SURVEY OF OPHTHALMOLOGY VOLUME 53  NUMBER 5  SEPTEMBER–OCTOBER 2008

DIAGNOSTIC AND SURGICAL

TECHNIQUES
MARCO ZARBIN AND DAVID CHU, EDITORS

Cosmetic Eyelid and Facial Surgery

Guy J. Ben Simon, MD,1 and John D. McCann, MD, PhD2

1
Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; and 2The Center for Facial Appearances,
Salt Lake City, Utah, USA

Abstract. The goal of cosmetic surgery is to reverse anatomical changes that occur in the face with
aging. It is a rapidly growing subdiscipline of ophthalmic plastic surgery and includes forehead, eyelid,
mid-face, lower face, and neck surgery, most performed by ophthalmic plastic surgeons. The current
article reviews updates in cosmetic eyelid and facial surgery, including minimally invasive techniques
such as cable suspensions, injections, and fillers. (Surv Ophthalmol 53:426--442, 2008. Ó 2008
Elsevier Inc. All rights reserved.)

Key words. botulinum toxin injections  cosmetic surgery  endoscopic browlift  fillers 
forehead  lower face / neck life  mid-face life

Ophthalmic plastic surgery has traditionally been
divided into four sub-disciplines: eyelid, lacrimal,
orbit, and cosmetic. Twenty years ago the average
specialist focused on the first three disciplines with
few surgeons having any interest in cosmetic surgery
and even fewer with an emphasis on cosmetic
surgery. This trend has reversed in the last decade.
Today most specialists perform some cosmetic
surgeries and many emphasize this area of their
practice. A good metric of the growth of the
subdiscipline of cosmetic surgery is the annual
two-day national meeting of the American Society
of Ophthalmic Plastic and Reconstructive Surgery,
which devotes half of the meeting to cosmetic
surgery. Cosmetic surgery is no doubt the most
rapidly changing subdiscipline of ophthalmic plastic
surgery. The recent trend toward greater interest in
this subdiscipline has generated much recent
advancement. It is exciting to see the ophthalmol-
ogist bring the traditions of precision and finesse
that characterize ocular microsurgery to the field of
cosmetic facial surgery. This review should serve as
an update of recent major changes in the field.
Upper Face
UPPER LID BLEPHAROPLASTY
The eyes are an important component of facial
aesthetics. Cosmetic surgery of the eyelids can have
a dramatic effect on facial harmony and the percep-
tion of aging. Upper and lower blepharoplasties are
commonly performed together. Occasionally other
facial and skin rejuvenation procedures such as
brow/midface lift and laser or chemical skin resur-
facing are also performed at the same time.54

426
Ó 2008 by Elsevier Inc. 0039-6257/08/$--see front matter
All rights reserved. doi:10.1016/j.survophthal.2008.06.011
COSMETIC EYELID AND FACIAL SURGERY
Upper eyelid blepharoplasty (Fig. 1) is one of the
most common cosmetic procedures performed by
general and ophthalmic plastic surgeons. Both men
and women complain about tired-looking eyes,
excess skin, droopy eyelids, or circles around the
eyes. Several distinct anatomic features may contrib-
ute to patients’ perception of the need for upper
eyelid blepharoplasty.19 Excess and laxity of upper
eyelid skin can cause superior visual field defects
that are usually temporal rather than nasal, reflect-
ing the tendency of the eyelid skin to be more
extensive temporally. This may even confound
diagnostic automated field testing in patients with
glaucoma or ocular hypertension.71
PREOPERATIVE EVALUATION
Preoperative evaluation includes a thorough and
complete eye and facial clinical examination. The
patient must undergo a complete medical work-up,
with the emphasis on ocular surface disease and dry
eyes, as well as establishment of rapport and realistic
patient expectations. Patients should discontinue
use of acetylsalicylic acid and other anticoagulants
such as plavix, nonsteroiodal anti-inflammatory
drugs (NSAIDs), vitamin E, and herbals two weeks
before surgery. Coumadin should be stopped after
general practitioner/cardiologist approval. Smokers
should also be advised to stop smoking two weeks
before the procedure, as smoking can delay wound
healing.54 The relationship of concomitant eyelid
and eyebrow malposition should be evaluated and
documented. Evaluation of pre-septal and eyebrow
fat pads is important in redefining the superior
sulcus. In recent years there has been an increas-
ingly popular belief that fullness of the eyelids is
a sign of youth; this has led most cosmetic surgeons
to preserve as much pre-septal fat as possible.
Standard pre- and postoperative photography, on
a blue background with diffused overhead lighting,
are of utmost importance in aesthetic surgery and
Fig. 1. Before (left) and after upper lids blepharoplasty.
