MOC

An Evidence-Based Approach to Blepharoplasty

Jack A. Friedland, M.D.
Don H. Lalonde, M.D.
Rod J. Rohrich, M.D.
Scottsdale, Ariz.; Saint John, New
Brunswick, Canada; and Dallas,
Texas
The Maintenance of Certification module series is designed to help the clinician
structure his or her study in specific areas appropriate to his or her clinical
practice. This article is prepared to accompany practice-based assessment of
preoperative assessment, anesthesia, surgical treatment plan, perioperative
management, and outcomes. In this format, the clinician is invited to compare
his or her methods of patient assessment and treatment, outcomes, and com-
plications, with authoritative, information-based references.
This information base is then used for self-assessment and benchmarking in
parts II and IV of the Maintenance of Certification process of the American
Board of Plastic Surgery. This article is not intended to be an exhaustive treatise
on the subject. Rather, it is designed to serve as a reference point for further
in-depth study by review of the reference articles presented. (Plast. Reconstr.
Surg. 126: 2222, 2010.)

CLINICAL SCENARIO METHODS FOR IDENTIFYING

EVIDENCE

A
56-year-old woman requests improvement
in the appearance of her upper and lower
eyelids. She had LASIK surgery 3 months
earlier. She has ptosis of her left upper eyelid.
What is the best evidence to guide you in the
management of her condition?
There is very little high level evidence in the
blepharoplasty literature at this time. The age of
evidence is just upon us, and objective measure-
ment in aesthetic surgery is in its infancy. This
article is a starting point where most of the ev-
idence is level IV (case series) and level V (case
reports or expert opinion). There is almost no
level III evidence (retrospective comparative
case series) and virtually no level II evidence
(prospective comparative studies). It will be very
difficult to create level I studies that are pro-
spective randomized blinded controlled studies.
Nevertheless, we have to start somewhere. One
hundred years from now, there will be serious
useful evidence-based studies in cosmetic plastic
surgery, like looking from the top of a sky
scraper. This is the first step at examining where
we are in the basement of evidence based med-
icine in aesthetic blepharoplasty.
From private practice; the Division of Plastic Surgery, Dal-
housie University; and the Department of Plastic Surgery,
University of Texas Southwestern Medical Center.
Received for publication March 10, 2010; accepted April 30,
2010.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181f949a2
A literature search of PubMed, Cumulative In-
dex to Nursing and Allied Health Literature, and
the Cochrane Library was performed to obtain the
best available evidence on blepharoplasty, with
emphasis on preoperative assessment, treatment,
and outcomes. The following search terms were
combined as appropriate, and PubMed MeSH
terms were used when available: blepharoplasty,
eyelid surgery, diagnosis, preoperative assessment,
risk factors, smoking, diabetes mellitus, pulmo-
nary embolism, venous thrombosis, dry eye syn-
dromes, anticoagulants, DVT prophylaxis, an-
tibiotic prophylaxis, anesthetics, premedication,
surgical treatment plan, treatment, surgery, out-
come, complications, postoperative complica-
tions, pain management, and analgesia. The ini-
tial search was limited to human studies that were
published from 1999 to 2009 and indexed as meta-
analyses, randomized controlled trials, clinical tri-
als, or comparative studies. Very few studies were
found through the initial literature search; there-
fore, the search was later expanded to include
studies published in 2010 that were case series,
case reports, or expert opinion. Additional refer-
ences were included if deemed necessary for dis-
cussion. Studies were excluded if the full text was
inaccessible or of non-English language, as the
Disclosure: The authors have no financial interest
in any of the drugs, devices, or products mentioned
in this article.

2222 www.PRSJournal.com
Volume 126, Number 6 • Evidence-Based Blepharoplasty
study quality could not be evaluated. Relevant
studies were appraised for quality and validity ac-
cording to criteria published by the Critical Ap-
praisal Skills Program1 and assigned a level of ev-
idence with the American Society of Plastic
Surgeons Evidence Rating Scale for Therapy (Ta-
ble 1). Levels of evidence are indicated through-
out the text below. Evidence ratings were not as-
signed to studies with inadequately described
methods and/or worrisome biases or to refer-
ences included for discussion purposes only (e.g.,
narrative reviews).
