may be suspended by any means the surgeon feels
comfortable with. I prefer suture suspension in thinner patients in whom soft tissue augmentation of the zygoma is preferred.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The direct or periocular approach to the mid face is
by means of the lateral eyelid, and this may be further
subdivided into an upper or lower eyelid technique.
Generally, the upper eyelid approach is preferred in
patients in whom disinsertion of the lateral canthal
tendon and canthopexy is planned and/or in those who
do not want or need a lower eyelid skin incision. The
dissection affords a more cephalic and lateral exposure
of the superior lateral orbital rim, although the
approach is farther from the malar soft tissues. As with
all midface and canthal procedures, adequate mobili-
zation of the soft tissues is necessary and canthopexy of
the common canthal tendon requires that the surgeon
128
carefully avoid lateral elements of the levator apo-
neurosis or lateral horn of the levator in the fixation
sutures. Superior tethering of the lateral upper lid may
result in incomplete lateral closure, and a peaked lateral
contour can result from lateral levator entrapment in
the canthopexy. As in the facialplasty approach, the
dissection is carried out above the periosteum, dividing
the orbital malar ligament and releasing the soft tissues.
The malar fat pad is vertically and laterally elevated by
way of the suspension sutures. The lateral canthus can
then be tightened and/or elevated, and a conservative
skin excision may be performed (Figs. 9-6 and 9-7).
 T H E M I D FA C E A N D L A T E R A L C A N T H U S

MODIFIED CHEEK LIFT

A Access via upper or lower

blepharoplasty incision

Orbital fat

Orbital septum
Orbicularis
muscle
Malar bag
Orbitomalar
ligament
SOOF
Malar fat pad
Zygomaticus muscle
SMAS
Buccal fat pad
B Extent of sub-orbicularis muscle/
malar fat pad/SMAS undermining

Single mattress
suture repair

C Cheek flap is elevated and sutured

to deep temporal fascia or
periosteum of lateral orbital rim

Figure 9-6 The anatomy of the soft tissue of the cheek overlying the zygoma. The arrow in red
depicts the plane of dissection to the midfacial structures in the cheek in a supraperiosteal approach.
A, Access may be by way of the upper lid or lower lid blepharoplasty incision. Dissection should be
carried out to the malar fat pad, and it may be suspended to periosteum along the orbital rim or
more laterally to the deep temporal fascia. I find the upper lid approach technically more difficult to
execute but much easier to engender the appropriate cheek vector suspension. B, In both approaches
a canthal support procedure is used, remembering to completely mobilize the lateral canthus with
lysis of the entire lateral retinaculum. This is usually best performed before the cheek suspension is
completed and access becomes limited. C, One or two mattress sutures are sufficient to suspend the
cheek structures.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

B C
Figure 9-7 The midfacial structures may be approached by way of the upper or lower eyelid. I prefer a lateral upper eyelid technique because
this is most amenable to allowing the surgeon to access all the structures and induce the appropriate vector to the mid face elevation with the
least complications and as few unsightly incisions as possible. I also find a direct vertical transcutaneous or transconjunctival midface
suspension to be less effective and more prone to complications. These pure lid approaches, while not requiring a lateral extent to the incision,
do not induce enough suspension in the appropriate vector. A, A close-up view of the exposure to the mid face accessed by the lateral extent of
an upper blepharoplasty incision. The entire lateral retinaculum and canthal tendon have been mobilized, and a suture has been placed
through the common canthal tendon. The exposure allows the inferior orbit and mid face to be accessed. B, This is the same patient as seen in
the operating room (A) before surgery. She had undergone a facelift and a blepharoplasty by another surgeon in the distant past. She presents
with scleral show (right greater than left) and an elongated distance between her eyelid and mid face. She complains of dry eyes, symptoms of
corneal exposure, as well as the appearance of her periocular and midface region. She does not have significant generalized facial ptosis. Note
the blunting of the right canthus. C, The same patient preoperatively seen with a focused view of the eyelids and midface region from the right
side. Note the orbital rim viewed in relief. There is increased bowing of the right lower eyelid in its lateral one half and upper lid retraction.
These all account for her functional and cosmetic complaints. She preferred to maintain her upper lid position if possible. Continued

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 T H E M I D FA C E A N D L A T E R A L C A N T H U S

D E

F G
Figure 9-7 Continued D, The same patient after an upper lid skin trim, common canthoplasty, and midface suspension all through the upper
eyelid. I used the erbium laser to resurface the lower eyelid skin. The lateral canthi have been rendered more acute and the intercommissure
distance elongated. This is especially visible on the right. The eyelid-to-midface distance has been foreshortened. E, A close-up view of the same
structures after surgery shows a significant improvement but some residual asymmetry in the eyelid-to-globe relationship. F, The purely vertical
midface suspension is seen in this patient. Access is through a limited transcutaneous lower eyelid incision, and the structures to be suspended
are held in the forceps. G, Suspension sutures are placed between the mid face deep soft tissue structures and the periosteum along the
orbital rim.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
The lower lid approach to the mid face is similar to
the upper lid approach; however, it cannot be used to
transpose the entire lateral canthal unit cephalad as can
be achieved in the upper lid approach. I find it very
difficult to accomplish the correct vertical and lateral
canthal position when one uses an inferior eyelid access
incision. I also find the incision lines to be less well
tolerated and more frequently prone to requiring
revisions or modifications compared with an upper
lid or facialplasty approach. Fat repositioning or con-
servation procedures may be used in any of these
approaches, and a transconjunctival approach with a
lateral canthotomy and midface suspension combined
with conservative skin excision may be an ideal route of
choice in some patients. Common to all approaches,
the mid face must be adequately released and mobi-
lized in every case. It must be adequately elevated in a
vertical lateral plane paralleling a line between the
lateral commissure of the mouth and the lateral
canthus. It is important to fixate the malar tissue with
long-acting sutures to nonmovable stable areas of the
orbit, such as the deep temporal fascia and periosteum,
invoking the appropriate vector orientation to the lift.
The lower eyelid or common canthal tendon must be
adequately mobilized, stabilized, and fixed to the inter-
nal orbital rim periosteum, and skin excision should be
132
deferred or only conservatively performed, being
mindful of the vertical lateral vector and the inherent
flexibility to perform a secondary skin procedure. Skin
excision, whether primary or secondary, should always
employ the same vector (lateral and superior) as in the
midface suspension. Midface suspension procedures
combined with blepharoplasty account for a significant
number of revisional procedures in most experienced
hands; although these are usually small procedures, any
revision in my practice is significant. In my series, the
over 200 cases of transeyelid (upper and/or lower) mid-
face elevations combined with blepharoplasty resulted
in a 12% complication rate. Half of those patients (6%)
required only additional skin resection or scar modifi-
cations as an outpatient office procedure. The other half
(6% of complications) had more significant problems,
including asymmetry of the lateral canthus or malar soft
tissues, warranting more significant modifications,
again as an outpatient procedure.
Midface suspension by way of a facialplasty approach
resulted in significantly less complications and need for
revisions; however, these were generally applied as an
optimal choice by the surgeon for patients with fewer
ocular symptoms, greater cosmetic concerns, and those
seeking more generalized rejuvenative procedures
(Fig. 9-8).
 T H E M I D FA C E A N D L A T E R A L C A N T H U S

A B

C D

Figure 9-8 Classical approaches to the mid face and periocular region can be modified by incorporating more modern, powerful, and direct
approaches to the canthi, mid face, and other periocular structures. In general, I find these direct approaches very potent, but also more prone
to less forgiving complications. These direct approaches also do not afford a generalized rejuvenative procedure, which in many instances is
what is really indicated. A, This is a patient with generalized facial ptosis that is manifested by jowling, neck redundancy, midface ptosis, brow
ptosis, and upper eyelid redundancy. She also has lower lid ptosis, scleral show, and lateral canthal dystopia. B, Postoperative view 1 year after
facialplasty with internal midface and SMAS suspension, blepharoplasty, levator plication, lower lid canthoplasty, and endoscopic resection of
the brow protractors. Note the significant correction in midface ptosis. There is more notable periocular correction of the canthal dystopia, lower
and upper eyelid malposition, as well as the generalized facial improvement and rejuvenation. C, Full right lateral view preoperatively. D, Full
right lateral view 1 year postoperatively. Continued

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

E F

G H
Figure 9-8 Continued E, Close-up view of the periocular and midface region preoperatively demonstrating scleral show, canthal dystopia,
upper lid asymmetric ptosis, and dermatochalasis. F, Close-up frontal view of the periocular region postoperatively. G, Lateral view
preoperatively showing pathology in the periocular region. H, Lateral view postoperatively demonstrating improvement in the mid face and
lower and upper eyelids.

134

P E A R LS A N D P I T FA L LS
1. The lower eyelid and mid face are contiguous and limited both
anatomically and aesthetically. Over time the distance
between the lower eyelid and the cheek elongates.
2. Aging changes also occur in the lateral canthal tendon, leading
to a negative canthal angle and lower eyelid and midface
ptosis, with scleral show and deepening of the nasolabial fold.
3. The common canthoplasty is an ideal procedure for the patient
with lower lid laxity, vertical dystopia, and medialization of the
lateral canthal complex.
References
Collawn SS, Vascconez LO, Gamboa M, et al: Subcutaneous
approach for elevation of the malar fat pad through a
prehairline incision. Plast Reconstr Surg 97:836-841, 1996.
Finger ER: A 5-year study of the transmalar subperiosteal mid
face lift with minimal skin and superficial musculo-
aponeurotic system dissection: A durable, natural-appearing
lift with less surgery and recovery time. Plast Reconstr Surg
107:1273-1283; discussion 1284, 2001.
Gunter JP, Hackney FL, Hester TR Jr, et al: A simplified
transblepharoplasty subperiosteal cheek lift. Plast Reconstr
Surg 103:2029-2041, 1999.
Hamra ST: Evolution of technique of the direct trans-
blepharoplasty approach for the correction of lower lid and
mid facial aging: Maximizing results and minimizing
complications in a 5-year experience: Discussion. Plast
Reconstr Surg 105:407-408, 2000.
Hamra ST: Frequent face lift sequelae: Hollow eyes and the
lateral sweep: Cause and repair. Plast Reconstr Surg
102:1658-1666, 1998.
Hesse RJ: The tarsal sandwich: A new technique in lateral
canthoplasty. Ophthalmic Plast Reconstr Surg 16:39-41,
2000.
Hester TR Jr: Evolution of lower lid support following lower
lid/mid face rejuvenation: The pretarsal orbicularis lateral
canthopexy. Clin Plast Surg 28:639-652, 2001.
Hinderer UT: Vertical preperiosteal rejuvenation of the frame
of the eyelids and mid face. Plast Reconstr Surg 104:1482-
1499; discussion 1500-1501, 1999.
Jelks GW, Glat PM, Jelks EB, Longaker MT: The inferior
retinacular lateral canthoplasty: A new technique. Plast
Reconstr Surg 100:1262-1270; discussion 1271-1275, 1997.
T H E M I D FA C E A N D L A T E R A L C A N T H U S
4. The mid face may be approached by way of the upper or lower
lateral eyelid, transconjunctivally, and by way of a facialplasty
route.
5. The facialplasty approach is associated with fewer com-
plications and revisions but is more applicable to patients with
fewer ocular symptoms and more generalized cosmetic
concerns.
Little JW: Three-dimensional rejuvenation of the mid face:
Volumetric resculpture by malar imbrication. Plast Reconstr
Surg 105:267-285; discussion 286-289, 2000.
Little JW: Volumetric perceptions in mid facial aging with
altered priorities for rejuvenation. Plastic Reconstr Surg
106:1653-1656, 2000.
McCord CD Jr, Codner MA, Hester TR: Redraping the inferior
orbicularis arc. Plast Reconstr Surg 102:2471-2479, 1998.
Mendelson BC: Surgery of the superficial musculoaponeurotic
system: Principles of release, vectors, and fixation. Plast
Reconstr Surg 107:1545-1552, 2001.
Moelleken B: The superficial subciliary cheek lift, a technique
for rejuvenating the infraorbital region and nasojugal
groove: A clinical series of 71 patients. Plast Reconstr Surg
104:1863-1874; discussion 1875-1876, 1999.
Moss CJ, Mendelson BC, Taylor GI: Surgical anatomy of the
ligamentous attachments in the temple and periorbital
regions. Plast Reconstr Surg 105:1475-1490, 2000.
Olver JM: Raising the suborbicularis oculi fat (SOOF): Its role
in chronic facial palsy. Br J Ophthalmol 84:1401-1406,
2000.
Pessa JE, Zadoo VP, Adrian EK Jr, et al: Variability of the mid
facial muscles: Analysis of 50 hemifacial cadaver
dissections. Plast Reconstr Surg 102:1888-1893, 1998.
Turk JB, Goldman A: SOOF lift and lateral retinacular
canthoplasty. Facial Plast Surg 17:37-48, 2001.
Yaremchuk MJ: Subperiosteal and full-thickness skin rhyti-
dectomy. Plast Reconstr Surg 107:1045-1058, 2001.
135

COSMETIC AND
ANATOMIC CONSIDERATIONS
OF THE BROW
Patients sometimes present with complaints related to
the cosmetic appearance of their upper eyelids. They
may not perceive how associated eyebrow ptosis or
drooping of their eyebrows accentuates their upper eye-
lid abnormalities. Sometimes, fullness of the lateral
brow region, especially in females, is described by the
patient as solely encompassing abnormalities related to
upper eyelid pathology. It is up to the examining
surgeon to isolate the eyelid and eyebrow abnormalities
and carefully review with the patient the contribution
these entities make. Patients may indeed have upper lid
dermatochalasis and herniated fat, but they may also
have associated sub-brow fat pad thickening and/or
lateral brow ptosis that cannot be optimally repaired
with a blepharoplasty alone. Suboptimal blepharoplasty
will result when brow ptosis and sub-brow fat pad
hypertrophy is left unaddressed. The eyebrow in most
individuals is an expressive unit of the face that is
functional owing to a movable superficial musculo-
cutaneous plane that slides over a rigidly fixed bone and
periosteal plane. Below the preseptal and preorbital
orbicularis is a distinct fat pad that is more prominent
laterally than medially. This fat pad enhances eyebrow
motility and through it dense attachments secure the
brow to the supraorbital ridge. This brow fat pad com-
monly extends inferiorly into the preorbital septal
plane, especially in older individuals, and should be
distinguished from the preaponeurotic fat or postseptal
fat, which is commonly addressed in the blepharoplasty
procedure.
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CHAPTER TEN
The Eyebrow and
Lacrimal Gland
Size and position of the brow fat pad can contribute
to sexual differences, and the surgeon must be cogni-
zant of these differences not only in performing reju-
venative procedures but in avoiding masculinization of
the female patient and, more commonly, feminization
of the male patient. The brow is generally arched and
above the level of the supraorbital rim in females. In
males it is flatter and positioned at or just slightly above
the supraorbital rim. The fat pad in males is more
prominent than in females, producing a fuller medial-
to-lateral brow that is usually proportional to the
increased bony supraorbital fullness found medially
and centrally but is secondary to increased frontal sinus
aeration. Obviously, planning a surgical procedure
should take into account gender variations so as to
maximize the aesthetic result. The position of the lateral
one third of the eyebrow is considered the most aesthet-
ically important region of the brow, and it is also the
most commonly ptotic area, owing to a relative paucity
of firm attachments of the brow fat pad to the supra-
orbital rim periosteum in this region. Medially, the
brow is more firmly fixed to the underlying supraorbital
ridge in all individuals. The frontalis muscle inter-
digitates with the orbicularis oculi muscle medially, and
this serves as an additional support mechanism for the
medial eyebrow.
The surgeon should be familiar with the relevant
anatomy of the supraorbital and supratrochlear neuro-
vascular bundles as well as the course of the frontal
branch of the facial nerve before performing any pro-
cedures involving positioning or debulking the eyebrow
region. The patient who presents with upper lid
dermatochalasis associated with brow ptosis should be
examined as described previously, and the surgeon
should reposition the eyebrow digitally and examine
the eyelids for dermatochalasis. Female patients who
have dermatochalasis with lateral brow ptosis asso-