427
can provide a useful method of evaluating improve-
ment and anatomical changes in the eyelid position
in relation to the globe, orbit, and eyebrow.117
Standard preoperative and postoperative photo-
graphs are as important to cosmetic surgery as pre-
and postoperative visual acuities are to cataract
surgery. Photographs should be taken without flash
in order to see wrinkles and bags.
SURGICAL TECHNIQUE
Surgery is designed primarily to enhance aesthetic
appearance and improve visual field deficits. Im-
provement in visual field is a function of excision of
redundant eyelid tissue and is most dramatic in
patients with a margin reflex distance equal to or
smaller than 3.5 mm.40
Knowledge of the eyelid anatomy is an absolute
prerequisite for performing blepharoplasty. There
are two fat compartments in the upper eyelid: a pale
yellow medial compartment, which derives from the
adipose body of the orbit; and a deep yellow lateral
compartment, derived from the preaponeurotic fat.
Accessory or ectopic fat compartments have also
been described in 20% of cases and may represent
an extension of the lateral preaponeurotic fat pad.98
The superolateral aspect of the adipose part of the
orbit does not reach the upper eyelid and therefore
is not resected in blepharoplasty. The superomedial
part, which is located between the superior oblique
and medial rectus muscles and reaches the orbital
septum, represents the medial compartment of the
upper eyelid and is usually removed in upper
blepharoplasty when fat sculpturing is performed.
The preaponeurotic fat pad is located under the
orbital roof and lies on the aponeurosis of the levator
palpebrae muscle, in contact with the orbital septum.
Laterally it extends behind the lacrimal gland, and
medially a fibrous structure containing the reflected
tendon of the superior oblique muscle separates it
from the nasal fat pad. This preaponeurotic fat is the
428 Surv Ophthalmol 53 (5) September--October 2008
lateral fat compartment that is resected in upper
blepharoplasty.
Skin margins are outlined with the patient in
sitting position, these marks should be checked with
the patient lying supine. The lower margin of the
incision is made along the eyelid crease, beginning
medially above and lateral to the medial canthus.
Care must be taken not to include the naso-orbital
depression, as this can cause webbing. Laterally, the
line is extended to the sulcus between the orbital
rim and the eyelid, and may be directed slightly
upward.96 It is important to lift the eyebrow
manually, elevating the excess of skin. The amount
of skin to be excised is checked with toothed forceps
to ensure that overcorrection of the skin is avoided.
In our experience, it is important to leave 22 24
mm of anterior lamella to prevent postoperative
shortening and lagophthalmos. These numbers
should be adjusted upward for proptotic patients,
patients with deep superior sulcus, and for the
novice surgeon.
Usually, a crescent-shaped incision is made in the
upper eyelid. However, in advanced age lateral
hooding with greater excess of eyelid skin laterally
is commonly seen, so it might be preferable to use
a scalpel-shaped incision that is widest laterally and
tapers medially. That incision can provide indirect
upward support of the lateral eyebrow.45
The eyelid is then injected with 1% lidocaine with
1:100,000 epinephrine. The initial skin incision is
usually made with a sharp no. 15 scalpel, monopolar
cautery, radiofrequency (Ellman) or laser. Before
the skin muscle flap is excised with sharp scissors,
laser, or Colorado needle-tip electrocautery (Colo-
rado Biomedical, Evergreen, CO), bleeding vessels
should be cauterized; this can be done by electro-
cautery or by defocusing the laser 6 8 inches (15--
20 cm) away from the tissue.115
A survey conducted among plastic surgeons
determined that 70 90% of all surgeons use laser
as the only tool for cutting and hemostasis in
blepharoplasty, and that carbon dioxide (CO2)
lasers are the most common. The laser has
a hemostatic effect of up to 0.1 mm on blood
vessels, creating a nearly blood-free surgical site
while the skin and orbicularis are being dissected
and the retro-septal fat is being excised.90 Advan-
tages of CO2 laser blepharoplasty are reduced
bleeding; shorter intraoperative time and postoper-
ative recovery period; improved anatomic dissec-
tion; and less pain, edema, bruising, and
scarring.72,90 It is imperative to protect the patient
by using stainless steel corneal shields when
performing laser blepharoplasty because of the risk
of globe perforation.115 Many general plastic sur-
geons in public academic centers, however, do not
BEN SIMON AND MCCANN
use laser and would rather use sharp blade or radio-
surgery (Ellman unit).
After skin and orbicularis removal, if fat sculpting
is desired, the orbital septum is gradually opened,
using sharp and blunt dissection, thermal cautery, or
laser. One or more passes of the laser are made
through the septum, permitting orbital fat to bulge.