EVIDENCE ON PREOPERATIVE
ASSESSMENT
Preoperative patient evaluation for blepharo-
plasty should include general medical and peri-
orbital histories. Previous surgery (including laser-
assisted in situ keratomileusis LASIK surgery),
smoking history, cardiac disease, bleeding and/or
clotting disorders, thyroid problems, and chronic
illnesses, such as diabetes and hypertension,
should be documented. Medications, including
dietary supplements, aspirin, and anticoagulants
may need to be adjusted to decrease the risk of
postoperative bleeding. An eye history which in-
cludes dry eyes, glaucoma, the need for glasses,
trauma, allergies, excess tearing, and ophthalmol-
ogist or optometrist assessment must be obtained.
Blepharochalasis is an inflammatory condition
which is recurrent, intermittent, and difficult to
treat. It results in edema, erythema, and excess
eyelid skin.
Dry eye syndrome (dysfunctional tear syn-
drome) is a problem of tear deficiency and eye
discomfort that may result in damage to the cor-
nea. This common problem (5 to 15 percent of the
Table 1. American Society of Plastic Surgeons
Evidence Rating Scale for Therapy
Level of
Evidence Qualifying Studies
I High-quality, multicenter or single-center,
randomized controlled trial with
adequate power; or systematic review of
these studies
II Lesser-quality, randomized controlled trial;
prospective cohort study; or systematic
review of these studies
III Retrospective comparative study, case-
control study, or systematic review of
these studies
IV Case series
V Expert opinion; case report or clinical
example; or evidence based on
physiology, bench research, or “first
principles”
population) is best obtained by history and can be
described by patients as dryness, burning, foreign-
body sensation, blurred vision, photophobia, itch-
ing, redness, tearing, and discharge of mucus. The
Schirmer test is no longer considered the standard
means for diagnosing patients with dry eye syn-
drome. Women on hormone replacement ther-
apy, including estrogen, after menopause have a
70 percent higher risk of developing dry eye, with
an additional 15 percent increase in the risk of
developing dry eye every 3 years while on hormone
replacement therapy. Preservative-free artificial
tears in the day and/or lubricant ointments at
night before and after surgery should be consid-
ered. Preoperative counseling should include the
mention of the high incidence of postoperative
dysfunctional tear syndrome and the risk of symp-
toms worsening after blepharoplasty. Patients with
prior laser vision correction should wait at least 6
months before undergoing blepharoplasty be-
cause of the effects on corneal sensation, tear pro-
duction, and tear film alteration.2 Hamawy et al.
have published an algorithm for treating dry eye
(Level IV Evidence).3
The physical examination should include a
general physical examination, including blood
pressure. The eye examination should consist of
visual acuity, extraoccular muscle and pupil eval-
uation, and Bell’s phenomenon for corneal pro-
tection. Whether or not skin removal for der-
matochalasis is required should be determined.
The strength of the orbicularis and lower lid lig-
aments should be determined with a snap test or
with the ability to pull the eyelid more than 6 mm
from the eye to see if a canthopexy or canthoplasty
is required. Blepharoplasty in a lax lower lid may
accentuate lid malposition and lead to postoper-
ative scleral show or ectropion. The medial can-
thal position is normally 2 mm inferior to the
lateral canthal position (positive canthal tilt).
Lateral canthal repositioning may be required.
Fat excess and appearance should be assessed as
well as the tear trough (nasojugal groove) de-
formity. The orbital rim’s position relative to the
cornea on lateral view is important to assess. If
the rim is located posteriorly, a negative vector
or prominent eye will make lower eyelid surgery
more challenging (Level IV Evidence).4 The up-
per lid margin normally covers 2 to 3 mm of the
iris. A lower position may indicate ptosis, which
needs to be documented and addressed preop-
eratively. Ptosis in conjunction with a high tarsal
fold is indicative of levator dehiscence. The po-
sition and shape of the brow needs to be assessed
2223
 Plastic and Reconstructive Surgery • December 2010
to see if brow lifting or shaping is required in
addition to blepharoplasty.