ciated with a fullness extending from the eyebrow into
the lateral eyelid are often candidates for debulking the
lateral brow fat pad. Males and females who have lateral
brow ptosis may undergo suspension or browpexy at
the time of blepharoplasty to improve aesthetic results.
The objective should be for the surgeon to create an
aesthetically discrete eyelid that is distinct from the
eyebrow and brow region yet smoothly and naturally
blends from eyelid to sulcus to eyebrow. Ptosis and/or
excessive sub-brow fat (especially in women) can blur
this distinction. Therefore, the results in upper lid
blepharoplasty can be enhanced by restoring the
natural height and curvature of the eyebrow along with
diminishing the bulk of the eyebrow.
In all approaches to the browlift, especially combined
with blepharoplasty, the amount of browlift desired is
determined while the patient is sitting, and the amount
of skin resection should be determined after the brow is
digitally stabilized at the desired height. This should
serve to avoid overcorrection of the brow and, more
commonly, the eyelid, resulting in lagophthalmos. It is
also important and helpful to clinically determine the
location of the supratrochlear and supraorbital neuro-
vascular bundles because these should be identified and
preserved in any of the techniques used for brow sus-
pension. These are reliably found approximately 11 and
22 mm, respectively, from the midline of the naso-
frontal junction. One can simply palpate their respec-
tive bony notches or foramen and ascertain the course
of their corresponding neurovascular bundles without
the need for memorizing any numbers.
THE LACRIMAL GLAND
Disorders of the suspensory ligaments and the orbital
septum around the lacrimal gland are an additional
pathologic state worth discussing at this juncture. As
discussed in Chapter 1, the gland is divided into an
orbital and palpebral lobe with the orbital lobe
suspended within the lacrimal fossa just internal to the
orbital rim. The gland can prolapse forward with
relaxation of these suspensory ligaments and produce a
noticeable bulge in the upper eyelid. Patients may
complain of a movable soft nontender and nonpainful
mass that encroaches on the upper outer eyelid. It is
encountered in most states of intrinsic relaxation and
associated with aging, although it may occur secondary
T H E E Y E B ROW A N D LA C R I M A L G LA N D
to trauma, after repeated bouts of orbital edema, or in
true blepharochalasis as described in Chapter 4. The
physical examination is consistent with a sharply
demarcated easily reducible mass in the upper outer
orbit. In cases of markedly herniated orbital fat, the
prolapsed gland may not be discovered until the actual
blepharoplasty is performed. The lacrimal gland is
normally suspended within the lacrimal fossa by small
ligaments to the frontal bone superiorly, zygoma
inferiorly, and periorbita posteriorly. It is tethered by
the lacrimal nerve and vessels that enter the gland from
the periorbital surface. The lateral aspect of the orbital
section of this gland is contiguous with preaponeurotic
fat and can be visualized in many blepharoplasty
procedures. In distinction, the palpebral lobe of the
gland is about one fourth to one third the size of the
orbital lobe and lies beneath the levator aponeurosis,
within the confines of the superior lateral fornix. From
a functional standpoint, it is best not to remove any
sections of the gland because this may result in a dry eye
syndrome. Obviously, biopsies or full glandular
resections for various tumors and inflammatory
processes may be necessary. Suspension of the lacrimal
gland should be considered in every blepharoplasty
case, along with brow positioning, browplasty, and
other periocular procedures (Fig.10-1).
BROWPLASTY, BROWPEXY, AND
LACRIMAL GLAND SUSPENSION
One may perform a browplasty, browpexy, eyebrow fat
pad reduction, or lacrimal gland suspension in any
standard blepharoplasty of the upper eyelid. A cephalic
dissection can be carried out in the submuscular plane
through the postorbicularis fascia, without violating
periosteum, after skin, muscle, and preaponeurotic fat
are appropriately resected from the upper lid. The dis-
section should be carried out 1.5 to 2 cm above the
superior and lateral orbital rim. The easily palpable
brow fat pad may be identified overlying the lateral
orbital margin. I prefer to resect a desired amount of fat
from medial to lateral, being cognizant of the course of
the supraorbital neurovascular bundle. An approxi-
mately 1 cm vertically high (widest point) ellipse of fat
is resected and tapered medially and laterally without
violating periosteum. The periosteum is left intact to
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maintain the gliding surface and as a fixation point
should browpexy be necessary or desired. I prefer to use
an insulated needle tip cautery for this dissection, and it
is useful to optimize exposure with one or two small
rakes or double-pronged retractors on the superior edge
of the blepharoplasty incision line, performed as
described previously in the text after the blepharoplasty
and fat pad are addressed. This is an especially powerful
technique in female patients with thickened brow pads
who are undergoing blepharoplasty. It allows the
surgeon to diminish the difference between a full and
more masculine brow and the thin upper eyelid.
Browpexy or suspension of the eyebrow may be
performed at the time of upper lid blepharoplasty with
or without browplasty or brow fat resection. In male
patients, one is more likely to leave the brow fat pad
intact to maintain the normal anatomic fullness in this
region. In distinction, appropriate female patients may
have the brow fat pad reduced at the time of browpexy.
The dissection is similar to that described in browplasty,
with fixation or plication of the eyebrow to the supra-
orbital rim periosteum. I prefer two interrupted fixation
points either mimicking the straighter brow of males or
the mid-arched eyebrow of females. The underlying
periosteum is exposed without violating it in the sub-
brow space to approximately 2 cm above the orbital rim
or to the area for suspension as described in the
browplasty approach. Each suspension suture is passed
through the subcutaneous tissue of the eyebrow at the
level of the inferior eyebrow hairs. These sutures are
then fixed to the periosteum at the desired level of
suspension and tied down. I prefer to use a 3-0 absorb-
able monofilament (e.g., Monocryl, PDS). It is impor-
tant to place the brow fixation sutures deeply enough so
as to avoid dimpling of the overlying skin and yet
provide enough fixation and stability to induce a mild
browlift effect that lasts but that still allows good range
of motion of the overlying soft tissues. I find it helpful
to evaluate the patient preoperatively by using pre-
determined vertical orientation lines. The brow is di-
gitally elevated to a desired position. The distance from
the inferior brow margin along these vertical meridians
is measured and noted. These distances can then be
used to dictate suture placement intraoperatively. I use
methylene blue and 25-gauge needles to facilitate the
transfer of these measurements from external brow
topography to the periosteal surface (Figs. 10-2 and 10-3).

A B
Figure 10-1 The lacrimal gland may prolapse and cause upper outer lid fullness that is not correctable with fat resection alone. Lacrimal gland
suspension using the capsule of the gland and orbital periosteum as anchor points is a solution that can be achieved through an upper
blepharoplasty incision. This is the same patient as seen in Figure 1-18. A, This patient demonstrates lateral upper lid fullness anterior and
below the orbital rim. Palpation allows discrimination of the orbital fat from that of lacrimal gland prolapse. Eversion of the upper eyelid
can also allow the surgeon to appreciate the prolapse of structures in this region (see Fig. 1-17). B, The lacrimal gland prolapse can be seen in
Figure 1-18. Note the capsule of the gland has been violated to demonstrate the enclosed glandular structure. This should be avoided in general
when suspension techniques are employed. Capsule violation, however, does not preclude a successful suspension. This photograph demonstrates
how the suspension technique is employed. The forceps is pushing the gland back under the lateral orbital rim. The technique required sutures
to be placed between the gland capsule and the internal orbital periosteum. I prefer a double-armed semicircular needle to allow easy execution
of this procedure.

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 T H E E Y E B ROW A N D LA C R I M A L G LA N D

BROW SUSPENSION THROUGH UPPER LID

Supraorbital nerve

Medial dissection
to access brow
protractors
A Dissection in the (corrugator and
suborbicularis procerus muscles)
muscle plane

Orbital rim

Figure 10-2 An alternative to the

external browlift (endoscopic,
temporal, or coronal) is the internal
browplasty by way of an upper eyelid B Debulking the brow fat pad
approach. Transpalpebral brow fat pad
reduction and browlift, especially in
the lateral one third, are easily
executed. The same incision and access
route may be applied medially to
address the protractors of the brow
(corrugator and procerus muscles). The
medial dissection warrants
preservation of the supraorbital and
supratrochlear neurovascular bundles.
The lateral dissection is devoid of
neurovascular structures. A, The
dissection plane is accessed by way of
a blepharoplasty incision. Dissection is
carried in the suborbicularis plane onto
the periosteal surface of the orbital rim
and then may be continued superiorly.
B, The undersurface of the eyebrow
(fat pad) may be debulked with needle- C Subbrow tissue anchored
to suprabrow periosteum
tip insulated cautery if indicated.
C, With the use of both a cutaneous
and a bony landmark as guides (lower
margin eyebrow hair and orbital rim)
the deep dermis is sutured to the
frontal bone periosteum at the desired
level of suspension. The eyelid incision
may be closed in the usual fashion.

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A B

Figure 10-3 A, An upper blepharoplasty incision is used to gain access to the supra-eyelid region by carrying the dissection cephalad over
the orbital rim, leaving the periosteum intact. Note the blue marks extending from the eyebrow into the temporal hair. Preoperatively, I
delineate areas of the brow and the line I would like to elevate these in with the patient sitting or standing. I also pick several reference points
(i.e., inferior eyebrow hairline and a distance above the orbital rim) on the soft tissue of the brow and the underlying bone. This allows
appropriate intraoperative fixation and positioning. B, A suture is then passed between the soft tissue pad at the preoperatively chosen reference
point. This suture should engage soft tissue as deeply as possible without overtly passing through the skin surface. The periosteum is then
engaged at the desired level above the orbital rim. In this photograph one can see a single suture already through the soft tissue and the needle,
in continuity with the first pass, engaging the periosteum above the orbital rim at the preoperatively chosen level. I usually pick at least two
fixation points, one in the central and one in the lateral one third of the brow. C, This patient presented with a residual or lateral brow
asymmetry several years after a viral illness (Bell’s palsy). The right eyebrow is ptotic compared with the left. The eyelids are closed to eliminate
any impact the visual axis and eyelid position may have on intrinsic eyebrow position. Continued

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Figure 10-3 Continued D, Appearance of patient in C approximately 6 months after right brow suspension by an internal approach as already
described. Note the right brow elevated into a symmetric or slightly overcorrected position. E, This is a patient with benign essential
blepharospasm who underwent a protractor stripping (removal) and a subtle internal brow suspension through the upper eyelid. No upper
eyelid skin was removed, and the degree of brow suspension was purposely small because the patient also suffers from a dry eye syndrome.
F, The postoperative view shows that I undercorrected the right brow suspension, but there is a small but appreciable elevation to the brows as
evidenced by less upper lid crowding.

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DIRECT TEMPORAL LIFT
In patients with mild-to-moderate lateral brow ptosis
who are not undergoing an upper lid blepharoplasty to
access the brow fat pad, a direct lateral temporal lift can
be effective either as an extension of a facialplasty or
alone. An incision is made down to the deep temporal
fascia depending on the surgeon's choice for a facial-
plasty incision (pre- or post-hairline). The incision ex-
poses the deep temporal fascia, and anterior dissection
is carried out between the superficial temporal fascia
and superficial layer of the deep temporal fascia. Blunt
digital dissection is all that is necessary once one
completely exposes the deep temporal fascia devoid of
any overlying soft tissue elements. The frontal branch of
the facial nerve can be injured either with traction or
dissection, and establishing the appropriate plane and
utilizing minimal instrumentation is the best approach
142
to obviating complications. Dissection is carried out to
the junction of the lateral third of the eyebrow; and
fascial attachments, as described earlier, are lysed. It is
important that the entire lateral third of the eyebrow
extending from the frontal bone to the frontal process
of the zygoma is freed and mobilized. The brow should
be freed across the frontozygomatic articulation to
allow correction of lateral upper lid hooding. The flap is
rotated posteriorly and cephalad, and an appropriate
amount of scalp or skin is resected. Dog-ears are
removed at the superior extent of the incision. These
invariably occur when the flap is rotated superiorly
rather than simply pulled posteriorly. Care should be
taken not to create significant tension, because this
results in alopecia. A layered closure with several stay
sutures encompassing the deep temporal fascia assists
in maintaining stability to the browlift and avoids
widening of incision lines (Fig. 10-4).
 T H E E Y E B ROW A N D LA C R I M A L G LA N D

A B
Figure 10-4 The lateral one third of the eyebrow may be suspended through an incision in or just in front of the temporal hairline alone or as
an extension of a facialplasty incision. The deep temporal fascia can be used as a fixation point, and this can serve to obtain a natural looking
brow suspension laterally. In cases where a more medial or central brow elevation is indicated along with a facelift, I have combined the
endoscopic route with this technique to address respective areas of brow ptosis. A, The staple line indicates the pretrichial incision line with the
deep temporal fascia as an anchor for the lateral brow suspension. B, The incision line in continuity with facialplasty incision approximately
1 year postoperatively.

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DIRECT BROWLIFT
Direct browlift by means of external skin excision above
the eyebrow is well described and has a long history,
especially in the ophthalmic literature. It is effective in
mild-to-moderate cases of brow ptosis and quick and
easy to perform. It requires an extremely accurate and
precise closure of the skin to achieve even a moderately
acceptable scar for most patients. There are functional
brow ptosis cases in aged individuals or other miti-
gating conditions in which this procedure may be
warranted and acceptable; however, in general, I do not
recommend this approach, given the number of other
procedures available and the significant risk of gen-
erating unsatisfactory incision lines. Surgeons who have
considerable experience with this technique stress the
need for meticulous biconcave elliptical excisions of
skin that are beveled cephalad in the direction of the
eyebrow hair growth and mimic an endogenous fore-
head crease. The dissection is always above the perios-
teum to preserve neurovascular integrity. A meticulous
layered closure is necessary, and the final residual scar
should lie just above and hugging the superior eyebrow
hair follicles. Full browlifting by means of a coronal or
an endoscopic approach is amply described in other
texts and publications, and therefore it is not necessary
to include these approaches in this discussion.
For the sake of completeness, extending the medial
upper eyelid dissection cephalad into the medial brow,
as is done in the lateral brow for pexy or plasty pro-
cedures, can be a useful approach to the protractors
of the eyebrow (corrugator supercilii and procerus
144
P E A R LS A N D P I T FA L LS
1. The examining surgeon should isolate the eyelid and eye-
brow and assess the relative contribution each makes to the
cosmetic abnormality.
2. The lateral one-third of the brow is most prone to ptosis
and is the most important aesthetic aspect contributing to
a senescent appearance.
3. In performing the browlift and upper blepharoplasty in a
single procedure, one must be careful to avoid over-
correction producing lagophthalmos. It is helpful fo make
preoperative markings with the patient sitting and the brow
stabilized in the planned superior position.
4. Lacrimal gland prolapse can present as lateral upper lid
fullness, which can blend with a laterally ptotic and
thickened brow pad.
5. In women, a thickened brow fat pad must be thinned
during blepharoplasty. This should generally be avoided in
men as it can be feminizing.
6. Direct brow lifts generally result in unacceptable scars and
the procedure requires precise surgical technique to
produce acceptable results.
7. The upper eyelid incision can be used to access the
protractors of the eyebrow (corrugator supercilii and
procerus muscles).
muscles). Each of these muscle bellies can be isolated
and identified while preserving the supraorbital and
supratrochlear neurovascular bundles. The muscle
bellies may be divided and partially resected to assist in
improving mid-forehead glabella folds and engen-
dering a slight medial lift. This area is prone to signi-
ficant ecchymosis and swelling after any muscle
resection, and meticulous hemostasis in this area is
helpful in avoiding some of these postoperative
sequelae (Fig. 10-5).
 T H E E Y E B ROW A N D LA C R I M A L G LA N D

A B
Figure 10-5 The protractors of the eyebrow including the procerus and the corrugator supercilii can be approached through the upper eyelid.
In the lateral and central brow suspension, neurovascular structures do not complicate the procedure, but in the medial brow suspension and/or
protractor muscular resection, the supraorbital and supratrochlear structures should be identified and preserved. A, The neurovascular structures
(supraorbital) are identified and preserved as seen above and medial to the forceps. B, A muscular protractor of the right eyebrow corrugator is
isolated and is grasped in the forceps. I then remove a large portion of the muscle with a needle tip cautery with the neurovascular bundle
protected. The procerus muscular complex may be similarly addressed.