Fat is resected to the desired amount. Of the medial
and central fat, only fat that comes easily into the
wound is excised. It is important not to actively pull
fat from the orbit. Medially the fat is whiter than in
the central compartment and its anatomic position
may vary. Because blood vessels present in the
medial fat compartment are larger, they cannot be
coagulated with the CO2 laser and must be
cauterized.90 Gentle pressure on the globe causes
herniation of the medial fat compartment and may
help in identification. If lower eyelid blepharoplasty
is planned, the skin incision is left unsutured until
lower blepharoplasty is completed. This is especially
important in cases where incision in the upper
eyelid crease is planned for lateral canthopexy.
The skin incision can be closed using running or
interrupted sutures with various absorbable or perma-
nent materials, with no apparent effects on aesthetic
outcome. The use of tissue-adhesive cyanocrylate glue
in skin closure has also been reported.129
The sub-brow fat pad can be repositioned during
wound closure with use of eyelid suspension sutures.
This can be done with 2 3 absorbable sutures that
incorporate the orbicularis from the lower and
upper sides of the incision along with the supero-
lateral arcus marginalis. Placing of the sutures in
this way might result in early over-correction of the
upper eyelid, which, however, softens within days
after the surgery.
The transconjunctival approach to upper eyelid
blepharoplasty is of limited usefulness in primary or
secondary cases with pseudo-herniation of the
medial fat pad.54,55,61
POSTOPERATIVE CARE
Postoperatively, patients should be advised to use
ice packs on the surgical site for 3 days to minimize
postoperative swelling, and erythromycin ophthal-
mic ointment on the incision sites for 2 weeks. Non-
absorbable sutures, if used, can be removed 7 10
days after the procedure.
COMPLICATIONS
The most common complication of cosmetic
surgery is failure to meet the patient’s expectations.
This can be avoided by preoperative counseling of
what reasonably can be achieved with surgery. In
such a way patients with unreasonable expectations
COSMETIC EYELID AND FACIAL SURGERY
can be identified. From a medico-legal standpoint, it
is probably best for the surgeon to define reasonable
expectations as a statement that is read and signed by
the patient.66
Possible complications include upper eyelid
retraction with scleral show from anterior lamellar
inadequacy, lagophthalmos, and corneal exposure.
Patients might present with various degrees of
scleral show, tearing, ocular discomfort, and dry
eyes. Acquired strabismus accompanied by persis-
tent diplopia can occur, and superior oblique palsy
and acquired Brown syndrome have been
described.123,133 Blurred vision from induced cor-
neal astigmatism usually lasts for up to 3 months
after surgery, and subjective visual disturbances
might last for 1 year.116
ENDOSCOPIC BROW LIFT
The endoscopic approach to forehead and midface
lift has become a popular method of facial rejuvena-
tion, requiring minimal incision (Figs. 2 and
3).13,20,22,60 The use of endoscopy has led to improved
aesthetics with respect to postoperative scarring, as
well as to decreased healing time and greater patient
satisfaction. In the past, most browlifts involved
bicoronal dissection with a large incision;108 the
endoscopic browlift is less invasive, better tolerated,
and less prone to intra- and postoperative complica-
tions.70 The goal of forehead rejuvenation is to
elevate the brows and midface, depending on the
extent of dissection, and to address glabellar frown
lines by weakening the corrugator and procerus
muscles. It is best suited for brows with mild to
moderate ptosis of up to 1.5 cm.70,108,134
A thorough understanding of the temporal
anatomy, location of the retaining ligaments of the
cheek, and relationship of the facial nerve to the
temporal planes is of utmost importance in order to
achieve aesthetic improvement and prevent
complications.
Fig. 2. A 55-year-old man, before (left) 2 months after (right) forehead lift (endoscopic brow lift), and four-eyelid
blepharoplasty. Note marked improvement in eyebrow position, forehead rhytids, and lower eyelid bags.
429
In younger patients it allows repositioning of the
orbital portion of the orbicularis oculi muscle; in
midface rejuvenation it lifts the malar pads, allowing
a smooth transition onto the upper face that blends
nicely into the lower face. In older patients
endoscopic brow lift serves as a useful adjunct to
eyelid and midface surgery. It corrects orbital
festoons and lower eyelid bags and smoothens the
upper third of the nasolabial fold.12
SURGICAL TECHNIQUE
Preoperative marking is done with the patient in
an upright position for placement of temporal and
paramedian incisions, the desired brow elevation
(5 8 mm medially and 8 10 mm laterally), and the
anticipated course of the temporal branch of the
facial nerve.108
The surgery can be performed under intravenous
sedation or general anesthesia. Lidocaine 1% and
epinephrine 1:100,000 are locally injected at the
incision sites and to block the supraorbital and
supratrochlear neurovascular bundles. The fore-
head and upper midface are injected with 0.01%
lidocaine and 1:10,000,000,000 epinephrine solu-
tion (tumescent solution) to facilitate dissection and
reduce bleeding. Incisions are made behind the
hairline and include one central or paracentral and
two temporal incisions, which are placed on a line
connecting the ala nasi and the lateral canthus.