The key elements in the problem of the lower
eyelid blepharoplasty are the negative vector, the
sagging lower eyelid, and the prominent tear
trough. These are the elements that are difficult to
correct and for which the postoperative results
may be suboptimal. These elements need to be
pointed out to patients preoperatively (Fig. 1).
EVIDENCE ON SURGICAL TREATMENT
PLAN
The old adage that “less is more” still holds in
blepharoplasty (Level V Evidence).5 There has
been a large number of more aggressive proce-
dures described in the last few years, especially to
the lower lid. The results can be terrific, but the
complications can be very troublesome.
There is no good evidence which shows that
perioperative antibiotics in blepharoplasty is ben-
eficial, despite the fact that many surgeons use
them.6 Changing the position and shape of the
eyebrows in relation to the orbits is performed
frequently, mostly though incisions in the tempo-
ral region, the scalp, or though the upper eyelid
(Level IV, V Evidence).7–11 Rohrich and Beran
review endoscopic brow fixation techniques.12
Treatment of the corrugators or the orbicularis
occuli that affect the position of the brows can
alternatively be done from below, through the
blepharoplasty incision.13 Alternatively, the brow
can be shaped and lifted with Botox.14
In general, removal of upper eyelid skin is
more liberally performed than removal of lower
eyelid skin. Showing of the tarsal skin (2 to 3 mm
Fig. 1. The anatomy of the tear trough deformity demonstrates
the muscular triangle formed by the orbicularis oculi, levator labii
superioris, and levator labii alaeque nasi. (Reprinted from Codner
MA, Wolfli JN, Anzarut A. Primary transcutaneous lower blepha-
roplasty with routine lateral canthal support: A comprehensive
10-year review. Plast Reconstr Surg. 2008;121:241–250.)
2224
above the lid margin) is desirable in the upper
eyelid for application and visibility of makeup. In
the lower lid, conservative removal of a pinch of
skin is more appropriate as excessive skin removal
leads to undesirable scleral show (Level IV
Evidence).15 Lateral removal of lower eyelid skin,
however, can be more aggressive.
Orbicularis occuli suspension in the lower lid is
gaining increasing popularity as well (see Video, which
demonstrates the transcutaneous approach to
lower blepharoplasty, http://links.lww.com/A346)
(Level IV Evidence).16 This helps to support the
lid and the lower lid fat. In the cited reference,
Codner et al. report their 10-year experience with
routine use of this technique, which is also illus-
trated in the linked video. Codner et al. also dis-
cuss canthoplasty, which is a division of the canthal
ligament with reconstruction, and canthopexy,
which is a suture reinforcement of the ligament
(Figs. 2 and 3).
There is an increasing feeling that removing eye-
lid fat and orbicularis muscle contributes to a
“sculpted” appearance, and therefore fat preserva-
tion and injection techniques have increased.17,18
Choo and Rathbun have used the orbital septum
tightening approach to reduce herniated fat
pads with electrocautery of the septum in a grid
pattern and have shown that this does not cause
eyelid retraction in almost 1500 cases (Level IV
Evidence).19 They feel that this approach is as
efficacious as removal of the fat and that it is
safer, quicker, and less painful. Another study
that compared electrocautery and carbon diox-
ide for tightening of the septum showed no
Fig. 2. The orbicularis is suspended to the lateral orbital rim for
additional anterior lamellar support. (Reprinted from Codner M,
Wolfli, James N, Anzarut A. Primary transcutaneous lower bleph-
aroplasty with routine lateral canthal support: A comprehensive
10-year review. Plast Reconstr Surg. 2008;121:241–250.)