References

Carter SR, Choo PH: New techniques in eyebrow surgery.
Ophthalmol Clin North Am 13:731-748, 2000.
Dayan SH, Perkins SW, Vartanian AJ, Wiesman IM: The
forehead lift: Endoscopic versus coronal approaches.
Aesthet Plast Surg 25:35-39, 2001.
Knize DM: Muscles that act on glabellar skin: A closer look.
Plast Reconstr Surg 105:350-361, 2000.
Leopizzi G: A transpalpebral approach to treatment of
eyebrow ptosis. Aesthet Plast Surg 23:125-130, 1999.
Paul MD: Subperiosteal transblepharoplasty forehead lift.
Aesthet Plast Surg 20:129-134, 1996.
Ramirez OM: Transblepharoplasty forehead lift and upper
face rejuvenation. Ann Plast Surg 37:577-584, 1996.
Yeatts RP: Current concepts in brow lift surgery. Curr Opin
Ophthalmol 8(5):46-50, 1997.
Zarem HA, Resnick JI, Carr RM, Wootton DG: Browpexy:
Lateral orbicularis muscle fixation as an adjunct to upper
blepharoplasty. Plast Reconstr Surg 101:1736, 1998.

145

Cosmetic Cranio-orbital
Surgery
There is a subgroup of patients with cosmetic problems
that are often beyond correction within the realm of
soft tissue procedures alone. Bony changes must be
instituted in addition to the soft tissue procedures,
which have already been described. These include
patients with severe enophthalmos who present with
pseudoptosis and superior sulcus deformities that are
beyond correction with some of the “masking” proce-
dures, such as elevating the upper eyelid, filling the
superior sulcus, or other described techniques. Patients
with Graves’ disease or thyroid ophthalmopathy, either
of a bilateral or more commonly unilateral form, are
another group. These patients have upper eyelid and
lower eyelid retraction that is intrinsic to the infiltrative
disease, but the major component of their cosmetic
eyelid deformity, when severe, is pseudoretraction, or
retraction that is secondary to the orbital contents and
eyeball being displaced anteriorly. In either case,
whether there is enophthalmos or exorbitism, the
intrinsic soft tissue abnormalities are outweighed by the
discrepancy between orbital bony volume and orbital
soft tissue volume. To address this underlying patho-
physiology, the procedures of choice include and rely
on altering bony volume so that it is consistent and
appropriate with given orbital soft tissue volume. All
surgeons who treat cosmetic and functional problems
in and around the orbit and periocular tissues should
be familiar with these options and have a perspective
on the limitations of soft tissue surgery alone and
the power and efficacy of altering the volume of the
bony orbit.
Of the eight bones forming the orbit, the zygoma is
by far the most important bone in the craniofacial
skeleton for the surgeon. It is extracranial and accessible
in part by various routes, and most surgeons of various
specialties are at least familiar with exposing or treating
it in some fashion (e.g., fractures).
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CHAPTER ELEVEN
ENOPHTHALMOS
Enophthalmos most commonly presents as a post-
traumatic deformity after a displaced zygoma remains
malpositioned. These fractures are usually associated
with displacements of the orbital floor and/or ethmoid
complex. The deformity is basically caused by a new
bony orbital volume that is disproportionately large for
the existing orbital soft tissue volume. This volume
discrepancy has been well described both narratively
and pictorially. Orbital floor disruption leads to an
increase in medial and inferior orbital volume, and this
is associated with soft tissue contracture that leads to
the deformity. The underlying pathophysiology is an
inferior and lateral displacement of the zygoma, and the
soft tissue abnormalities that result are specific and
almost pathognomonic. They are a lateral canthal dys-
topia to produce an “anti-mongoloid” slant, scleral
show, malar insufficiency, upper lid pseudoptosis, and
enophthalmos with a superior sulcus deformity. Based
on the description in Chapter 1 of the salient anatomy
of the orbit and adnexal structures, the secondary soft
tissue abnormalities resulting from an inferior and
laterally displaced zygoma, largely due to masseter
muscle pull, are self-evident. For example, because the
lateral retinaculum inserts on the frontal process of the
zygoma, inferior displacement of the zygoma will
produce the classic anti-mongoloid slant. The inferiorly
and laterally displaced zygoma also pulls on the inferior
orbital septum, which produces lower lid retraction and
scleral show. The retropositioned eyeball or globe
allows the upper lid to drape down lower anteriorly,
hence the appearance of ptosis or “pseudoptosis.” This
assumes normal levator function and aponeurotic
insertion on the tarsal plate. The superior sulcus de-
formity, globe depression, and enophthalmos are
secondary to insufficient soft tissue to fill the acquired

new space. In earlier chapters I have described soft tissue
procedures to address ptosis, scleral show, and canthal
dystopia among other abnormalities; however, in the
patient who presents with late post-traumatic soft tissue
abnormalities after a zygoma fracture, soft tissue
correction alone should be viewed as a masking or
cover-up procedure and not one that addresses the
underlying problem. These masking procedures may be
satisfactory in mild soft tissue abnormalities or ones in
which the patient is unwilling or unable to undergo
underlying volume correction. In my experience, it is
always preferable to reposition the zygoma with
appropriate osteotomies, provide stable rigid fixation,
and proceed with bone grafts of the orbital floor and/or
ethmoid complex after appropriate soft tissue mobili-
zation than to initiate soft tissue masking procedures
first. In other words, soft tissue orbital surgery is almost
never an appropriate substitute for orbital bone
procedures when they are indicated. I like to think of
it as first repairing the walls and underlying hard struc-
tures before painting, hanging curtains, and decorating.
In the case of the displaced zygoma, repositioning the
bone with appropriate bone grafting provides lower
eyelid elevation, correction of the lateral canthal dys-
topia or “anti-mongoloid slant,” anterior globe posi-
tioning, and correction of the pseudoptosis and the
superior sulcus deformity. This is all performed in one
procedure that addresses the problem directly and
appropriately. Secondary soft tissue abnormalities may
be required in the future; however, they are usually
small, easy to perform, and very effective. Evaluation of
patients who present with late post-traumatic orbital
soft tissue abnormalities, as in the displaced zygoma
fracture, should have all the preoperative examination
and documentation that has already been described and
more. For example, visual acuity, visual fields (gross
and/or formal), extraocular motility studies, sensory
and motor nerve assessment, versions (passive eye
movement), and forced ductions (when appropriate)
should be considered. The degree of exophthalmos
should be assessed when appropriate. The Hertel
exophthalmometer may not be useful because it uses
the lateral orbital rim (zygoma) as a reference point.
Worm's eye and lateral orbital views, using the superior
orbital rim or nasion as a reference point, may be more
appropriate. Computed tomographic scans (coronal
and axial) can be invaluable in the assessment and
planning stage of treatment. Viewed simply, treatment
consists of complete subperiosteal soft tissue dissection,
osteotomies that basically re-create the fracture, mobili-
zation, repositioning, and rigid fixation of the bone
segments with appropriate bone grafting. These con-
C O S M E T I C C R A N I O - O R B I TA L S U R G E RY
cepts are not new and are largely attributable to Tessier
and a few others.
The zygoma and orbit should be exposed adequately.
I prefer coronal, transconjunctival with lysis of the
lower crus of the lateral canthal tendon, and vestibulo-
buccal incisions. These incisions give optimal exposure
to the zygomatic arch and to articulations of the
zygoma with the greater wing of the sphenoid, maxilla,
and frontal bone. They provide enough exposure to
adequately protect vital structures such as the globe,
medial canthus, and lacrimal system. They serve to
allow the surgeon to provide adequate reduction of the
fractures, bone grafting of the orbit, and an optimal
chance for complete correction. So-called limited expo-
sure techniques (e.g., elimination of the coronal inci-
sion) do not provide adequate exposure, are arduous to
execute, and are less likely to produce reliable and
excellent correction and results. Instead, I reserve this
route for patients who are bald or unwilling to accept a
coronal incision. The limitations of this modified
exposure technique should be reviewed with the patient
in advance. I favor the transconjunctival rather than
transcutaneous route to the orbital floor because the
incision can be carried medially behind the lacrimal
fossa, providing easy access to the ethmoid structures.
Lysis of the inferior crus of the lateral canthal tendon
provides additional exposure of the orbital floor for
bone grafting, eliminates undue traction on the medial
eyelid, which can tear through the lacrimal system, and
is easily repaired with several absorbable sutures, as
long as the common canthal tendon and its superior
crus remain intact. In fact, foregoing a formal repair of
the inferior crus usually produces excellent results,
which are similar to those obtained when the inferior
crus of the lateral canthal tendon is severed as part of
the treatment in acute orbital hemorrhages and raised
intraocular pressure. I recommend resuspension of the
malar soft tissues (masseter and overlying structures)
after osteotomy, mobilization, reduction, fixation, and
bone grafting is completed. In my view, spontaneous
reattachment of the malar soft tissues occurs “too low,”
and although bone may be positioned correctly, the
overlying soft tissues may remain relatively ptotic after
subperiosteal stripping and cephalomedial reposi-
tioning of the zygoma. Finally, I prefer to suspend the
lower eyelid cephalad by means of a temporary
tarsorrhaphy (Frost suture), linking the lower eyelid to
the upper eyelid and then to the eyebrow. This should
remain in place for several days to 1 week post-
operatively. Light perception through the eyelid is
adequate for evaluation of visual function in the
immediate perioperative period. However, if one prefers
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closer monitoring, the tarsorrhaphy may be made
reusable and the lids may be opened, the globe
assessed, and the lids reclosed and suspended with tape.
Tarsorrhaphy provides excellent corneal coverage and
comfort for these patients, who inevitably have some
form of intraoperative corneal de-epithelialization
during surgery. It also allows a maximal recession of the
lower lid retractors, which are lysed during the trans-
conjunctival approach to the orbital floor (Figs. 11-1
and 11-2).

ORBITAL VOLUME REDUCTION

A Soft tissue
dissection

Displaced
zygoma fracture
causes
enophthalmos

Fractured
orbital floor

B Fracture is recreated Displaced

to mobilize zygoma fragment zygoma fracture

C Zygoma fragment is
repositioned with
a bone graft bridging
the gap in the zygomatic arch

Preoperative
zygoma position

Figure 11-1 The orbital volume discrepancy between bone and soft tissue contained within is common after an unreduced zygoma fracture.
The presenting soft tissue deformities, including enophthalmos, superior sulcus depression, lateral canthal dystopia, scleral show, and
pseudoptosis, are all tempting to address with soft tissue procedures alone. A, In all but the mildest cases the surgeon should always consider
repositioning the displaced bone first, before considering soft tissue “masking” procedures. The zygoma and orbit can be degloved with a coronal
(hemi), vestibulobuccal, and transconjunctival incision. The inferior crus of the lateral canthal tendon can be divided, giving complete access to
the orbital floor with the risk of traction tears. Every attempt should be made to remain preseptal and then subperiosteal in a continuous plane
with this dissection (arrow). Although exaggerated here, the orbital floor is already healed with fibrous and/or bony union in a displaced
position. B, Osteotomies are then performed using a power microsaw of personal preference (sagittal, oscillating). It is important to completely
disjoin the zygoma at its frontal, maxillary, sphenoid, and arch articulations while protecting the intraorbital contents with a malleable
retractor. C, The entire zygoma is then repositioned into an anatomic position under direct vision. A bony gap or significant stepoff along the
arch, as well as the orbital floor, may be grafted. Recontouring the orbital floor is more salient in correction of the orbital soft tissue deformities,
whereas the zygomatic arch is relevant to facial width. Significant bony orbital volume reduction is possible in this powerful procedure. Rigid
fixation of the zygoma with the assistance of temporary wire fixation in one or two points (e.g., zygomaticofrontal) is helpful. Soft tissue closure
of the incisions may be accomplished in the usual fashion with the inferior crus of the lateral canthal tendon approximated carefully to the
common tendon with a small absorbable suture, followed by cutaneous repair. The malar soft tissue should be suspended to obviate
postoperative soft tissue ptosis, and, lastly, a temporary tarsorrhaphy is performed.

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A B C

D E
Figure 11-2 In patients who have enophthalmos, and a volume discrepancy exists between the intraorbital contents and the acquired orbital
bony volume, an ideal procedure is to osteotomize the zygoma and reposition it to create a smaller bony orbit. This should more closely
resemble the normal anatomy and be appropriate for the soft tissue contents. Sometimes a bone graft is necessary to further reduce volume,
especially in the floor region, which does not reduce well after osteotomy, especially in the late post-traumatic cases. A, A 29-year-old woman
suffered right facial trauma and repair approximately 2 years before presentation to me. Coronal view of her orbits on computed tomographic
scan demonstrates the large orbital volume discrepancy between the treated right side and the untreated left side. Her most significant
complaints are related to her appearance. B, I performed multiple osteotomies and mobilized the zygoma by way of hemicoronal,
gingivobuccal, and transconjunctival eyelid incisions. Here the zygomaticosphenoid junction and arch of the zygoma are exposed for osteotomy.
C, The zygomaticomaxillary and nasal buttresses are exposed by way of a gingivobuccal approach and are then osteotomized. The
transconjunctival approach to the zygomaticomaxillary junction is not shown here because this approach has been seen previously in the text
(Chapter 6). D, This is the patient at presentation 2 years after injury and repair by other surgeons. Note the significant enophthalmos and
inferiorly displaced eye (low eye) with a superior sulcus deformity on the right. She also has a depressed malar eminence. E, This is the patient
1 year after I performed a zygoma repositioning and autogenous bone graft. Note the significant improvement in enophthalmos, superior sulcus
deformity, and elevation in the globe produced by the orbital volume reduction. The malar eminence is also normalized compared with the
contralateral side.

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TREATMENT OF
EXOPHTHALMOS
Exophthalmos or protrusion of the globe anteriorly
presents as a typical set of signs and symptoms, which,
like enophthalmos, are almost pathognomonic. The
most common underlying condition associated with
either unilateral or bilateral exophthalmos is Graves’
disease. These patients may present with a spectrum of
infiltrative disorders, which may range from mild true
upper lid retraction secondary to infiltrative disease
involving Müller’s muscle and other structures. Alterna-
tively, they may present with or progress to severe
exophthalmos with corneal exposure and even optic
nerve compression due to significant infiltration and
swelling of the extraocular muscles and orbital fat
posterior to the equator of the eyeball at the orbital
apex. Indications for orbital decompression fall into the
categories of intractable exposure or compression per-
manently endangering vision. These are well described
(e.g., NO SPECS classification) and appropriate for
various graded decompression procedures. The purpose
of this discussion is not to review the literature and
procedures for orbital decompression but to focus on
the underlying soft tissue abnormalities that in mod-
erate to severe cases of orbital Graves’ diseases should
be addressed with selective well-executed osteotomies
in conjunction with appropriate soft tissue procedures.
They should not be treated with simple gross fractures
into sinuses and/or soft tissue “masking procedures.”
An understanding of why these osteotomies work in
rearranging specific soft tissue elements allows us to
integrate all the useful anatomy already covered.
The procedure of choice for these unilateral cases is
based on lateral orbital wall repositioning with selective
decompression of the other walls of the orbit. As in the
treatment of late enophthalmos, the zygoma and its
bony articulation are the key anatomic structures to be
addressed. In these cases, the upper segment of the
zygoma (above the maxillary buttresses, lateral to the
infraorbital nerve and anterolateral to the greater
sphenoid wing) is osteotomized and rotated anteriorly
or counterclockwise on the right side and clockwise on
the left, producing a “valgus” fracture. The incisions for
exposure are similar to those used in the enophthalmos
procedure, including coronal, vestibulobuccal, and
transconjunctival routes. The lateral retinaculum
(lateral canthal tendon) should be left intact when pos-
sible because the location of the zygoma produces a
150
lateralization of Whitnall's tubercle and hence traction
or tightening of the tendon. This elevates the lower
eyelid and defines the lateral canthus more anteriorly
on the globe. A formal canthoplasty with bony fixation
may be performed should disinsertion of the lateral
canthal tendon occur. I sometimes electively perform a
soft tissue canthopexy or tightening of the lateral
canthus and thereby elevate the lower eyelid beyond
what would be produced by rotating the zygoma alone.
The decompression of the orbital floor and ethmoid
region is well accessed by way of the transconjunctival
route, again sweeping posteriorly to the lacrimal fossa.
The lateral wing of the sphenoid can be resected up
to the external aspect of the middle cranial fossa.
Periorbita must be incised widely; however, intractable
diplopia and other complications can be avoided by
incising it from the ethmoid medially and around to the
superior and lateral orbit. I prefer to leave the inferior
periorbita intact. Gentle pressure is placed on the globe
to allow herniation of orbital contents, and every
attempt is made to match the contralateral side when it
is normal. The arch of the zygoma may require a bone
graft to maintain curvilinear facial width and appear-
ance. A temporary tarsorrhaphy is performed and left
for the first postoperative week. In cases of bilateral
exophthalmos, one may consider the above procedure
either in stages or concomitantly, or one may perform
a subcranial Le Fort III minus the Le Fort I segment.
Simply put, this is an en bloc bilateral orbital advance-
ment above the level of the maxillary teeth (Figs. 11-3
and 11-4).
P E A R LS A N D P I T FA L LS
1. Soft tissue manipulation alone is inadequate for the
correction of cosmetic problems in a subgroup of patients,
most of whom suffer from orbital volume/soft tissue
discrepancies.
2. Soft tissue orbital surgery should almost always follow bony
procedures.
3. Limited incision exposure techniques for osteotomies of
the zygoma and orbit are technically demanding and are
limiting to ideal positioning of osteotomized segments.
4. Although all the pathophysiology in Graves’ disease of the
orbit is related to soft tissue changes, it is the “valgus”
maneuver of the zygoma along with other bony
osteotomies that are most effective in cosmetic and
functional corrections.
5. Nonfunctional aesthetic abnormalities in Graves’ disease
and other abnormalities of the orbit are sometimes best
treated with osteotomies and other bone-altering
procedures.
6. In orbital expansion procedures, the inferior periorbital is
best left intact to obviate inferior dystopia of the eyeball.
 C O S M E T I C C R A N I O - O R B I TA L S U R G E RY