Some surgeons make two additional paracentral
incisions. Incisions are made to the depth of the
periost centrally and to the depth of the deep
temporalis fascia laterally. The central pocket is
dissected in the sub-galeal or subperiosteal planes
using a curved semi-sharp dissector. The lateral
pockets are dissected toward the central pocket,
while taking care to detach the conjoint fascia.
Endoscope-assisted dissection is done from 1 cm
above the orbital margin while working towards the
430 Surv Ophthalmol 53 (5) September--October 2008
Fig. 3. Before (left) and after (right) forehead lift, and upper and lower eyelid blepharoplasty.
supraorbital and supratrochlear neuromuscular
bundles. It is important to lyse periosteal attach-
ments at the superior and lateral orbital rims until
the sub-brow fat pad is visualized. If midface lift is
desired, dissection is extended to the zygomatic arch
and the lateral canthus. Medially, the corrugator
muscles located adjacent to the neurovascular
bundles can be lysed or sharply dissected. The
procerus muscle can be dissected in a similar
fashion. Prior to fixation the amount of dissection,
residual adhesions, and desired lift are examined by
a finger test (passing index finger in the superior
orbital margin to evaluate residual adhesions that
hold the eyebrow and may prevent it from adequate
elevation postoperatively).
There are several methods of suture fixation. The
temporal pockets are fixated to the deep temporalis
fascia. It is important to grasp a robust part of the
superficial temporalis fascia distally and adjust
the tension to the desired amount by fixating it to
the deep fascia precisely at the location needed,
usually in a mattress suture.
Centrally, the forehead can be sutured to absorb-
able75 or titanium screws that are drilled in the frontal
bone, or to a cortical tunnel on the outer table of the
calvarium.87 Some surgeons use 2/0 monofilament
nylon sutures to secure the forehead to the subgaleal
tissue posteriorly. These can create bolsters, which
disappear when the sutures are removed 2 weeks
postoperatively. Additional fixation techniques in-
clude the use of fibrin glue, K-wire fixation, and
temporary titanium screws.65,70,85,93 Skin incisions
are sutured using absorbable sutures or surgical
staples. Some surgeons advocate the use of dressing
and elastic band for 1 week; sutures or staplers are
removed 14 days postoperatively.
A described limitation of endoscopic browlift is
the inability to predict the long-term results of
forehead elevation.108 Minimally invasive brow
suspension has been described using subcutaneous
suspension sutures with no open dissection, but its
long-term outcome in comparison to endoscopic
brow lift is not known.26
BEN SIMON AND MCCANN
COMPLICATIONS
Possible complications, which may vary with
different dissection planes, include frontal branch
weakness, temporary numbness, hematoma, seroma,
incisional alopecia, temporal fat atrophy, wound
dehiscence, suture abscess, unbalanced eyebrows,
and in cases of lower blepharoplasty incision
endoscopic midface lift lower eyelid retraction with
lagophthalmos.24,64 Leakage of cerebrospinal fluid
after endoscopic browlift was reported in a patient
with a previous history of head trauma.51
Lower Face
LOWER EYELID BLEPHAROPLASTY
Aging in the lower eyelid can cause a number of
aesthetic changes, including skin laxity or excess,
orbital septum laxity, orbicularis laxity or hypertro-
phy, herniation of the orbital fat, canthal laxity, malar
festoons, crow’s feet, and periocular wrinkles
(Fig. 4).25,115 Common complaints include eyelid
bags, circles under the eye, wrinkles around the eye,
or a tired look. In the past a simplified approach was
taken for patients seeking surgical treatment for
eyelid bags. Only patients whose problem was
amenable to removal of skin and fat were considered
suitable candidates for classic blepharoplasty.36,106
Anatomically, relaxation of the orbital septum,
orbicularis muscle, and skin can cause protrusion
and shifting of intraorbital fat and eyelid bags. The
traditional procedure in lower eyelid blepharoplasty
was to remove the pseudo-herniated fat via skin
incision. A recent, more conservative approach
includes repositioning of the herniated fat in cases
of tear trough deformity into the subperiosteal
space. Both of these approaches may be accompa-
nied by strengthening procedures for the attenu-
ated septum or septorhaphy and tightening of the
orbicularis muscle and skin.52,89 Defocused CO2
laser irradiation of the undersurface of the orbicu-
laris results in persistent shortening and tightening
of the muscle tissue.115
COSMETIC EYELID AND FACIAL SURGERY
Fig. 4. A 40-year-old woman, before (left) and 2 years after (right) four-eyelid blepharoplasty, upper eyelid skin muscle
removal and fat sculpting, and lower eyelid transconjunctival fat removal.