Volume 126, Number 6 • Evidence-Based Blepharoplasty
Fig. 3. Canthopexy. The tarsoligamentous sling is tightened by
suturing the lateral canthal tasral plate to the lateral orbital rim.
(Reprinted from Codner MA, Wolfli JN, Anzarut A. Primary trans-
cutaneous lower blepharoplasty with routine lateral canthal sup-
port: A comprehensive 10-year review. Plast Reconstr Surg. 2008;
121:241–250.)
difference in the two tools (Level II Evidence).20
On the other hand, Sadove prefers to suture the
lower lid septum orbitale to reduce the herni-
ated fat (Level IV Evidence).21 Camirand recon-
structs lower lid fat support for the same pur-
pose (Level V Evidence).22
What is really needed in lower lid blepharo-
plasty are prospective comparative studies of skin
only versus skin muscle flaps, muscle-preserving
versus muscle-altering techniques, transconjunc-
tival versus transcutaneous approaches, orbital
septal tightening versus orbital septum perfora-
tion, fat-preserving versus fat-transposing tech-
niques, etc. We just do not have those types of
studies yet that will tell us which techniques are
truly superior. Until then, we really only have opin-
ion. One of the very few prospective studies on the
physiology of lower lid blepharoplasty has shown
us that there is very little muscle denervation (by
preoperative and postoperative electromyography
determination) with a transcutaneous incision,
skin muscle flap, and orbicularis suspension by the
Atlanta group (Level V Evidence).23
Many patients who present for blepharo-
plasty also have upper lid ptosis and can benefit
from its repair at the time of blepharoplasty.24
For the correction of involutional ptosis, Ben
Simon et al. retrospectively compared an exter-
nal approach for levator advancement (81 eye-
lids, 37 with blepharoplasty and 51 alone) with
a Muller’s muscle– conjunctival resection (184
eyelids, 104 with blepharoplasty and 80 alone)
(Level III Evidence).25 Patients who underwent Mül-
ler’s muscle– conjunctival resection attained a better
cosmetic outcome and had a lower reoperation.
Brown and Putterman showed that concomitant
blepharoplasty that includes orbicularis resection
will decrease the eyelid raising effect of a Müller
resection ptosis procedure (Level III Evidence).26
Erb et al. showed that after levator advancement
for unilateral ptosis repair, 17 percent of patients
will have a decrease in contralateral eyelid height
of more than 1 mm due to the Hering dependence
phenomenon with 5 percent of patients requiring
surgical repair during the first postoperative year
(Level III Evidence).27 McCulley and associates
found that 8.7 percent of patients with primary ac-
quired good-function blepharoptosis underwent ad-
ditional surgery after external levator aponeurosis
advancement (Level III Evidence).28 Patients with
severe ptosis appeared to have an increased risk of
persistent postoperative blepharoptosis.
The approaches to rejuvenation of the lower
eyelid are either external, utilizing a skin-muscle
flap with fat removal, or internal, through the
transconjunctival approach for fat removal or
repositioning via a septal reset. Taban and as-
sociates found no difference in lower eyelid po-
sition after transconjunctival approach for fat
removal with and without skin removal using the
pinch technique (Level III Evidence)29 and pos-
tulated that the position of the lid is not affected
either way because the middle lamella was not
violated (Fig. 4).
In the last few years, some surgeons have
begun using some form of midface lift with
lower eyelid blepharoplasties (link to movie
http://links.lww.com/PRS/A123 from Korn
et al.30) (level IV evidence).30 Although the re-
sults have been spectacular in softening of the
tear trough deformity, the price of detaching
the orbitomalar ligament has been an increase
in the complication rate of eyelid retraction
causing scleral show or ectropion, which can be
difficult to repair (Level IV Evidence).31,32
Other recent solutions to the tear trough defor-
mity have been fat grafting (Level IV, V Evidence),33,34
fat redraping (Level IV Evidence),35 orbital septal
reset (Level V Evidence),36 and injection of tem-
porary fillers such as hyaluronic acid (Level V
Evidence).37,38 Fat grafting is a permanent solu-
tion but has the drawback of possible irregular-
ities or overfilling deformities, which require
more surgery to repair. Fillers, such as hyal-
2225
 Plastic and Reconstructive Surgery • December 2010
Fig. 4. Orbitomalar ligament cross-sectional anatomy demon-
strates the osteocutaneous ligament between the inferior oculi
rim and the orbicularis and dermis. SOOF, sub– orbicularis orbital
fat. (Reprinted from Codner MA, Wolfli JN, Anzarut A. Primary
transcutaneous lower blepharoplasty with routine lateral can-
thal support: A comprehensive 10-year review. Plast Reconstr
Surg. 2008;121:241–250.)