ORBITAL EXPANSION

A Osteotomize zygoma
and rotate nasally

Inferior displacement of lower lid

with scleral show

Osteotomy line

B Partial removal of orbital

walls and periorbita
incised

Rotation of zygoma tightens

lateral canthal tendon and
elevates lower lid

Bone graft

Figure 11-3 The patient with exophthalmos presents with a bony and soft tissue volume discrepancy opposite to that found in the case of
enophthalmos. Here the bony orbit is too small for the soft tissue contained within. Soft tissue procedures alone (“masking”) are partially
effective both cosmetically and functionally only in mild cases; however, they do not anatomically address the underlying pathophysiology in a
global fashion. Standard intraorbital decompression procedures (without zygoma repositioning) are sometimes effective in retrodisplacing the
globe and in decompression but are not effective in addressing the adnexal and canthal positional deformities and are not applicable as a single
“cosmetic” procedure in the patient who has significant exophthalmos secondary to orbital thyroid disease or other processes that are
“nonfunctional” in that the cornea is adequately wetted (with drops/gels/ointments) and there is no evidence for orbital apex compression. The
orbit in these cases is expanded in two ways: (1) a valgus maneuver of the zygoma and (2) bone resection and incision of the periorbita with
herniation of the orbital contents are performed. Exposure is gained as in the enophthalmos correction. The zygoma is osteotomized in a
nonanatomic fashion in that the bone segment may be mobilized outside the normal articulations or suture lines. For example, a beveled
osteotomy above the zygomaticofrontal junction and through the body of the zygoma should be carried out when indicated, and these may be
tailored to conform to individual anatomy. A, Access incisions are similar to those previously described; however, care should be taken to
preserve the insertion of the common lateral canthal tendon. It may be reattached to bone if necessary. The orbital walls are resected in the
ethmoid, maxillary, and sphenoid region. The transconjunctival incision is useful here in that it can be carried behind the lacrimal fossa with
excellent exposure of the medial orbital wall and ethmoid complex. Laterally, I resect the zygoma behind the orbital rim up to the greater wing
of the sphenoid and bur down the latter, short of exposing the middle cranial fossa. Periorbita is incised laterally, superiorly, and medially but
not inferiorly to avoid glove depression; and light pressure is used to accentuate herniation of orbital contents. B, The zygoma is repositioned by
rotation and slight impaction and rigidly fixed, with bone grafts applied where needed (A [black arrow] and B). Contouring (bur) is helpful at
the junction between the rotated and nonosteotomized bone segment to soften the step off. Closure is completed with a temporary tarsorrhaphy.

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A B
Figure 11-4 Enophthalmos or protrusion of the globe is ideally corrected by manipulating the bony orbital confines and increasing its volume.
Osteotomies through the zygoma and adjacent bone with rotational repositioning is a very powerful technique for repositioning not only the
affected soft tissue structures in the deep and middle orbit but also the anterior adnexal structures. A, A 22-year-old woman presented with
unilateral left orbital Graves' disease and 5 mm of proptosis without optic nerve compression and with corneal exposure that is controlled with
wetting agents. She is especially bothered by her appearance and cites multiple examples of how social, school, and work interaction with others
is compromised. Note upper and lower eyelid malposition. B, The lateral orbital wall is repositioned by way of osteotomies performed through
the coronal and vestibulobuccal routes. The orbital floor and medial orbit is accessed by way of a transconjunctival incision that is extended
behind the posterior lacrimal crest. In this photograph, the osteotomy lines are delineated in blue. The temporalis muscle is reflected only in its
anteriormost extent to gain access to the zygomaticosphenoid junction. Continued

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C D
Figure 11-4 Continued C, The zygoma is rotated and repositioned (clockwise in this case) and rigidly fixed. I prefer to rongeur the zygoma and
sphenoid articulation surfaces to create the large lateral orbit gap. The orbital floor and ethmoid walls are removed, and the periorbita is
opened from the ethmoid region medially through the superior and lateral region, leaving the inferior periorbita intact. A small bone graft is
usually needed along the arch of the zygoma to maintain facial width and contour. D, The patient as seen in A approximately 1 year
postoperatively after lateral orbit repositioning. She is asymptomatic without corneal exposure and diplopia. The proptosis is alleviated, and the
lid position is satisfactory, closely matching the contralateral side. The superior sulcus on the operated side is more concave, owing to the volume
redistribution caused by the surgery. I am planning a small soft tissue procedure to fill the sulcus deformity.

References

Chan CH, Spalton DJ, McGurk M: Quantitative volume
replacement in the correction of post-traumatic enophthal-
mos. Br J Oral Maxillofac Surg 38:437-440, 2000.
Chen CT, Chen YR: Endoscopically assisted repair of orbital
floor fractures. Plast Reconstr Surg 108:2011-2018; dis-
cussion 2019, 2001.
Clavser L, Galie M, Sarti E, Dallera V: Rationale of treatment in
Graves ophthalmopathy. Plast Reconstr Surg 108:1880-
1894, 2001.
Hobar PC, Burt JD, Masson JA, et al: Pericranial flap correction
of superior sulcus depression in the anophthalmic orbit. J
Craniofacial Surg 10:487-490, 1999.
Karacaoglu E, Tezel E, Guler MM: Rotation ligamentoplasty for
the correction of epicanthus inversus. Ann Plast Surg
45:140-144, 2000.
Longaker MT, Kawamoto HK Jr: Evolving thoughts on
correcting posttraumatic enophthalmos. Plast Reconstr Surg
101:899-906, 1998.
Van den Bosch WA, Tjon-Fo-Sang MJ, Lemij HG: Eyeball
position in Graves orbitopathy and its significance for
eyelid surgery. Ophthalmic Plast Reconstr Surg 14:328-335,
1998.
Zabramski JM, Kiris T, Sankhla SK, et al: Orbitozygomatic
craniotomy: Technical note. J Neurosurg 89:336-341, 1998.

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Laser Resurfacing in the
Periocular Region
Cosmetic skin rejuvenation currently stands at an
interesting juncture between the ablative resurfacing
techniques developed during the 1990s and the
nonablative skin rejuvenation technology of the 21st
century. During the 1990s, treatment options for rhytids
and atrophic scars were limited to ablative laser
resurfacing that required an extended healing period as
well as invited post-treatment complications. Nonethe-
less, ablative resurfacing is still considered to be the
most effective skin resurfacing treatment, yielding the
most dramatic results. With the turn of the century,
medical technology has redirected its efforts to create a
second treatment option for patients with mild-to-
moderate rhytids or atrophic scars. This nonablative
technology attempts to stimulate the skin to produce
collagen without the trauma of destroying the
epidermis in the process.
As a result of these developments laser surgeons are
now faced with the ever-more complicated task of
evaluating the appropriate treatment for their patients
given ever-present financial and time constraints.
Compounding the dilemma is the fact that as the
number and complexity of these choices increases, so
do the nuances between them. We will attempt to sim-
plify the choices to be made. A common request from
patients is to improve the aging appearance around the
eyes. This is often the first cosmetic region to show the
effects of time and solar damage. However, it is also the
most delicate and often difficult to treat with lasers. This
survey of the various laser skin rejuvenation techniques
that are available to laser surgeons today is intended to
provide an overview of, and perhaps introduction to,
this technology.
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CHAPTER TWELVE
Amy B. Lewis and Henry M. Spinelli
ABLATIVE VS. NONABLATIVE
LASERS
When discussing laser technology, it is important to
understand which lasers are used and how they affect
the skin and the rejuvenative process.
The two most commonly used ablative resurfacing
lasers are the ultrapulsed CO2 laser and the
erbium:yttrium-aluminum-garnet (YAG) laser. The CO2
laser ablates approximately 100 µm of tissue and leaves
an additional 50 µm of thermally damaged tissue. The
erbium:YAG laser ablates less tissue, between 20 and
40 µm, and leaves thermal damage of an additional
20 to 30 µm. However, both lasers cause sufficient
enough damage to the epidermis and dermis that speci-
fic precautions, to be discussed later, should be taken
by both the physician and the patient. Nonablative
lasers include the modified diode, erbium:YAG,
neodymium:YAG (Nd:Yag) or pulsed dye lasers cali-
brated to specifically induce the skin to produce colla-
gen. However, individual laser manufacturers have
differing technologic theories as to the optimal fluences
needed to best induce collagen production. These
theories originated in anecdotal evidence provided by
physicians and patients that pulsed dye lasers treating
vascular conditions produced the unexpected effect of
tightening collagen. From this unanticipated side effect,
laser manufacturers began investigating the rejuvena-
tion potential of nonablative lasers.
The novelty of nonablative technology has prevented
any long-term studies or definitive data to be produced.

The first nonablative lasers premiered commercially
in the United States at the American Academy of
Dermatology Convention in Washington, D.C., in
March 2001. Consequently, as of yet, there is no gener-
ally used or recognized nonablative laser used by most
laser surgeons. Physicians are reluctant to commit
themselves to particular nonablative laser technology
until more concrete data are produced by laser
manufacturers or physicians.
ABLATIVE LASERS
Although the prospect of smoother skin free of wrinkles
or scars may be enticing to the patient, the physician is
obligated to speak frankly about both the logistical and
the psychological impact of ablative laser resurfacing.
This discussion should begin with the realistic aesthetic
evaluation of how laser resurfacing can effectively treat
rhytids or textural changes caused by trauma, actinic
damage, biologic aging, or prior surgery. The physician
should outline the amount of time that will be required
for the patient to heal as well as prepare the patient for
the impact of how the patient's face will look imme-
diately after laser treatment and as it heals. The patient
needs to understand that the first 10 days after treat-
ment will require vigorous aftercare because of signi-
ficant edema, erythema, some crusting, and occasional
discomfort. In addition, the patient should expect at
least 3 to 6 months of mild-to-moderate erythema,
which can be concealed with camouflage makeup
and sunglasses and, as healing progresses, simple
foundation makeup.
Once the physician has explained the healing time
required as well as the psychological impact of an
ablative laser treatment, the patient should be given
adequate time to process this information. A patient
will also need to consider how this procedure can be
scheduled among professional, family, social, and other
personal obligations. Bear in mind, that as with most
cosmetic procedures, especially those requiring signi-
ficant “down” time, physicians must be prepared to
provide the patient with ample emotional support.
Ultimately, an informed and prepared patient will return
to the physician to do laser resurfacing with realistic
expectations about the procedure, aftercare, and results.
Erbium:YAG vs. CO2 Laser
CO2 laser resurfacing is considered the most effective
form of treatment available for extensive cutaneous
L A S E R R E S U R FA C I N G I N T H E P E R I O C U L A R R E G I O N
photodamage, moderate-to-severe rhytids, moderate-to-
severe atrophic scarring or fibrosis, and other epidermal
and dermal lesions. With a wavelength of 10,600 nm,
CO2 lasers emit high-energy beams that predictably
vaporize 20 to 60 µm of tissue per pass and leave
acceptably narrow zones of residual dermal damage.
The CO2 laser’s effects are primarily photodermal,
and the residual dermal necrosis modulates wound
healing, thus substantially affecting the ultimate
cosmetic outcome. The heat generated within tissue
intraoperatively causes immediate collagen shrinkage of
15% to 25%; and during the subsequent healing period,
continued collagen contraction and reorganization are
evident over the ensuing 12 to 18 months.
A number of companies provide CO2 laser tech-
nology. A 2- to 3-mm spot size is available for delicate
areas directly under the eyes or in the immediate lateral
and medial canthi. A larger scanner can be employed for
the temples and larger areas to enhance the quickness of
the procedure. The skin is vaporized laterally to the
temples and inferiorly to the full extent of the rhytids. A
common setting for the 3-mm collimated handpiece is
50 mJ/pulse at 3 to 7 W. Usually two to three passes are
performed in the periorbital region and, between
passes, icewater-soaked gauze is used to wipe away any
debris. Eye protection for the patient can be accom-
plished in several ways. Many laser surgeons prefer to
use water-soaked gauze pads over the eyes so that they
may reposition the gauze pads appropriately as the laser
moves around the area being treated. However, this
requires additional comfort and skill with the
procedure. Consequently, standard eye shields placed
over the cornea are often a more preferred approach.
The erbium:YAG laser emits a wavelength of 2940
nm, which corresponds specifically to the main absorp-
tion peak of water and consequently is absorbed 12 to
18 times more efficiently by superficial cutaneous tissue
than the CO2 laser. Irradiated tissue is immediately and
forcibly ejected from the surface of the skin, permitting
most of the thermal energy generated to escape.
Therefore, the erbium:YAG laser resurfaces skin photo-
mechanically whereas the CO2 laser remodels skin
photothermally.
The erbium:YAG laser is an excellent option for the
treatment of mild-to-moderate rhytids on younger
patients who have less actinic damage and shallower
wrinkling in the periorbital region. In addition, the
erbium:YAG laser appears to create less thermal diffu-
sion and damage and thus shortens the reepitheliali-
zation of the skin, usually 5.5 days after the erbium:YAG
resurfacing, compared with 8.5 days for CO2 laser
resurfacing,5 as well as the time needed for resolution of
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the postoperative erythema and edema. Laser surgeons
must remember, however, that unlike the CO2 laser the
erbium:YAG laser is not an ideal hemostatic device and
is associated with petechial bleeding from the dermal
capillary nexus.
The variability of treatment afforded by these two
lasers has led laser surgeons to explore more creative
applications by combining the CO2 laser and
erbium:YAG laser into a single treatment protocol. For
patients presenting varying levels of photodamage and
lesional involvement, some laser surgeons have opted
to treat less severely damaged areas with the erbium:YAG
laser while reserving treatment with the CO2 laser for
the more ravaged areas that would require more drastic
improvement.
Another interesting combined modality tries to
capture the advantages offered by both the erbium:YAG
and the CO2 lasers. The resurfacing protocol is superior
because it achieves maximum cosmetic improvement
while minimizing morbidity. In some cases we like to
begin by treating the affected area with a single pass
of the ultra-pulsed CO2 laser set at 300 to 500 mJ,
immediately followed by two passes of the erbium:YAG
laser with a 3-mm spot size. The single pass of the CO2
laser creates dermal remodeling by collagen shrinkage
while minimizing collateral damage. The erbium:YAG
laser is used to ablate the epidermis mechanically and
overall improve texture. It also serves to lessen the
thermal zone of damage dispersed by the CO2 laser.
Because both the CO2 laser and the erbium:YAG laser
have wavelengths that fall within the invisible infrared
spectrum, the preoperative, intraoperative, and post-
operative care protocols are similar for ablative resur-
facing regardless of whether it is CO2 laser, erbium:YAG
laser, or a combination of both used on the patient.
Pretreatment
Starting 2 to 4 weeks before the procedure, patients may
be started on 0.025 to 0.05% retinoic acid cream at
night, hydroquinone 4% cream twice daily, and/or 5%
to 10% glycolic acid lotion. However, this is still
controversial, and many laser surgeons choose not to
pretreat with topical agents. Sunscreens containing
ultraviolet A and B blockers as well as a sun protective
factor of 15 or higher should be used daily by the
patient. The best sunscreen available for the patient
before and after treatment is one containing mexoryl
(Anthelios 60+: La Roche-Posay, Paris, France).
A preoperative questionnaire is helpful for the
physician to learn about the patient’s history of
156
smoking, postinflammatory hyperpigmentation or
hypopigmentation, radiation therapy, scarring, herpes
simplex virus (HSV) infections, and some use of
isotretinoin (Accutane: Roche Laboratories, Nutley, NJ).
In particular, some surgeons believe that patients with a
history of isotretinoin use within the previous 1 to 2
years may not be eligible for ablative laser resurfacing.
Beginning 1 day before laser resurfacing patients
should be placed on preoperative antibiotics (erythro-
mycin or dicloxacillin, 500 mg orally, two to four times
a day, or azithromycin [Zithromax Z-pack]) and anti-
viral therapy (acyclovir or its derivatives) and continue
this regimen for 7 days thereafter or until total
reepithelialization is achieved.
Intraoperative Care
Safety precautions must be followed when using invis-
ible infrared laser, which can inadvertently discharge
and burn areas outside the field of treatment. The
operating room door must have a cautionary laser sign
displayed, and all personnel must wear wavelength-
specific eye protection. Surgical drapes should be fire-
resistant or moistened, and oxygen delivery should be
turned off when using the laser. A water-filled spray
should be ready in the treatment area to extinguish any
fire. Finally, the erbium:YAG laser produces a large
plume of dust containing water vapor and ejected
particles. This “tissue dust” may be harmful to inhale,
and all personnel must wear laser facemasks that filter
particles as small as 1 µm. A strong smoke evacuator is
mandatory to capture the plume of dust.
During treatment, the erbium:YAG laser makes a loud
popping sound and the CO2 laser makes a more muted
sound with each pulse. There is more airborne debris
and very little gross contraction of tissue during the first
pass of erbium:YAG irradiation. In contrast, there is
little debris during the first pass and immediate physical
contraction during the second and third passes of the
CO2 laser. The erbium:YAG laser creates a focal pinpoint
bleeding that increases with each pass.
Generally, if only one or two cosmetic units are being
resurfaced, local anesthesia with nerve blocks is used in
addition to mild sedative and pain reducers such
as a diazepam and meperidine cocktail. With the
erbium:YAG laser, some suggest adding only topical
anesthetic cream such as lidocaine (ELA-Max) or topical
butacaine. However, if a full face resurfacing with the
CO2 laser is planned, intravenous sedation is usually
necessary. The periorbital area, however, is difficult to
anesthetize with nerve blocks and is a very sensitive area