Most cosmetic surgeons today have developed
a customized approach to eyelid surgery in which
the specific anatomic problems are identified and
the operation is individualized to address these
problems. Additional anatomic changes that con-
tribute to eyelid bags include pseudoherniation of
fat pads, damaged skin, orbicularis muscle hyper-
trophy, eyelid fluid, tear trough deformity, and
triangular malar mound.36,106
SURGICAL TECHNIQUE
In cases of fat removal or repositioning or
pseudoherniation of orbital fat, enhancement of
the deficient suborbital portion of the malar
complex is the principal component of modern
lower eyelid blepharoplasty. Skin removal is usually
unnecessary because there is typically inelasticity
rather than actual excess of skin. The widely
preferred approach is transconjunctival incision,
which results in less eyelid retraction, less scleral
show, and less postoperative ectropion than other
methods.106,138,139 Some surgeons prefer a transcu-
taneous approach in patients who have hypertrophy
of the orbicularis oculi muscle and therefore
require muscle excision.1 The inferior fornix, eyelid
skin, and lateral canthus are anesthetized with 1%
lidocaine containing 1:100,000 epinephrine. The
lower eyelid is retracted with a lacrimal or Desmarre
retractor. A tarsoconjunctival incision is made 4 6
mm below the lid margin through the conjunctiva
and lower eyelid retractors; this can be done using
sharp dissection, monopolar cautery, or laser. In
laser blepharoplasty, protective shields for the
patient’s eyes must be used. The eyelid can be
retracted using forceps with a 0.5-mm tip or by
placement of a 6 0 silk suture. Gentle retropulsion
on the globe helps to identify the fat compartments.
The medial, central, and lateral fat pads are
identified and conservative, individualized fat re-
moval is accomplished. Hemostasis is achieved using
monopolar or bipolar cautery or by defocused laser
applications. Care must be taken not to damage the
inferior oblique muscle that separates the medial
431
from the central fat pocket. The endpoint for
excision is reached when gentle retropulsion on
the globe results in the anterior aspect of the orbital
fat being flush with the orbital rim.
The tarsoconjunctival incision is left unclosed, but
the inferior and superior edges of the tarsoconjunc-
tival incision are properly apposed and the lower
eyelid is pulled up to make sure there is no overlap
between the cut edges of the conjunctiva.15
Some surgeons routinely perform canthopexy in
lower eyelid blepharoplasty. This can be done
through a lower or upper eyelid; it eliminates
unnecessary skin resection and is believed to restore
tone and youthful contour.29,48,115 Through an
incision in the upper eyelid crease,57 dissection is
extended inferiorly to the level of the lateral orbital
rim, leaving the periosteum intact. This stage of
dissection can facilitate lateral fad pad resection if
this was not fully addressed during lower blepharo-
plasty. The inferior limb of the lateral canthal
tendon can be cut with scissors under visual
inspection. A double-armed suture on a semicircular
needle is placed 2 mm above Whitnall’s tubercle
inside the orbital rim. The suture then travels
through the orbital rim periosteum and emerges
in half-buried horizontal mattress fashion through
the inferior canthal tendon. Additional sutures can
be used to tighten the orbicularis muscle to the
superficial orbital rim. Alternatively, lateral canthal
resuspension can be performed using the lateral
canthal strip procedure described by Anderson and
Gordy.5
Wrinkles and excess of vertical skin can be dealt
with by skin resurfacing techniques, such as chem-
ical peeling and CO2 or erbium YAG laser resurfac-
ing. These techniques are applicable in patients with
Fitzpatrick skin types I--III. Patients with darker skin
are at risk of pigmentary changes; these can be
managed by the pinch technique. Excess skin is
crushed using a straight hemostat 1 2 mm sub-
ciliary and excised. Care must be taken to excise as
little as possible of the orbicularis muscle. The skin
is closed with a running suture.95 Regardless of
the timing of laser treatment, transconjunctival
432 Surv Ophthalmol 53 (5) September--October 2008
blepharoplasty with adjunctive CO2 laser resurfacing
results in improvement of lower eyelid bulging and
skin wrinkling.18
Another modification of lower blepharoplasty
involves transcutaneous plication of the orbital
septum.50 An interesting report describes non-
surgical treatment for pseudoherniation of orbital
fat pads by phosphatidylcholine injection, with
marked improvement over a 2-year period.105
COMPLICATIONS
Severe complications, such as visual loss from
orbital hemorrhage, orbital injection, or posterior
optic nerve infarction have been described.38,127
Other possible complications are lower eyelid re-
traction with scleral show, lagophthalmos, and
corneal exposure. As with upper lid blepharoplasty,
patients might have various amounts of scleral show,
tearing, ocular discomfort, and dry eyes. Various
surgical techniques have been described to address
scleral show, eyelid retraction, and ectropion after
lower eyelid blepharoplasty, including free tarsocon-
junctival graft,27 grafting of autogenous hard palate
mucosa,130 and cheek suspension using transoss-
eous fixation and titanium screws.135 Temporary
tarsorrhaphy can be used to prevent and treat scleral
show and ectropion secondary to laser resurfacing
or blepharoplasty.109
Acquired strabismus that includes incomitant
vertical deviation consistent with an inferior rectus
paresis has been described.123 In some patients,
upward rotation of the globe was found to be
mechanically restricted.