uronic acid, are a temporary solution that would
not lead to further surgery as this substance will
go away by itself if the patient does not like the
result. It can also be removed with hyaluroni-
dase injection.
If horizontal laxity of the lower eyelid exists,
lateral canthal anchoring is performed by can-
thopexy, canthoplasty, or a tarsal strip procedure.
Medial eyelid laxity is a difficult problem. Fante
and Elner describe a transcaruncular orbital ap-
proach for medial canthal tendon plication to im-
prove postoperative medial eyelid position, cor-
rection of epiphora, and superficial punctate
keratopathy (Level IV Evidence).39 For the treat-
ment of moderate lower eyelid laxity, Lessa and
Nanci described a lateral canthopexy technique
without canthotomy that avoids release of the lat-
eral canthal tendon in 316 patients (Level IV
Evidence).40 To smooth the external surface of the
lower eyelids or reduce fine periorbital rhytids,
injection of fat or dermal fillers and laser or chem-
ical resurfacing are occasionally performed at the
same time as surgery, depending on the tech-
niques utilized.
EVIDENCE ON PAIN MANAGEMENT
Many anesthetic techniques have been in-
vestigated in an attempt to provide comfort for
2226
patients and alleviate pain. Slow controlled rate
injection hurts less than uncontrolled rate in-
jection for eyelid pain (Level II Evidence).41
Goel et al. found that applying ice in a sterile
glove over the eyelid skin for 2 minutes before
injection of the local anesthetic reduced the
sensitivity to the injection by 25 percent (Level
II Evidence).42 A prospective randomized con-
trolled trial of nitrous oxide versus air for eyelid
surgery by Bhatt et al. showed no difference in
diminishing the pain of injection of local anes-
thetics but did find more side effects in the
nitrous oxide group (Level II Evidence).43 In a
2009 double-blinded study in which lidocaine was
injected in one eyelid and articaine was injected
into the other eyelid, 22 of 30 patients found the
articaine to be less painful (Level II Evidence).44
Although it is more expensive, articaine has a
safety profile similar to lidocaine. Articaine has a
more rapid onset and lasts longer than lidocaine.
Articaine has gained recent popularity in the den-
tal community (Level II Evidence).45,46
Periocular local anesthesia has been shown to
activate the sternatutory reflex, which may mani-
fest as sneezing. Propofol sedation has been im-
plicated in liberating the reflex. Tao et al. admin-
istered fentanyl or alfentanil in an attempt to
suppress the sneezing and noted 43.6 percent of
patients who did not receive an opioid sneezed
while none of the patients who received an opioid
sneezed, thus preventing inadvertent needle in-
jury during injection of local anesthetic with
propofol sedation (Level II Evidence).47 Ferraro
et al. found that sedation with remifentanil pro-
vided significant patient comfort, and they noted
fewer incidents of bradycardia, hypertension, and
respiratory problems than when patients were se-
dated with midazolam and propofol (Level III
Evidence).48 The well-known downside of opiates
is nausea and vomiting, which can be avoided if
pure local anesthesia is used.