to treat. Periorbital laser treatment is often combined
with another procedure, such as a blepharoplasty, that
may require intravenous sedation. If done alone, the
option of topical anesthesia with the aforementioned
cocktail or sedation is offered to the patient. It is easier
for the laser surgeon to effectively treat the periocular
area if the patient is not moving or wincing. Therefore,
we suggest conscious sedation for resurfacing around
the eyes unless an excellent anesthetic block and
adequate ocular protection are provided.
Postoperative Care
The number and variety of post laser care regimens is
even larger than the therapy choices available to begin
with. Basically, after the laser procedure, either non-
occlusive or occlusive dressings may be used. This is a
controversial point in laser care at this time because
each technique has distinct advantages as well as
drawbacks.
Occlusive dressings are applied by the surgeon imme-
diately after the treatment and are left in place for
several hours to a few days, thus requiring minimal
patient involvement in wound management. This
method reportedly reduces postoperative pain and
modestly accelerates the initial healing process. How-
ever, occlusive dressings may prevent visual inspection
of the wound and increase the risk of bacterial or yeast
infection on the skin if left intact for an extended period
of time. These include Second Skin (Spenco Medical
Corporation, Waco, TX), Vigilon, and other hydrogel
derivatives.
Nonocclusive dressing involves frequent application
of healing ointments such as Catrix 10 Correction
Cream, Aquaphor (Beirsdorf, Inc., Norwalk, CT), Elta
Renew Cream, or pure petrolatum by the patient. The
patient also treats the wounds with application and
soaks to decrease edema and any buildup of adherent
crust. This method decreases the risk of infection and
allows the surgeon to visualize the wound bed and
intervene promptly if complications occur. However,
postoperative pain is greater, there is significantly more
crusting, and initial healing may be slightly slower.
Most importantly, this method is highly dependent on
strict patient compliance, and this should be taken into
account by the surgeon considering postoperative care
options. Whether the surgeon chooses the postoperative
occlusive or nonocclusive technique is less important
than keeping any uncovered area moist by the appli-
cation of one of the previously mentioned ointments.
L A S E R R E S U R FA C I N G I N T H E P E R I O C U L A R R E G I O N
NONABLATIVE LASERS
The newest generation of laser rejuvenation is still in its
early stages but theoretically promises to present the
opportunity for laser skin rejuvenation to an in-
creasingly expanding array of patients. The procedure
will likely cost less, requires no recovery period, and, in
fact, does not even ablate the epidermis. Patients could
theoretically rejuvenate their appearance without even
their closest friends being aware of their going through
the process. One caveat to this treatment is the “too
good to be true” phenomenon, that is, there are no
long-term quality studies regarding the efficacy or
extent of the benefit of these lasers. As more laser sur-
geons collect data based on patient treatment, a more
thorough clinical review of this procedure will be
necessary. However, this survey of laser skin rejuvena-
tion techniques is intended merely to familiarize the
reader with the new and continually evolving
technology of nonablative lasers.
Generally there are three theories as to why non-
ablative lasers cause skin rejuvenation. Individually, one
of these three theories may explain the science behind
nonablative technology; however, it is more likely that
these factors work together in varying capacities to
create the resulting skin rejuvenation.
First, photothermal heating in the dermis may pro-
duce a nonspecific dermal wound response inducing
fibroblast activation and subsequent collagen re-
modeling. Essentially, the photothermal heating tricks
the dermis into thinking that it has been injured and
stimulates collagen and fibroblast production to repair
itself. Second, nonablative technologies may cause dis-
placement of elastic photodamaged dermis, which is
replaced by a more normal-appearing dermal matrix. By
breaking down the damaged tissue, the dermis is able to
replace it with more regularly structured healthy tissue.
Third, laser-induced endothelial disruption leads to
cytokine activation, which may induce subsequent col-
lagen remodeling. In other words, by injuring but not
destroying the dermal microvasculature, the injured
vessels release cytokines to stimulate collagen produc-
tion. Heat shock protein, vascular endothelial factors,
and β-fibroblastic growth factors have all been shown to
be up-regulated after clinical photoendothelial inter-
action. Clearly, there are measurable changes that occur
as a result of nonablative lasers; however, it may take
another generation or two of mechanical devices to
translate these changes into a broadly useful tool.
As stated earlier, how and to what extent these various
dermal reactions contribute to the final result of im-
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proved skin texture still remains a mystery. The elusive
explanation as to how nonablative skin rejuvenation
works does not diminish the fact that some studies
seem to indicate that it is an effective option for patients
with mild rhytids and a reluctance to undergo more
invasive treatments. In a study evaluating pulsed dye
laser therapy for damaged skin, 9 of 10 subjects with
mild-to-moderate wrinkling and 4 of 10 with moderate-
to-severe wrinkling showed clinical observable improve-
ment at 6, 12, and 24 weeks after a single treatment.
Histologic evaluations confirm post-treatment collagen
remodeling, thickening of the stratum spinosum, and
increased mucin deposition.
Candidate Selection and Treatment
As with ablative resurfacing, the laser surgeon must
carefully select candidates for nonablative laser skin
rejuvenation. The ideal candidate is a person with pale
(type I or II) skin, minimal epidermal damage, and
realistic expectations about this treatment modality. An
unsuitable candidate would be a person with darker
skin tone (type IV to VI), moderate to severe rhytids or
scars, and/or a lot of dyschromia. Although darker skin
types can be treated with wavelengths used in
nonablative technology, fluence parameters may change
and physicians who are relatively inexperienced with
this technology are advised to work first with light-
skinned patients.
Once a candidate is selected, obtaining baseline
photographs is an essential aspect of this treatment. In
contrast to ablative skin resurfacing, nonablative skin
rejuvenation is a gradual change that is clinically visible
only after a minimum of 60 to 90 days. As the collagen
and fibroblast remodel and re-form themselves, the
patient is often unaware of the subtle changes occurring
in his or her skin. Consequently, laser surgeons must
understand and communicate the importance of these
photographs to their staff to ensure that every patient
treated will have an accurate photographic record to
reflect the rejuvenation process at its various stages. In
addition, the surgeon should communicate clearly to
the patient that nonablative treatments do not yield
overnight results. Patients should be prepared for the
fact that this type of dermal remodeling is progressive
and slow.
Similar to ablative procedure, a pretreatment patient
history should be taken, especially concerning HSV,
warts, and scarring. Although nonablative laser treat-
ments rarely can reactivate prior HSV infection, it is
158
advisable to prescribe HSV prophylaxis to patients with
a history of HSV outbreaks. Surgeons should closely
monitor variables such as skin thickness, sensitivity of
the area of treatment, and hair distribution (densely
bearded areas in men tend to retain more heat) when
determining the appropriate level of energy applied
during the treatment. Mild erythema and mild swelling
are the treatment end points: there should not be
blistering, scabbing, or crusting of any kind. If vesi-
culation occurs after the procedure, pigmentary changes
and scarring are potential concerns. Otherwise, no
preoperative wound care is necessary and most patients
can immediately resume their regular skin care regimen.
Finally, a follow-up appointment should be scheduled
3 months after the treatment to determine the clinical
efficacy and to take follow-up photographs as well as to
perform other treatment modalities if desired.
The commercially available 1320-nm Nd:YAG laser
with a cooling device is known as the “Cool Touch.”
The Cool Touch I was the first laser to be introduced as
a noninvasive process to stimulate the production of
new collagen fibers to reduce fine lines and combat the
effects of aging. Marketed in 1996, this modality
boasted “results from the inside out” by selectively
targeting collagen producing fibroblasts in the epi-
dermis. The upgraded Cool Touch II is now available
and is reportedly four times faster than the older system.
The 1320-nm wavelength not only penetrates into the
dermis with significant, and beneficial, horizontal scat-
tering, but it also has the capacity to cause epidermal
blistering. Therefore, cryogen cooling of the epidermal
layers is coupled with the laser beam. This creates a
dermal wounding without a risk to the epidermis.
In one study, 10 patients underwent treatment with
the original Cool Touch laser to evaluate clinical and
histologic changes. Pretreatment biopsy specimens
from all patients showed solar damage with elastosis
and a thinned epidermis. Sixty percent showed im-
provement only 1 month after the fourth treatment,
and all showed evidence of new collagen formation by
6 months after the last laser session. All participants had
some degree of temporary erythema, and none showed
scarring; however, the clinical results vary. Two patients
showed no improvement, 2 had a significant change,
and 6 showed moderate clinical rejuvenation. In this
study, the handpiece was a thermal sensor to optimize
the clinical effect. A similar study was performed by
Menaker and colleagues on a prototype 1320-nm laser.
They found improvement in only 40% of patients, and
pitted scarring was seen in 30%. No thermal sensor was
used in this group, and the follow-up was only 3

months long, which may account for the differing
results.
The dynamic cooling device can be manipulated to
further control the laser irradiation and create the
desired results. The cryogen spray can come before or
after the laser pulse. Usually the first pass is done with
the cryogen spray first, which cools the epidermis and
upper papillary dermis. This allows heating of the lower
papillary dermis and the upper reticular dermis. The
second pass is usually done with the cryogen spray after
the laser pulse. This causes the upper papillary dermis to
heat up, stimulating the fibroblast, and the spray cools
the epidermis before the heat wells upward. The laser
pulse also is given at six pulses with a defined delay
time and pulse duration for the Cool Touch II and only
three passes for the Cool Touch I. There is some mild
edema and erythema afterward that typically is resolved
in 1 hour. The eyes are the hardest to treat because if
there is extensive laxity and sagging skin a skin trim or
other surgical procedure may be necessary; in less signi-
ficant cases a CO2 or other ablative laser may suffice.
The Smoothbeam was introduced in Paris, France, on
January 5, 2001, by the Candela Company as a revolu-
tionary new nonablative diode laser. The 1450-nm
wavelength targets 100 to 450 µm below the skin
surface into the epidermis and is absorbed by water 10
times greater than the 1320-nm wavelength of the Cool
Touch. Both of these infrared lasers have minimal
melanin absorption and rely on their water target for
the rejuvenating effects. This technology was designed
to emulate the injury of the CO2 lasers in the dermal
layer without ablation to the epidermis. The target
tissue is high up in the papillary dermis, and cooling of
the skin surface is achieved with the use of their
proprietary dynamic cooling device.
The cryogen tetrafluoroethane is released as a pre-
laser spray divided into three spurts and a post-laser
spray. All sprays are adjustable for pulse durations.
Because the dermal elastosis and disorganization of
collagen, which appears as photodamage and rhytids,
lies in the epidermis, limiting the heating of this area is
advantageous. The energy is absorbed where it is most
needed, and the deeper tissue is spared, leading to less
potential side effects. The wound healing response to
this superficial thermal blast leads to deposition of new
collagen by activated fibroblast.
Ross and colleagues studied the effects of the proto-
type Smoothbeam laser on wrinkles in nine patients.
Histologic evaluation from punch biopsies 2 months
after treatment revealed newly deposited, well-
organized collagen fibers and an increased number of
L A S E R R E S U R FA C I N G I N T H E P E R I O C U L A R R E G I O N
fibroblasts. Three treatments were done to the same area
at 3-week intervals. The wrinkle severity was judged
before and 3 months after the third session by four
independent blinded observers. The overall improve-
ment was statistically significant (P = .004) for reduc-
tion in wrinkle severity on the treated side as compared
with a control wrinkle treated with the cryogen alone.
The NLite is a pulsed dye laser that operates at
585-nm wavelength. While treating vascular lesions,
physicians have noticed that over time the classic pulsed
dye laser, at 585 or 595 nm, allowed for some collagen
improvement after several treatment sessions. In
addition, the same wavelengths were used successfully
to flatten the thickened collagen and scar tissue. The
laser energy emitted from the NLite has a slightly
different configuration than the older pulsed dye lasers.
The NLite laser produces a light beam at 585 nm,
with a 350-ms pulse delay that is targeted to the
microvasculature in the dermal layer. This wavelength
reportedly induced an 84% increase in type III collagen
production after only one laser exposure in study
patients.18 The interaction of the light with the blood
vessels leads to mild inflammation, but not destruction,
of the dermal plexus. This, in turn, causes release of
natural wound healing mediators, which increase the
collagenesis. In the study by Bjerring and colleagues,
30 patients were treated with the NLite laser to evaluate
the clinical improvement of this nonablative procedure.
In all participants, there were no untoward pigmentary
changes, and three independent observers noted
cosmetic improvement in all wrinkle severities.
Although this laser system has significant promise for
wrinkle reduction, some clinicians have been somewhat
disappointed thus far in this technology. When first
introduced, it was recommended that one treatment
should yield appreciable results. However, most users
now believe that multiple treatment sessions are
required and that the results may be subtle at best.
Unfortunately, there are limited scientific data to
support the efficacy of the nonablative lasers. Any or all
of them may prove to be effective in wrinkle reduction,
but more investigation is still needed.
One final note on nonablative laser resurfacing: the
novelty of this technology indicates that a more
thorough review of the individual nonablative lasers
and their efficacy is premature at this time. The logis-
tical operating data for each of these three most popular
and other less used machines are readily available.
However, objective data reporting the cosmetic results
from specific lasers is pending until further studies are
conducted.
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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
CONCLUSION
Options are increasing for the patient desiring peri-
orbital resurfacing. The ablative lasers still yield
unparalleled results with collagen tightening along with
surface improvement. However, the associated healing
time and morbidity is not acceptable to many. In addi-
tion, the more aggressive the ablative laser (i.e., CO2 vs.
erbium:YAG), the better the efficacy in improving
rhytids. But with this greater efficacy comes a higher
morbidity and unsatisfactory results. The advent of the
nonablative series of lasers allows for many more
References
Alster TS: Controversies in laser resurfacing: Presurgical and
postsurgical care. Cosm Dermatol (May):63-66, 2001.
Alster TS: Cutaneous resurfacing with ER:YAG lasers. Dermatol
Surg 26:73-75, 2000.
Alster TS, Weinstein C: Skin resurfacing with high energy
pulsed carbon dioxide lasers. In Alster TS, Apfelberg DB
(eds): Cosmetic Laser Surgery. New York, Wiley-Liss, 1996,
pp 9-25.
Bjerring P, Clement M, Heickendorff L, et al: Selective non-
ablative wrinkle reduction by laser. J Cutan Laser Ther 2:9-
15, 2000.
Fitzpatrick RE, Smith SR, Sriprachya-anunt S: Depth of
vaporization and the effect of pulse stacking with a high-
energy, pulsed carbon dioxide laser. J Am Acad Dermatol
40:615-622, 1999.
Goldberg DJ: Smoothbeam, non-ablative dermal remodeling
with the 1450-nm diode laser in combination with DCD.
Candela Clinical Application Notes 1(1, Feb), 2001.
Goldberg DJ: Non-ablative subsurface re-modeling: Clinical
and histologic evaluation of a 1320-nm Nd:YAG laser. J
Cutan Laser Therapy 1:153-157, 1999.
Khatri KA, Ross V, Gravelink JM, et al: Comparison of
erbium:YAG and carbon dioxide resurfacing of facial
rhytids. Arch Dermatol 135:391-397, 1999.
Kopelman J: Erbium:YAG laser: An improved periorbital
resurfacing device. Semin Ophthalmol 13:136-141, 1998.
Manuskiatti W, Fitzpatrick RE, Goldman MP: Treatment of
facial skin using combinations of CO2, Q-switched
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people to take advantage of periorbital rejuvenation
without sacrificing social or professional obligations.
Although the preliminary data suggest some improve-
ments in rhytids and texture, the change is gradual and
therefore may be moot. It is often only seen when
comparing the pretreatment and post-treatment
photographs. The treatment protocols are still in flux,
and it is not known how many treatments and at what
intervals will yield the best results. Significant techno-
logic and applicational improvement will no doubt
lead to an important role for nonablative lasers in the
periocular and other facial regions.
alexandrite, flashlamp-pumped pulsed dye, and Er:YAG
lasers in the same treatment session. Dermatol Surg 26:114-
120, 2000.
Menaker GM, Wrone DA, Williams RM, Moy RL: Treatment of
facial rhytids with a non-ablative laser: A clinical and
histological study. Dermatol Surg 25:440-444, 1999.
Millman AL, Mannor GE: Histologic and clinical evaluation of
combined eyelid erbium:YAG and CO2 laser resurfacing.
Am J Ophthamol 127:614-616, 1999.
Pollack H: NLite laser: Non-ablative wrinkle reduction.
Aesthet Surg 21:371-372, 2001.
Romero P, Alster TS: Skin rejuvenation with the Cool Touch
1320-nm Nd:YAG laser: The nurse's role. Dermatol Nurs
13:122-125, 2001.
Ross EV, Hardaway CA: Sub-surface skin renewal by treatment
with a 1450-nm diode laser in combination with dynamic
cooling. Candela Clin Application Notes 1(1), 2001.
Rubenstein R, Roenick HH, Stegan SJ, Hanke CW: Atypical
keloids after dermabrasion of patients taking isotretinoin. J
Am Acad Dermatol 15:280-285, 1982.
Sadick NS: Considerations in non-ablative laser/IPL
technologies for skin rejuvenation. Cosm Dermatol
(May):41-44, 2001.
Shim E, Yardy T, Valasquez E, et al: Short-pulse carbon dioxide
resurfacing in the treatment of rhytids and scars: A clinical
and histological study. Dermatol Surg 24:113-117, 1998.
Zelickson BD, Kilmer SI, Bernstein E, et al: Pulsed dye laser for
sun damaged skin. Lasers Surg Med 25:229-236, 1999.