FAT REPOSITIONING
In young people the eyelid--cheek complex is
a single smooth convex profile. Aging causes
descent of the globe and pseudoherniation of
intraorbital fat, producing a double convex or tear
trough deformity on the eyelid profile and a nasoju-
gal groove at the medial aspect of the lower eyelid.43
With advancing age this depression appears more
prominent because of attenuation and descent of
the orbicularis oculi and cheek fat, resulting in
skeletonization of the orbital area and revealing the
topographical contour of the inferior orbital rim.6
Simple removal of orbital fat can result in a hollow
appearance of the lower eyelid.
Preservation of the lower orbital fat is a new
concept in facial rejuvenation, designed to prevent
the hollow appearance that may follow the removal
of excess fat in lower eyelid blepharoplasty. Such
preservation creates a smooth transition to the
malar eminence, blending nicely into the upper
face.42,43 Aging causes progressive exposure of the
BEN SIMON AND MCCANN
underlying skeletal anatomy in the periorbital area,
unlike in the lower facial area, where thicker soft
tissue continues to cover bony landmarks.
SURGICAL TECHNIQUE
The basic surgical technique includes release of
the arcus marginalis and advancing of the subseptal
fat beyond the infraorbital rim and underneath the
orbicularis muscle. The fat pedicles are temporarily
externalized to the midface by suturing. They can be
placed in the sub- or supra-periosteal planes, with no
apparent effect on aesthetic results. This technique
camouflages the lower orbital rim anatomy and
provides more youthful rejuvenation of the
midface.35,43,81
Other methods suggested to correct tear trough
deformity include orbital fat removal, fat injections
or grafts, and alloplastic cheek implants. In general,
trans-conjunctival fat repositioning results in level-
ing of the tear trough deformity, a smooth contour
of the lower eyelid, and high patient satisfaction.63
COMPLICATIONS
Possible complications are incomplete resolution
of pigmentary changes (dark circles), temporary
skin irregularities from fat and edema, hardening of
repositioned fat, granuloma formation, restricted
ocular movements, or new-onset diplopia.37
SUBORBICULARIS OCULI FAT / MIDFACE LIFT
The midface lies between the lateral canthal angle
and the top of the nasolabial fold. It includes the
medial and lateral canthal tendon, lower eyelids,
suborbicularis oculi fat pad (SOOF), malar fat pad,
orbitomalar ligament, orbital septum, and origins of
the zygomaticus major and minor muscles and
levator labii superioris. 88,99
Volumetric distribution of the midface soft tissues
is an important factor in the youthful appearance of
the human face (Fig. 5). If these tissues are full
relative to the lower face, the individual appears
healthy and young.80 A fuller midface can be
achieved by an open surgical or endoscopic tech-
nique.101,103,122 Indications for midface lift include
lower eyelid retraction secondary to lower blepha-
roplasty, cicatricial ectropion, and paralytic ectro-
pion due to palsy of the 7th cranial nerve.49,92,122
Aesthetically, the goal of midface lift is to achieve
facial rejuvenation by increasing malar fullness,
decreasing skeletonization of the lower eyelid at
the inferior orbital rim, and reducing prominence
of the nasolabial and nasojugal (tear trough) folds.
COSMETIC EYELID AND FACIAL SURGERY
Fig. 5. A 65-year-old woman, before (left) and 8 months post (right) transconjunctival lower eyelid retraction as a result of
lower blepharoplasty. Note marked improvement in lower eyelids position.