EVIDENCE ON POSTOPERATIVE
OUTCOMES
Kashkouli et al. compared incisions made in
eyelid skin with a scalpel in one eyelid versus a
radiofrequency device in the other eyelid and
found no significant difference in the appearance
of postoperative scars or in recovery of sensation
(Level I Evidence).49 Greene et al. closed one
eyelid with octyl-2-cyanoacrylate and suture in the
other eyelid of the same patients and found no
difference in wound complications, duration of
healing, inflammation, or final incision appear-
ance (Level II Evidence).50 Vick et al. applied an
Volume 126, Number 6 • Evidence-Based Blepharoplasty
autologous platelet concentrate into eyelid inci-
sions in an attempt to decrease edema and ecchy-
mosis, but the improvement in postoperative
edema and ecchymosis did not achieve clinical
significance (Level II Evidence).51
Major adverse postoperative events, such as
retrobulbar hematoma, change or loss of vision,
infection, iatrogenic ptosis, ectropion, or lagoph-
thalmos, are rare. Transient malposition of the
lids, chemosis, and symptomatic dryness requiring
lubrication are occasionally seen in the immediate
postoperative period, but the majority of these
problems resolve with time.
Prolonged retraction of the lower eyelid is
difficult to correct with additional surgery. Ben
Simon et al. compared subperiosteal midface lift
with and without hard palate grafts to correct
post blepharoplasty lower eyelid retraction and
found that the addition of hard palate grafts was
superior (Level III Evidence).52 Li and associ-
ates compared the efficacy of hard palate grafts
with acellular human dermis grafts and found
no significant difference in the amount of eyelid
elevation, though a trend was seen that hard
palate grafts resulted in better elevation and
lower failure rates (Level III Evidence).53
Chemosis is a complication of drying out of
pouting conjunctiva, which can be managed in a
number of ways, including lubrication, ophthal-
mic steroid preparations, ocular decongestants,
eye-patching, temporary tarsorrhaphy (Level IV
Evidence),54 and direct pressure at the end of the
case55 (Fig. 5). Lelli and Lisman56 and Pacella and
Fig. 5. The patient elevates the lower eyelid over the conjunc-
tival chemotic area with a finger and compresses the area for 10
seconds. (Reprinted from Putterman AM. Regarding comprehen-
sive management of chemosis following cosmetic lower bleph-
aroplasty. Plast Reconstr Surg. 2009;124:313–314.)
Codner57 have published excellent recent review
articles of blepharoplasty complications.
SUGGESTED TREATMENT FOR
CLINICAL SCENARIO
When practicing evidence-based medicine,
the surgeon should consider the strength of the
available evidence and integrate the evidence with
his or her clinical expertise and the patient’s val-
ues and preferences to develop an appropriate
treatment plan. The treatment plan below is an
example of how the surgeon might use the evi-
dence to care for this particular patient.
Based on the available evidence our 56-year-
old woman should wait until 6 months after her
LASIK surgery to have her blepharoplasty. She
would likely be best treated under local anesthesia
with sedation, not just nitrous oxide (Level II Ev-
idence43), or general anesthesia with upper lid
blepharoplasty with skin excision and conservative
muscle and fat management. Skin closure could
be with sutures or glue (Level II Evidence50). She
should have the ptosis repaired but should be
warned that the eyelids still have a significant
chance of being at a different height after the
surgery (Level III Evidence27). If horizontal laxity
of the lower lids is detected, then a procedure to
provide support of the lower lids should be in-
cluded (Level IV Evidence40). If persistent lower
lid retraction should develop after surgery, recon-
struction with a hard palate graft could be con-
sidered (Level III Evidence52).
Jack A. Friedland, M.D.
7425 East Shea Boulevard, Suite 103
Scottsdale, Ariz. 85260-6411
jaf@aestheticsurgeonsofarizona.com
ACKNOWLEDGMENTS
The authors thank the following individuals for
their assistance with this project: American Society of
Plastic Surgeons staff member Jennifer Swanson, B.S.,
M.Ed., for project management and editorial support;
American Society of Plastic Surgeons staff member Karie
O’Connor, M.P.H., for literature searches; and Victoria
Briones Chiongbian, Ph.D., for critical appraisal of
studies included in this review.
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Volume 126, Number 6 • Evidence-Based Blepharoplasty
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