The continuous rise in demand for blepharoplasty in
the United States has predictably coincided with an
increased number of early and late complications
resulting from the procedure. It is imperative, therefore,
that the surgeon be familiar not only with undesirable
cosmetic outcomes but also with the sight-threatening
complications and their management. This chapter
attempts to give an overview of such complications and
discusses some preventive solutions and treatment
options.
VISUAL LOSS SECONDARY TO
HEMORRHAGE
Retrobulbar hemorrhage is one of the most commonly
feared complications of blepharoplasty. The degree of
visual loss can be profound should appropriate treat-
ment be deferred. The overall incidence of retrobulbar
hemorrhage is thought to be approximately 1 in 25,000
cases. Retrobulbar hemorrhage can occur during the
procedure or several days after the procedure. Bleeding
is believed to result from inadequate control of
hemostasis during the removal of superficial orbital fat
pads or secondary to disruption of deep orbital vessels
from manipulation of superficial fat pads, because these
pads are linked to deep orbital fat. Finally, hemorrhage
can occur as a result of trauma to the vasculature during
injection of local anesthetic. Patient-related factors
include hypertension and certain coagulopathies, as well
as the use of medication such as aspirin or vitamin E.
It is important to recognize the signs of retrobulbar
hemorrhage as early as possible to avoid permanent
CHAPTER THIRTEEN
Complications in
Blepharoplasty
Ebby Elahi and Henry M. Spinelli
visual compromise. On the operating table these in-
clude sudden pupillary changes, proptosis, visual loss,
and/or loss of ocular motility. Patients who are dis-
charged after routine blepharoplasty should be in-
structed to contact their surgeon in the event of severe
pain or visual loss. For these reasons, the eyes of
blepharoplasty patients should not be patched and
their vision should be checked after surgery and before
discharge. One of us (HMS) likes to have patients
describe gross objects or count fingers, which, despite
surgery and/or topical ointments, serves to screen out
potential visual compromise.
Should retrobulbar hemorrhage occur during the
procedure, the status of the globe (including intraocular
pressure) and the optic nerve should be properly
assessed, preferably by an ophthalmologist. However,
all surgeons should be familiar with Schiøtz tonometry
and basic techniques for assessing the globe. Mild
hemorrhage can be controlled by head elevation and
close observation. For more severe hemorrhage a
stepwise approach must be undertaken to decompress
the globe. These include the lysis of one or both crura of
the lateral canthal ligament. This procedure allows the
globe to move forward and protects the globe and optic
nerve from ischemic and/or compressive damage. In
addition, the intraocular pressure can be reduced by
means of topical medications (i.e., timolol 0.5%,
dorzolamide 2%, or brimonidine) or systemic adminis-
tration of hyperosmolar agents (mannitol). Finally, in
cases of severe hematomas uncontrolled by the pre-
viously described measures, one may choose to decom-
press the inferior orbital wall and/or explore the
retro-orbital space surgically to control the hemorrhage.
The sequence for treatment in the event of orbital
hemorrhage should usually be canthotomy with con-
comitant medical treatment: systemic corticosteroids,
hyperosmolar agents, and carbonic anhydrase inhib-
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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY
itors along with topical β-adrenergic blockers. All
surgeons who perform blepharoplasty should be fami-
liar with these treatment modalities. Finally, para-
centesis of the anterior chamber is very effective in
decreasing intraocular pressure. However, this should
be reserved for the ophthalmologist or more
experienced physician.
PERFORATION OF THE GLOBE
DURING ANESTHESIA
Perforation of the globe during anesthesia is a rare but
potentially devastating complication. This is best
avoided by protecting the globe with a corneal shield
before injecting the anesthetic agent and by directing
the needle away from the globe. Should this compli-
cation occur, however, it is important to recognize it
early and intervene quickly. Ophthalmic consultation
should be obtained, and the procedure should be
interrupted. Some indicative signs are sudden change in
vision or a change in the position or circular symmetry
of the pupil.
DAMAGE TO EXTRAOCULAR
MUSCLES
Extraocular muscles may also be damaged during local
anesthetic injection, resulting in temporary or per-
manent strabismus. This complication occurs more
commonly with blind retrobulbar or peribulbar injec-
tions. More commonly, however, is the damage that
occurs to extraocular muscles during surgical dissection.
A muscle that is theoretically at the highest risk of damage
in blepharoplasty is the inferior oblique muscle.
Damage to the inferior oblique muscle most
commonly occurs from failure to adequately identify
the muscle during lower lid blepharoplasty. This muscle
is the only extraocular muscle that originates anteriorly
in the orbit. Its insertion is on the maxillary bone
approximately one third of the way from the junction of
the medial and inferior wall. It then courses posteriorly
and laterally to insert on the globe near the corre-
162
sponding region on the macula. It is best observed
between the medial and central fat pads and has a
pink/purple coloration, which is easily distinguishable
from the surrounding tissues.
Superior oblique palsy has also been reported from
damage to the trochlea during upper lid blepharoplasty.
This is best avoided by careful nasal dissection, avoid-
ance of excessive cautery in the region of the trochlea,
and proper identification of the superior medial
palpebral artery inferonasal to the medial fat pad.
DAMAGE TO THE CORNEA
One of the common complications during blepharo-
plasty is trauma to the corneal epithelium. Although the
majority of “abrasions” heal spontaneously within 24
hours or less, this is a cause of significant discomfort to
the patient and a potential source of infection in some.
This complication commonly occurs from abrasive
movements of instruments and sutures as well as trau-
matic insertion and removal of protective contact
lenses. The best way to avoid this complication is to pay
close attention to the various instruments used during
the procedure and then fill the corneal protective shield
with lubricants before its insertion or at least to irrigate
the lens surface with balanced saline before placement.
Should an abrasion occur, however, antibiotic ointment
can be prescribed and the patient should be observed
daily until healing occurs. It is imperative to avoid using
topical anesthetic solutions to alleviate the pain because
this will significantly delay healing and put the patient
at risk for neurotrophic corneal ulcer.
WOUND DEHISCENCE
Wound dehiscence may occur acutely immediately after
the surgery or subacutely within days to weeks post-
operatively. Besides inadequate closure or disruption of
sutures, one of the most common causes of wound
dehiscence is the formation of a hematoma. This may
occur slowly as vessels recover from the effects of
epinephrine used with the anesthesia, or it may occur
from the lysis of the coagulum. In general, small
quantities of “oozing” can be observed carefully in the

recovery room, and the patient should be reassured
about the temporary nature of the bleeding. Occa-
sionally, however, one encounters more brisk bleeding.
This occurrence is extremely rare but may need to be
explored and adequately addressed in the operating
room. Lower lid fat excision may be associated with
“flash” hemorrhage from vessels deep in the orbit. This
may present as a retrobulbar hemorrhage or a con-
tinuous serosanguineous discharge through the lower
lid conjunctival incision. Sometimes it is best to loosen
the conjunctival suture to allow for the expression of
the fluid until hemostasis is obtained to avoid
pressurizing this orbit.
EYELID MALPOSITION
Eyelid malposition has been covered in detail pre-
viously (Chapter 3), but a few important points for
treatment are worth repeating and elaborating on.
Lower Lid
Final positioning of the lower lid relies heavily on the
adequate understanding of lower lid anatomy. Exter-
nally, the lower lid must be apposed to the globe in its
entire length. An imaginary line drawn from the medial
canthal angle to the lateral canthal angle should sub-
tend an angle of 10 to 15 degrees from the horizontal.
Furthermore, the relation between the lower lid margin
and the inferior corneal margin must be such that on
primary gaze no sclera is visible (i.e., inferior scleral
show). The general position of the lashes must be such
that they are not in contact with the cornea (entropion),
nor should the margin be rotated in such a way that
palpebral conjunctiva is exposed.
Overresection of skin or aggressive dissection and fat
removal during transconjunctival blepharoplasty can
lead to entropion or ectropion. This may be caused by
the lack of external skin (ectropion) or disinsertion of
the lower lid retractors (entropion).
Many patients with dermatochalasis also have varia-
ble degrees of eyelid laxity, which must be addressed
during the surgical intervention (e.g., canthal tight-
ening, lateral canthal strip). These malpositions often
become more apparent postoperatively after the
removal of skin and fatty tissue. It is, therefore, im-
perative that the surgeon carefully examine the relative
C O M P L I C AT I O N S I N B L E P H A R O P L A S T Y
position of the eyelid margin and tarsal consistency
before surgery (e.g., snap back test, eyelid distraction
test). Conjunctival chemosis with prolapse can be an
annoying postoperative problem. It may occur secon-
dary to significant tightening of the lower eyelid with
resultant edema, or it may occur when repositioning
severely and chronically malpositioned eyelids (i.e.,
ectropion). Ostensibly, this is caused by a stretching
or expansion of the conjunctiva, which results in a
redundancy when the eyelid is repositioned. Conjunc-
tiva, like any mucous membrane, requires moisture, and
desiccation is not well tolerated. Conjunctival prolapse
can be positive feedback in that exposure leads to
desiccation, which leads to edema, which leads to
further exposure. Proper wetting with the intensive use
of topical drops and ointments is usually helpful in
preventing or worsening of the cycle, but one of us
(HMS) finds it most useful to perform a temporary
lateral tarsorrhaphy for a speedier resolution in the
more severe cases.
Upper Lid
Upper lid malpositions tend to be less common than
those of their lower lid counterpart. The majority of
upper lid malpositions occur as a result of excessive skin
excision or damage to the levator complex.
During the preoperative examination, particular
attention must be given to eyelid closure. Any evidence
of lagophthalmos must be carefully noted, because it is
likely to worsen postoperatively. In deciding on the
amount of skin to remove, care must be taken not to
confuse excessive upper eyelid skin with brow ptosis
(especially in men). After the brow is held in its desir-
able anatomic position, smooth forceps can be used to
determine the amount of upper skin to be removed in
such a way that the lashes are slightly everted. Inade-
quate preoperative assessment of eyelid movement and
anatomy may result in postoperative lagophthalmos
and corneal dryness or decompensation.
Ptosis is a rare complication of blepharoplasty. It may
result from damage to the levator aponeurosis muscle
during the dissection or excessive stretching of an
already rarified muscle during surgery. Finally, it may
result from lack of recognition of preoperative ptosis in
a patient with significant dermatochalasis. The take-
home lesson in almost all cases of eyelid malposition
after surgery is not to intervene too quickly. The patient
and/or the surgeon may feel compelled to “correct the
problem”; however, many difficulties spontaneously
disappear or improve significantly, and often the initial
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corrective treatment chosen is inadequate, excessive, or
not appropriate in addressing the long-term problem.
LOSS OF LASHES
This complication is more common in patients under-
going combined cases of blepharoplasty and ptosis
repair where the anterior tarsal surface is exposed.
Excessive inferior dissection (2 to 3 mm from the lid
margin in the upper lid) can lead to damage of the hair
follicle, with subsequent atrophy and loss of lashes in
the postoperative period. For this reason, it is best to
avoid distal lid dissections.
DRYNESS
Postoperative complaints of dry eye occur in patients
with preoperative tear insufficiency. By widening the
palpebral fissure and increasing exposure to the envi-
ronment, blepharoplasty can result in decompensation
in the predisposed patient. Dryness may also be the
sequela of cicatricial changes in the skin (pulling the lids
apart) or conjunctiva. Finally, the lacrimal gland itself
may be damaged during upper lid blepharoplasty, where
it can mistakenly be excised as upper lid fat. This
complication is best avoided by avoiding aggressive
dissection laterally where the lacrimal gland is located.
Usually, there is a noticeable color difference between
the lacrimal gland and the upper eyelid fat. Lacrimal
gland tissue in general is whiter and septated compared
with the pearly smooth yellow appearance of fat.
Often the symptoms of dryness can be addressed by
the use of artificial tears and lubricants. However,
should the symptoms persist, a referral to an ophthal-
mologist is warranted to evaluate the status of the
corneal tear film. Possible treatment options include
the use of temporary or permanent punctal plugs along
with the aggressive use of topical wetting agents.
INFECTION
Infection is an extremely rare complication in
blepharoplasty owing to the extensive vascularity of the
164
eyelids and/or orbit. Nevertheless, once the orbital
septum has been violated, pathogens can easily gain
access to the deep orbital structures. A common source
of infection is believed to be the nasolacrimal outflow
system in patients with post–lacrimal sac stenosis in
whom bacteria can multiply and reflux toward the
conjunctiva. Signs of orbital cellulitis include pain,
redness, decreased vision, restricted ocular motility, and
proptosis. Systemic antibiotics are warranted in this
situation, and close management with appropriate
specialists is encouraged. As a precautionary measure,
proper assessment of the nasolacrimal apparatus before
surgery may avoid this potentially devastating
complication.
INCISIONAL SCARRING
Postoperative scarring after blepharoplasty is relatively
rare and can generally be well managed with massage
and topical corticosteroid application. More severe scars
can be managed by intralesional corticosteroid injec-
tion or excision with radiation. The surgeon should
resist any impulse to intervene early when scarring is a
problem. In cases in which tension is a contributing
factor, resection alone will rarely, if ever, improve on the
final result and in many instances may worsen the result.
EXCESSIVE UPPER LID FAT
RESECTION
Although the upper lid seems more forgiving cos-
metically from overzealous fat resection, the resultant
“hollow” appearance should be avoided whenever
possible. In certain patients with excessive skin the
natural tendency may be to remove the redundant pre-
aponeurotic fat after the skin has been removed.
However, many older patients present with consider-
able atrophy of the orbit fat, and the presence of “rings”
around the eyes only suggests laxity of the periocular
aponeurotic system. Removal of excess fat from the
upper lid—especially in the midportion—may result in
the accentuated appearance of this superior orbital rim.
The nasal fat pad, on the other hand, is more forgiving,
and overresection of this fat pad rarely results in any
significant cosmetic abnormality. If the surgeon believes