SURGICAL TECHNIQUE
In patients with tear trough deformity, trans-
conjuctival SOOF lift is adequate and yields good
aesthetic results. Dissection is carried out in the pre-
periosteal plane, extending beyond the inferior
margin of the tear trough deformity until the SOOF
is identified. An anchoring suture from the SOOF
pad to the periosteum of the infraorbital rim is
placed along the width of the deformity. After
adequate suspension, a single buried absorbable
suture is used to close the conjunctival incision
lateral to the cornea.32
When a more robust midface suspension is
required, effective reshaping of the soft tissue of
the aging midface necessitates freeing of the cheek
soft tissue, both superficially and deeply, from its
attachment to skin and bone. Incisions are made at
the temporal scalp, inferior conjunctiva, and alveo-
lar oral mucosa. Dissection is aimed at creating
a temporal pocket, mobilizing the midface by
subperiosteal dissection, and lifting the mobilized
face to the deep temporalis fascia while securing the
SOOF pad to the inferior orbital rim.122 Dissection
is performed as far as the oral commissure inferiorly
and toward the zygoma and lateral buttress of the
maxilla, along the infraorbital rim, and around the
infraorbital nerve in the subperiosteal plane. Care
must be taken to identify and preserve the infra-
orbital nerve. In the lateral orbit, a small area of
deep temporalis fascia is cleared near the lateral
canthus. No dissection is carried out at the
masseteric tendon or the zygomatic arch.80
Techniques used to re-shape the midface, once
the subperiosteal tissue has been freed, include
malar imbrication, insertion of suspension sutures
into the deep temporalis fascia, and mechanical
anchoring.
If the neck is to be treated, this is done before
the cheek is lifted. To avoid traction of the
midface, lateral plication of the superficial muscular-
aponeurotic system (SMAS) is performed only
after the midface has been adequately lifted.137
433
To avoid postoperative complications the follow-
ing steps are suggested: Reattach the lateral canthus
to its proper anatomic position; address the orbital
fat via a trans-conjunctival approach to prevent
middle lamellar scarring and orbital septum re-
traction; and place a suture at the inferior lateral
orbital rim that stimulating the orbitomalar liga-
ment that elevates the midface and suturing of the
orbicularis oculi muscle.97
COMPLICATIONS
Possible complications include temporary facial
nerve trauma (in up to 5% of cases), significant
orbital edema, and chemosis especially when com-
bined with lower blepharoplasty, prolonged swell-
ing, and skin dimpling along the suspension
sutures.102
LOWER FACE AND NECK REJUVENATION
Deep plane facelift techniques developed as
surgeons became more aware that elevation of the
deeper tissue layers of the aging face could achieve
longer lasting and more natural results.3,58
SURGICAL TECHNIQUE
The procedure is best carried out under general
anesthesia. The face and neck are infiltrated with
tumescent solution.59 Incisions are marked and
made through the temple hairline, above the ear
and down a natural skin crease in the pre-tragal
area, and continued post-auricularly to the level of
the superior conchal bowl. Pre- and post-auricular
skin flaps are elevated and over the sternocleido-
mastoid region and over a distance of 5 6 cm (2
inches) in the face, while taking care to dissect
superficial to the greater auricular nerve. In the
neck the platysma muscle is identified below the
angle of the mandible, and dissection is extended to
the submental region anteriorly and to the lowest
neck rhytid. To prevent damage to the facial nerve,
the deep plane is kept above the level of the
434 Surv Ophthalmol 53 (5) September--October 2008
masseteric fascia. Care is taken to limit dissection to
the undersurface of the platysma musculature in the
SMAS flap. At the level of the malar eminence
dissection is carried out toward the bone to identify
the zygomaticus major muscle, and the SMAS flap is
elevated anteriorly. Throughout the procedure this
flap is kept above the anterior border of the parotid
gland. Buccal fat can be resected as needed.
If needed, submental platysmoplasty with direct
fat excision is performed (Fig. 6).39,53,56 An incision
is made 2 cm posterior to the mandibular pro-
tuberance, the subdermal fat is lifter off the
underlying muscle, and the skin flap is connected
bilaterally to the pre-platysmal flaps. Fat and re-
dundant muscle are removed, and buried sutures
are used to reattach the muscle edges. Finally, the
SMAS flaps are repositioned and sutured along
a postero-superior vector. Prolene sutures are used
to attach the deep plane flap by tucking it into the
preauricular area and back to the mastoid fascia.