some excess fat is present, he or she should sculpt the
fat and periodically reposition the tissue to assess the
upper lid contour. This can easily be achieved with the
use of electrocautery instruments, ablative laser, or
other techniques. Fat, superficial fascia, and thin dermal
grafts may all serve as satisfactory late fillers.
INAPPROPRIATE LOWER LID
FAT RESECTION
Excessive fat resection especially from the lower lids can
result in a tear trough deformity that is cosmetically
displeasing. This complication can be prevented if the
relationship between the globe and the orbitomaxillary
junction is carefully studied before surgery. Excessive fat
removal must be avoided, and, when possible, the re-
moved fat must be repositioned on the orbital margin
to soften the superficial appearance of the inferior
rim. (See Chapters 4 through 6 and 9 for a detailed
discussion of these techniques.)
References
Allen MV, Cohen KL, Grimson BS: Orbital cellulitis secondary
to dacryocystitis following blepharoplasty. Ann Ophthal-
mol 17:498-499, 1985.
Brown SM, Coats DK, Collins ML, Underdahl JP: Second
cluster of strabismus cases after periocular anesthesia
without hyaluronidase. J Cataract Refract Surg 27:1872-
1875, 2001.
DeMere M, Wood T, Austin W: Eye complications with
blepharoplasty or other eyelid surgery. A national survey.
Plast and Reconstr Surg 53:634-637, 1974.
C O M P L I C AT I O N S I N B L E P H A R O P L A S T Y
Underresection of fat may also create superficial
asymmetry and a globular appearance of the lower skin.
This complication can be minimized by periodically
palpating and reexamining the superficial contour of
the lower lid after the removal of each fat compartment.
Should the uneven appearance persist beyond the 3-
month postoperative period, further resection is
warranted to establish appropriate lower lid contour.
CONCLUSION
Blepharoplasty is a seemingly straightforward proce-
dure; however, even the most experienced and skilled
surgeon may be faced with complications. Many of the
complications are avoidable through comprehensive
preoperative evaluation, adequate preoperative patient
education, thorough knowledge of eyelid anatomy, and
meticulous surgical technique. Despite all efforts, every
surgeon will eventually encounter postoperative com-
plications and must be prepared to handle them or risk
causing serious functional or cosmetic morbidity to the
patient.
Lisman RD, Campbell JP: Complications of blepharoplasty.
Facial Plast Surg Clin North Am 8:303-327, 2000.
Lisman RD, Hyde K, Smith B: Complications of blepharo-
plasty. Clin Plast Surg 15:309-335, 1988.
Wesley RE, Pollard ZF, McCord CD Jr: Superior oblique paresis
after blepharoplasty. Plast Reconstr Surg 66:283-286, 1980.
165

Note: Page numbers followed by f indicate figures.
A Browlift (Continued)
Ablative lasers, 154, 155-157, 160. See also
Laser resurfacing.
Acyclovir, prophylactic, for laser resurfacing,
156, 158
Anatomy, surgical, 2-26
pearls and pitfalls for, 26
Anesthesia. See also specific procedure.
extraocular muscle injury in, 162
globe perforation during, 162
Annulus of Zinn, 10, 11f
Anterior ciliary arteries, 10
Anterior lacrimal crest, 17f
Antibiotics, prophylactic, for laser resurfacing,
156
Anti-mongoloid slant, in zygomatic
displacement, 146
Antiviral agents, prophylactic, for laser
resurfacing, 156, 158
Arcus marginalis, 120
Asians
upper eyelid blepharoplasty in, 68
upper eyelid fold in, 58, 59f, 61f
Atrophic scars, laser resurfacing for, 154-
160
Azithromycin, prophylactic, for laser
resurfacing, 156
B Central fat pad, 10, 11f
Bleeding. See also Hemorrhage.
postoperative, 162-163
Blepharochalasis, definition of, 58
Blepharophimosis syndrome, 92
Blepharoplasty. See Lower eyelid
blepharoplasty; Upper eyelid
blepharoplasty.
Blepharospasm, vs. ptosis, 92
Blinking cycle, 16f, 22
Bone grafts, in orbital floor reconstruction,
147-148, 148f, 149f
Brow fat pad, 136
debulking of, 137-138, 139f
Browlift
anatomic considerations in, 136
direct, 144, 145f
direct temporal lift, 142, 143f
pearls and pitfalls for, 144
preoperative planning for, 137
results of, 140f-141f
with upper lid blepharoplasty, 60, 62, 63f,
137-138, 139f-141f
Browplasty/browpexy, 137-138, 139f-141f
anatomic considerations in, 136
pearls and pitfalls for, 144
preoperative planning for, 137
results of, 140f-141f
C
Canaliculi, 15f-17f
Canthal tendons, 4f, 7, 7f-9f
Canthopexy
common, 46, 47f
for exophthalmos, 150
lateral. See Lateral canthal suspension
procedures.
vs. canthoplasty, 36, 122
with disinsertion of canthal tendon, 122
Canthoplasty, 46, 47f, 122
definition of, 122
lateral. See Lateral canthal suspension
procedures.
technique of, 123f
vs. canthopexy, 36, 122
with midface suspension, 122, 123f
Capsulopalpebral fascia, 3f-5f, 6
Capsulopalpebral fascial dehiscence, 34
Check ligaments, 10, 11f, 18
Cheek
as midface component, 120
soft tissue anatomy of, 129f
Cheek suspension, for cicatricial
ectropion/entropion, 48
Cheimosis, conjunctival, postoperative, 163
Chronic external ophthalmoplegia, 95
Cicatricial ectropion, 36
repair of, 48, 48f, 49f
Cicatricial entropion, 36
repair of, 50, 50f, 51f
CO2 laser, 154-156. See also Laser resurfacing.
Commissuroplasty, 122
Common canaliculus, 14, 15f
Common canthal tendon, 4f, 9f
Common canthopexy, 46, 47f. See also
Canthopexy.
Common canthoplasty, 46, 47f, 122
definition of, 122
technique of, 123f
Index
Common canthoplasty (Continued)
vs. canthopexy, 36, 122
with midface suspension, 122, 123f
Complications, operative, 161-165. See also
Operative complications.
Congenital ptosis, 92-94, 93f. See also Eyelid
ptosis.
levator advancement for, 102-103, 104f-
109f
Conjunctiva, 3f, 5f, 6
examination of, 28
Conjunctival cheimosis, postoperative, 163
Conjunctival goblet cells, 20, 21f
Conjunctival prolapse, postoperative, 163
Cool Touch laser, 158. See also Laser
resurfacing.
Corneal injury, intraoperative, 162
Corneal light reflex distance, 94
Corneal shield, 162
Cranio-orbital surgery, 146-153
for enophthalmos, 146-148, 148f, 149f,
150
for exophthalmos, 150, 151f-153f
patient selection for, 146
Cryogen spray, for nonablative lasers, 158-
159
Cutaneous flaps, in lower lid blepharoplasty,
72-73
D
Deep temporal fascia graft, for upper lid
retraction, 114, 116f, 117f
Dehiscence
of capsulopalpebral fascia, 34
of levator aponeurosis, ptosis and, 92,
94
wound, 162-163
Dermatochalasis
definition of, 58
eyebrow ptosis and, 136-137
postoperative eyelid malposition and,
163-164
preoperative evaluation of, 62
vs. ptosis, 92
Dicloxacillin, prophylactic, for laser
resurfacing, 156
Direct browlift, 144, 145f
Direct temporal lift, 142, 143f
pearls and pitfalls for, 144
Dressings, for laser resurfacing, 157
167
INDEX
Dry eye
after ptosis repair, 95
eyelid ptosis and, 98-99
E retractors of, 6
Ectropion, 36. See also Eyelid malposition.
cicatricial, 36
repair of, 48, 48f, 49f
classification of, 34
lower eyelid shortening for, 36
pathophysiology of, 34
repair of, 36-46, 37f, 39f-43f, 45f, 47f. See
also Lateral canthal suspension
procedures.
En bloc orbital advancement, for
exophthalmos, 150, 152f, 153f
Enophthalmos
causes of, 146
vs. ptosis, 92, 93f
correction of, 147-148, 148f, 149f, 150
Entropion. See also Eyelid malposition.
cicatricial, 36
repair of, 50, 50f, 51f
classification of, 34
involutional, 29, 34, 35f
repair of, 52, 53f
pathophysiology of, 34
Erbium:YAG lasers. See also Laser resurfacing.
ablative, 154-156
nonablative, 154-155, 157-160
Erythromycin, prophylactic, for laser
resurfacing, 156
Ethmoid bone, 9f
Exophthalmos, 150, 151f-153f
Extraocular muscles, 10, 11f
check ligaments of, 10, 11f
intraoperative injury of, 162
Eyebrow. See also under Brow.
aesthetic considerations for, 136-137
anatomy of, 136
evaluation of, 136-137
gender differences in, 136
mobility of, 136
Eyebrow fat pad, 136
debulking of, 137-138, 139f
Eyebrow position, in upper lid
blepharoplasty, 60, 62, 63f
Eyebrow ptosis/hooding, 60, 136
browlift for. See also Browlift.
direct, 144, 145f
with upper lid blepharoplasty, 63f, 68,
70f, 136, 137-138, 139f-141f
dermatochalasis and, 136-137
direct temporal lift for, 142, 143f
Eyebrow suspension
anatomic considerations in, 136
in upper lid blepharoplasty, 60, 62, 63f,
137-138, 139f-141f
pearls and pitfalls for, 144
preoperative planning for, 137
results of, 140f-141f
Eyelashes, loss of, 164
Eyelid. See also Lower eyelid; Upper eyelid.
anatomy of, 2-26. See also specific
structures.
gross examination of, 28-29
168
Eyelid (Continued)
layers of, 2, 3f-5f
pulley system of, 6-7, 11f
reorienting mechanisms in, 6
Eyelid aperture, measurement of, 95, 97f
Eyelid fold, position of
in blepharoplasty, 62, 63f, 68, 70f
normal, 94
racial differences in, 58, 59f, 61f
supertarsal fixation and, 62, 63f, 68, 70f
Eyelid laxity
pinch test for, 29, 36
snap back test for, 29, 36
Eyelid malposition
lower lid, 33f, 34-56, 121. See also
Ectropion; Entropion; Lower eyelid
retraction; Scleral show.
cicatricial, 36, 48-50, 48f-51f
evaluation of, 29, 33f, 36
full-thickness lower eyelid shortening
for, 36
involutional, 29, 34, 35f
repair of, 52, 53f
lateral canthal inclination and, 34, 35f
modified lateral tarsal strip procedure
for, 38, 39f-43f
myopia and, 33f
pathophysiology of, 34
postoperative, 163-165
tarsal tuck for, 44, 45f, 90-91, 91f
with midface ptosis, 120, 121f, 122
midface suspension for, 122-135.
See also Midface suspension.
upper lid. See Upper eyelid ptosis; Upper
eyelid retraction.
Eyelid ptosis, 92-111
causes of, 92
choice of procedure for, 98-99
congenital, 92-94, 93f
levator advancement for, 102-103,
104f-109f
contralateral, 113f
dry eye and, 98-99
evaluation of, 92-95, 93f
frontalis sling procedure for
indications for, 98
technique of, 110, 111f
grading of, 95
in zygomatic fractures, 146-147
involutional, 29, 34, 35f, 94
levator advancement for, 102-109
eyelid retraction after, 112
indications for, 98
results of, 107f-109f
technique of, 102-103, 104f-107f, 109f
levator function evaluation for, 95, 96f,
97f
levator tuck for
indications for, 98
technique of, 102
myopathic, 94-95
pearls and pitfalls for, 118
physical examination in, 94-95, 96f, 97f
postoperative, 163-164
tarsal conjunctival müllerectomy for
indications for, 98
Eyelid ptosis (Continued)
technique of, 99, 100f, 101f
tear production and, 95
vs. pseudoptosis, 92, 93f
Eyelid retraction. See Lower eyelid retraction;
Upper eyelid retraction.
F
Facelift incision, in midface suspension, 124,
125f, 127f
Facial nerve, aberrant regeneration of, 95
Fasanella-Servat operation
eyelid retraction after, 112
indications for, 98
technique of, 99, 100f, 101f
Fat
eyebrow, 136
debulking of, 137-138, 139f
orbital. See Orbital fat.
Fat redistribution, 44, 45f, 90-91, 91f
Flaps
cutaneous vs. myocutaneous, in lower lid
blepharoplasty, 72-73
periosteal, in lateral tarsal strip procedure,
38, 42f-43f
Fractures, zygomatic, enophthalmos and,
146-147, 148f, 149f, 150
Frontal bone, 9f
Frontalis sling procedure
indications for, 98
technique of, 110, 111f
Frost suture, in enophthalmos repair, 147-
148
G
Globe, perforation of, 162
Glycolic acid lotion, for laser resurfacing
patients, 156
Goblet cells, 20, 21f
Gold weight insertion, for upper lid
retraction, 114, 118f
Graft
bone, in orbital defect repair, 147-148,
148f, 149f
interposition
for lower lid retraction, 54, 55f
for upper lid retraction, 114, 116f,
117f
skin, for cicatricial ectropion, 48, 49f
Graves‘ disease
exophthalmos in, 146, 150, 151f-153f
upper lid retraction in, 112. See also Upper
eyelid retraction.
H
Hemorrhage. See also Bleeding.
orbital, 20
retrobulbar, visual loss and, 161-162
Herpes simplex virus, prophylaxis for, for
laser resurfacing, 156, 158
History taking, 28
Hooding, eyebrow. See Eyebrow ptosis.
Hydroquinone 4% cream, for laser
resurfacing patients, 156

I Lateral canthal suspension procedures
Infection, wound, 164
Inferior lid retractor disinsertion, 34
Inferior oblique muscle, 6, 10, 11f
Inferior orbital fissure, 9f
Inferior rectus muscle, 6, 10, 11f
Inferior turbinate, 16f
Infraorbital foramen, 9f
Intercommissure distance, shortening of, 35f
Interposition graft
for lower lid retraction, 54, 55f
for upper lid retraction, 114, 116f, 117f
Intraoperative complications, 161-165. See
also Operative complications.
Involutional entropion, 29, 34, 35f
repair of, 52, 53f
Involutional ptosis, 29, 34, 35f, 94. See also
Eyelid ptosis.
L Lateral canthus
Lacrimal apparatus, 20, 21f
tear production in, 20-23. See also Tear(s).
Lacrimal bone, 9f
Lacrimal drainage system, 12, 13f, 14, 15f,
16f
Lacrimal duct, 15f, 16f
Lacrimal fossa, 9f
Lacrimal gland, 8f, 9f, 16f
anatomy of, 20, 21f, 137
intraoperative injury of, 164
prolapse of, 20, 21f, 137, 138f
Lacrimal gland suspension, 137, 138f
Lacrimal pump, 20, 22
Lacrimal puncta, 15f, 17f
displacement of, 12, 13f
Lacrimal sac, 12, 13f, 14, 15f-17f
Lagophthalmos
after ptosis correction, 94
preoperative evaluation of, 62
ptosis and, 94
Laser(s)
ablative, 154, 155-156
cooling devices for, 158, 159
nonablative, 154, 158-159
safety precautions for, 156
Laser resurfacing, 154-160
ablative, 154-157, 160
CO2 vs. erbium:YAG laser for, 155-156
intraoperative care in, 156-157
postoperative care in, 157
pretreatment in, 156
nonablative, 154-155, 157-160
candidate selection for, 158
dermal reaction in, 157-158
lasers for, 158-159
technique of, 158-159
Lashes, loss of, 164
Lateral canthal complex
transcutaneous approach to, 44, 45f
upper eyelid approach to, 46, 47f, 48, 49f
Lateral canthal suspension procedures
common canthoplasty, 46, 47f, 122,
123f
for cicatricial ectropion/entropion, 48-50,
48f-51f
(Continued)
for ectropion, 36-46, 37f, 39f-43f, 45f, 47f
for exophthalmos, 150
for involutional entropion, 52, 53f
for scleral show, 52-54, 54f, 55f
indications for, 46
interposition grafts in, 54, 55f
pearls and pitfalls for, 56
tarsal strip, 37f, 38, 39f-43f, 44, 45f
transcutaneous approach in, 44, 45f
upper eyelid approach in, 46, 47f
with midface suspension, 48-50, 49f-51f,
122-135
Lateral canthal tendon, 4f, 7, 7f-9f, 18, 19f
laxity of, 34, 35f, 120
tightening of. See also Lateral canthal
suspension procedures.
lacrimal puncta displacement and, 12,
13f
as midface component, 120
inclination of, 23, 34, 35f
Lateral fat pad, 11f. See also Orbital fat.
Lateral rectus muscle, 10, 11f
Lateral retinaculum, 4f, 18, 19f
Lateral tarsal strip procedure
results of, 37f
technique of, 38, 39f-43f
Le Fort III procedure, for exophthalmos, 150,
152f, 153f
Levator advancement, 102-109
eyelid retraction after, 112
indications for, 98
results of, 107f-109f
technique of, 102-103, 104f-107f, 109f
Levator aponeurosis, 3f-5f, 6, 7
dehiscence of, ptosis and, 92, 94
lateral horn of, insertion of, 7, 8f, 18, 19f
supertarsal fixation of, 68, 70f
Levator palpebrae superioris muscle, 6-7, 7f,
10, 11f
functional evaluation of, 95, 96f, 97f
Levator recession, for upper lid retraction,
114, 115f-117f
Levator tuck
for ptosis
indications for, 98
technique of, 102
in upper lid blepharoplasty, 68, 70f
Lid aperture, measurement of, 95, 97f
Lid lag
after ptosis correction, 94
preoperative evaluation of, 62
ptosis and, 94
Limbal goblet cells, 20, 21f
Lockwood‘s ligament, 4f, 7f, 18
Lower canaliculi, 15f-17f
Lower eyelid
as midface component, 120
displacement of, 23, 25f
extrinsic distraction forces on, 23, 24f, 25f
gross examination of, 28-29
homeostasis of, 23, 24f, 25f
intrinsic support for, 23, 24f, 25f
normal position of, 6, 23, 24f, 25f, 28
relationship of to upper eyelid, 5f, 6
INDEX
Lower eyelid (Continued)
rhytidectomy in, 80, 81f
snap back test for, 29, 36
transconjunctival approach to, 84-85, 86f
transcutaneous approach to, 45f, 73-74, 75f
Lower eyelid blepharoplasty, 72-89
complications of, 161-165. See also
Operative complications.
midface position and, 72
preoperative evaluation for, 72
transconjunctival, 80-89
advantages and disadvantages of, 73
indications for, 73, 80, 82f, 83f
pearls and pitfalls for, 85
results of, 82f, 83f
technique of, 84-85, 86f-89f
vs. transcutaneous approach, 72-73
transcutaneous, 72-78
advantages and disadvantages of, 72
cutaneous vs. myocutaneous flaps in,
72-73
indications for, 73
pearls and pitfalls for, 78
preoperative planning in, 72, 78
technique of, 73-74, 75f-77f, 79f
vs. transconjunctival approach, 72-73
with midface suspension, 132, 133f, 134f
Lower eyelid laxity. See also Eyelid
malposition.
modified lateral tarsal strip procedure for,
38, 39f-43f
pinch test for, 36
snap back test for, 29, 36
tarsal tuck for, 44, 45f, 90-91, 91f
Lower eyelid ptosis. See Eyelid malposition.
Lower eyelid retraction, 33f, 34, 52-54, 54f,
55f. See also Eyelid malposition.
evaluation of, 29, 33f
in Graves‘ disease, 146, 150, 151f-153f
in zygomatic fractures, 146-147
pathophysiology of, 34
repair of, 52-54, 54f, 55f
Lower eyelid shortening, full-thickness, for lid
laxity, 36
Lower eyelid–upper eyelid relationship, 5f, 6
M
Malar eminence, position of, evaluation of,
29, 31f, 33f
Malar support
evaluation of, 29, 31f
inadequate, 33f
Marcus-Gunn jaw-winking phenomenon, 95
Maxilla bone, 9f
Medial canthal tendon, 12, 13f
insertions of, 9f
Medial canthus
anatomy of, 12-14, 13f, 15f-17f, 18, 19f
inclination of, 35f
Medial fat pad, 10, 11f. See also Orbital fat.
Medial rectus muscle, 10, 11f
Meibomian glands, 2, 20
Mid face
age-related changes in, 120, 121f
anatomy and physiology of, 120, 121f
components of, 120
169
INDEX
Midface ptosis, 120, 121f
repair of. See Midface suspension.
Midface suspension
canthal approach in, 124
complications of, 132
direct (periocular) approach in, 128, 129f-
131f
facelift incision in, 124, 125f, 127f
facialplasty (preauricular) approach in,
124, 125f, 127f, 132
for cicatricial ectropion/entropion, 48, 49f
general technical aspects of, 132
indications for, 122
lower lid approach in, 132
pearls and pitfalls for, 135
results of, 131f, 133f, 134f
transeyelid approach in, 124
with blepharoplasty, 132, 133f, 134f
with common canthoplasty, 122, 123f
Modified lateral tarsal strip procedure
results of, 37f
technique of, 37, 39f-43f
Müller‘s muscle, 3f, 5f, 6
Muscles. See Extraocular muscles and specific
muscles.
Myocutaneous flaps, in lower lid
blepharoplasty, 73
Myopathic ptosis, 94-95
Myopia
inadequate malar support and, 33f
negative vector and, 33f
N
Nasolacrimal duct, 17f, 22
Negative vector, myopia and, 33f
Neodymium:YAG lasers, 154-155, 157-160.
See also Laser resurfacing.
cooling devices for, 158, 159
types of, 158-159
Nlite laser, 159. See also Laser resurfacing.
Nonablative lasers, 154-155, 157-160. See
also Laser resurfacing.
O history in, 28
Oculomotor nerve, aberrant regeneration of,
94-95
Operative anatomy, 2-26. See also specific
structures.
pearls and pitfalls for, 26
Operative complications, 161-165
corneal injury, 162
dry eye, 164
extraocular muscle injury, 162
eyelid malposition, 163-164
globe perforation, 162
hemorrhage-related visual loss, 161-162
incisional scarring, 164
infection, 164
insufficient/excessive fat resection, 164-165
loss of lashes, 164
wound dehiscence, 162-163
Operative procedure, selection of, 32
Ophthalmic artery, 10
Orbicularis oculi muscle, 2, 3f, 4f, 6, 12, 18,
19f
170
Orbicularis oculi muscle (Continued)
evaluation of, 94
innervation of, 6
Orbital advancement, en bloc, for
exophthalmos, 150, 152f, 153f
Orbital bones, 9f
Orbital decompression, for exophthalmos,
150, 151f-153f
Orbital fat, 3f, 5f, 8f, 10, 11f
excessive resection of, 164-165
malposition of, ptosis and, 94
pseudoherniation of, 34, 35f
repositioning of, 44, 45f, 90-91, 91f
underesection of, 165
vs. brow fat pad, 136
Orbital fissures, 9f
Orbital floor defects, in zygomatic fractures,
146-147, 148f, 149f
repair of, 147-148, 148f, 149f, 150
Orbital hemorrhage, 20
Orbital malar ligament
anatomy of, 120
laxity of, 120
Orbital septum, 3f-5f, 8f, 11f, 18, 19f, 20,
120
insertion of, 7f
orbital fat and, 20
Orbital volume discrepancy
in enophthalmos, 146-148, 148f, 149f
in exophthalmos, 150, 151f-153f
Orbital wall repositioning, for exophthalmos,
150, 151f-153f
Osteotomy, zygomatic
for enophthalmos, 147-148, 148f, 149f,
150
for exophthalmos, 150, 151f-153f
P incisional, 164
Palatal mucoperiosteum graft, in lower lid
retraction, 54, 55f
Palatine bone, 9f
Palpebral glands of Zeis and Moll, 20, 21f
Patient evaluation, 28-33
pearls and pitfalls for, 32
physical examination in, 28-30
Patient history, 28
Periosteal flaps, in lateral tarsal strip
procedure, 38, 42f-43f
Photodamage, laser resurfacing for, 154-160
Physical examination, 28-30
pearls and pitfalls for, 32
Pinch test, 36
Platysma muscle, 3f, 6
Postorbicularis precapsulopalpebral fascial
space, 5f
Preaponeurotic orbital fat, 3f, 5f, 8f, 20. See
also Orbital fat.
malposition of, ptosis and, 94
vs. brow fat pad, 136
Precapsulopalpebral fat, 5f, 20
Preoperative evaluation. See Patient
evaluation.
Preorbital orbicularis oculi muscle, 12
Preseptal orbicularis oculi muscle, 12, 18,
19f
Pretarsal gold weight insertion, for upper lid
retraction, 114, 118f
Pretarsal orbicularis oculi muscle, 12
Pseudoptosis, 92
in zygomatic displacement, 146-147
Ptosis
eyebrow, 60, 136
browlift for, 63f, 68, 70f, 136, 137-
138, 139f-141f, 144, 145f. See also
Browlift.
dermatochalasis and, 136-137
direct temporal lift for, 142, 143f
upper lid blepharoplasty and, 63f, 68,
70f
lower lid. See Eyelid malposition.
midface, 120, 121f
repair of. See Midface suspension.
overcorrection of, eyelid retraction and,
112-118, 113f. See also Upper eyelid
retraction.
upper lid, 92-111. See also Eyelid ptosis.
Pulsed dye lasers, 154-155, 157-160. See also
Laser resurfacing.
R
Retinoic acid cream, for laser resurfacing
patients, 156
Retrobulbar hemorrhage, visual loss and, 161-
162
Rhytidectomy, lower lid, 80, 81f
Rhytids, laser resurfacing for, 154-160. See
also Laser resurfacing.
S
Scars
laser resurfacing for, 154-160. See also
Laser resurfacing.
Schirmer test, 29, 31f
in ptosis, 95
Scleral show, 33f, 34. See also Eyelid
malposition.
evaluation of, 29, 33f
pathophysiology of, 34
repair of, 52-54, 54f, 55f
with midface ptosis, 120, 121f
Senile entropion, 29, 34, 35f
repair of, 52, 53f
Skin flaps, in lower lid blepharoplasty, 72-73
Skin grafts, for cicatricial ectropion, 48, 49f
SMAS muscle, 3f, 6
Smoothbeam laser, 159. See also Laser
resurfacing.
Snap back test, 29, 36
Snellen test, 29, 31f
Spacer graft, in lower lid retraction, 54, 55f
Sphenoid bone, 9f
Subconjunctival glands of Krause and
Wolfring, 20, 21f
Sun damage, laser resurfacing for, 154-160.
See also Laser resurfacing.
Sunscreens, for laser resurfacing patients,
156
Superior oblique muscle, 10, 11f
Superior orbital fissure, 9f

Superior rectus muscle, 10, 11f
Superior sulcus deformity, 94
Supertarsal fixation, 68, 70f
Supraorbital neurovascular bundle, location
of, 137
Supratrochlear neurovascular bundle,
location of, 137
Surgical anatomy, 2-26. See also specific
structures.
pearls and pitfalls for, 26
Surgical complications, 161-165. See also
Operative complications.
Surgical procedure, selection of, 32
T pearls and pitfalls for, 78
Tarsal conjunctival müllerectomy
eyelid retraction after, 112
indications for, 98
technique of, 99, 100f, 101f
Tarsal goblet cells, 20, 21f
Tarsal plate, 2, 3f, 6, 8f
in lower eyelid support, 23
lateral canthal tendon and, 18, 19f
Tarsal tuck with fat repositioning, 44, 45f, 90-
91, 91f
Tarsorrhaphy, temporary
in enophthalmos repair, 147-148
in exophthalmos repair, 150
Tear film, 16f, 20
evaluation of, 30, 31f
inadeqaute
after ptosis repair, 95
in ptosis, 98-99
refractive properties of, 20, 22
Tear trough deformity, iatrogenic, 165
Tear(s). See also under Lacrimal.
aqueous phase of, 20, 22
blinking cycle and, 16f, 22
constituents of, 20
distribution of, 22
drainage of, 12, 13f, 14, 15f, 16f, 22
evaporation of, 22
ptosis repair and, 98-99
homeostasis of, 22-23
layers of, 20
production of, 14, 16f, 20, 21f
Schirmer test for, 29, 31f, 95
quality of, evaluation of, 29-30
Tetrafluoroethane spray, for nonablative
lasers, 158-159
Thyroid ophthalmopathy
exophthalmos in, 146, 150, 151f-153f
Thyroid ophthalmopathy (Continued)
upper lid retraction in, 112. See also Upper
eyelid retraction.
Transconjunctival lower lid blepharoplasty,
80-89
indications for, 80, 82f, 83f
pearls and pitfalls for, 85, 86f-89f
results of, 82f, 83f
technique of, 84-85, 86f-89f
Transcutaneous lower lid blepharoplasty, 72-
78
advantages and disadvantages of, 72
cutaneous vs. myocutaneous flaps in, 72-73
indications for, 73
preoperative planning in, 72, 78
technique of, 73-74, 75f-77f, 79f
U Visual loss, due to retrobulbar hemorrhage,
Upper canaliculi, 15f-17f
Upper eyelid
age-related differences in, 58, 59f, 61f
baggy, 58, 59f, 61f
deep-set, 58, 59f
gross examination of, 28-29
maximal arch of, 28
normal position of, 6, 28, 94
normal variations in, 58, 59f
racial differences in, 58, 59f, 61f
relationship of to lower eyelid, 5f, 6
superior sulcus deformity of, 94
Upper eyelid approach, to lateral canthal
tendon and midface, 46, 47f, 48, 49f
Upper eyelid blepharoplasty, 58-70
brow fat pad debulking in, 137-138,
139f
browplasty/browpexy in, 137-138, 139f-
141f
complications of, 161-165
eyebrow position in, 60, 62, 63f
eyebrow ptosis and, 63f, 68, 70f
in Asians, 68
lacrimal gland suspension in, 137, 138f
lid crease position in, 62, 63f, 68, 70f
pearls and pitfalls for, 68
preoperative evaluation for, 58-62
preoperative planning in, 62, 63f, 66f
technique of, 62-68, 64f-67f, 69f, 70f
Upper eyelid excursion, measurement of, 95,
96f, 97f
Upper eyelid fold, position of
in blepharoplasty, 62, 63f, 68, 70f
INDEX
Upper eyelid fold, position of (Continued)
normal, 94
racial differences in, 58, 59f, 61f
supertarsal fixation and, 62, 63f, 68, 70f
Upper eyelid ptosis, 92-111. See also Eyelid
ptosis.
Upper eyelid retraction, 112-118
after ptosis surgery, 112
contralateral, 113f
in Graves‘ disease, 112, 146, 150, 151f-153f
interposition graft for, 114, 115f-117f
postoperative, 163-164
weight insertion for, 114, 118f
Upper eyelid–lower eyelid relationship, 5f, 6
V
Visual acuity testing, 29, 31f
161-162
W
Weight insertion, for upper lid retraction,
114, 118f
Whitnall‘s ligament, 3f, 4f, 7, 7f-9f, 19f, 21f
Whitnall‘s tubercle, 4f, 7, 9f, 18, 19f
Wound care, after laser resurfacing, 157
Wound dehiscence, 162-163
Wound infection, 164
Wrinkles
laser resurfacing for, 154-160. See also
Laser resurfacing.
lower lid rhytidectomy for, 80, 81f
X
Xerophthalmia
after ptosis repair, 95
eyelid ptosis and, 98-99
postoperative, 164
Z
Zygomatic bone, 9f
Zygomatic fracture, enophthalmos and, 146-
147, 148f, 149f, 150
Zygomatic osteotomy
for enophthalmos, 146-148, 148f, 149f
for exophthalmos, 150, 151f-153f
Zygomaticofacial foramen, 9f
Zygomaticofrontal suture, 9f
171