The skin is slightly lifted to prevent puckering and
the excess skin is trimmed. A drainage device is used
in the early postoperative period. A light pressure
dressing with fluffed cotton and Kerlex is
applied.3,4,9,41
COMPLICATIONS
Possible complications include hematoma, pares-
thesia, and facial nerve paresis. These can be
avoided by careful and meticulous dissection and
by operating only at the level of tissue planes known
to be safe.3
S LIFT
A recently developed technique requiring mini-
mal incision for mid-lower face rejuvenation is
performed via an S-shaped pre-auricular incision,
followed by elevation of the facial skin and SMAS
with the aid of two purse-string sutures.
Fig. 6. A 68-year-old woman, before (left) and after (right) lower face and neck lift including neck liposuction and
platysmoplasty. Note marked improvement in platysmal bands.
BEN SIMON AND MCCANN
SURGICAL TECHNIQUE
The procedure is performed on an outpatient
basis and under local anesthesia. As in most facial
rejuvenation procedures the operative area is
infiltrated with tumescent solution to facilitate
dissection and minimize bleeding. Incision sites
are anesthetized with 1 2% lidocaine containing
1:100,000 epinephrine. Following the S-shaped
incision, a limited skin flap is undermined in an
oval area extending from 1 cm above the zygomatic
arch to the mandibular angle caudally and 5 cm
anteriorly. Dissection is in the subcutaneous plane.
Superiorly the deep temporalis fascia is exposed,
while care is taken not to damage the superficial
temporal vessels. For the first purse-string suture
a 2 0 nylon or prolene suture is inserted in a U-
shaped fashion, descending to the mandibular
angle and engaging the parotid fascia. The suture
allows the anterior neck region to be lifted. The
second purse-string suture, directed at a 30 angle, is
extended to the edge of the undermined area,
allowing the jowls to be lifted. The periocular region
is sutured under minimal tension.110,126
A number of alternative approaches have been
introduced for face and neck rejuvenation, and
there is controversy over the relative advantages
of the more extensive and the minimal techniques
with respect to longevity and postoperative
complications.3,9
Skin Rejuvenation
PHOTODAMAGE
Exposure to the sun induces skin damage re-
ferred to as photoaging, which may be manifested
clinically as wrinkles, dryness, irregular pigmenta-
tion, telangectasias, brown spots, and seborrheic
keratosis. Premalignant sun-induced lesions include
actinic keratosis;118 malignant lesions include basal
COSMETIC EYELID AND FACIAL SURGERY 435

and squamous cell carcinomas. Patients with photo-

induced skin damage should be examined period-
ically for premalignant lesions. Sun protection
during childhood and throughout life has been
shown to reduce the risk of malignant skin
cancers.69,120 Ultraviolet A and B (UVA and UVB)
contribute to pigmentary changes, as well as to
wrinkles, telangectasias, and lentigines.68
Actinic keratosis, which is premalignant to squa-
mous cell carcinoma, can be treated with cryosur-
gery, topical 5% fluorouracil cream, and
photodynamic therapy with aminolevulinic acid.73
The effects of photoaging can be reduced to
a limited extent by the use of topical lotions
containing alpha- and beta-hydroxyl acids that are
exfoliants and moisturizers. Some of these materials
contain 5% glycolic acid and 8% lactic acid, both
shown to add to the improvement in roughness and
mottled pigmentation.121 Topical vitamin A deriva-
tives (retinoids) can be used to improve fine wrinkles
and irregular pigmentation.62 Peeling makes the skin
more vulnerable to UV radiation, and therefore sun
protection is of utmost importance after this pro-
cedure. Deep chemical peeling can be achieved by
trichloroacetic acid 35%, higher concentration than
50%, and phenol (Fig. 7). Possible complications of
chemical peeling include keloids, hypertrophic
scars, and hypopigmentation. Other modalities used
to treat photoaging damage include cryosurgery,
microderm abrasions, chemical and laser peeling,
tissue augmentation by injectable fillers, and botuli-
num injection to treat dynamic rhytides.46,119

LASER
Photodamaged skin and acne scarring can be
improved by treatment with different types of lasers:
ablative (high energy pulsed or scanned) CO2 lasers,
single or variable pulse or dual ablative/coagulative
mode erbium:yttrium aluminum garnet (Er:YAG)
lasers, non-ablative Q-switched neodymium:yttrium
aluminum garnet (Nd:YAG), diode lasers, and
combined wavelength systems. The pulsed Er:YAG
laser has poor penetration and is therefore used to
treat superficial rhytides; the CO2 laser is better for
deep rhytides and scars.94
Pulsed CO2 laser resurfacing causes ablation of
normal tissue with subsequent collagen regenera-
tion, and remodeling occurs by heat-induced
collagen contraction. A similar degree of skin
tightening can be achieved with the erbium laser.
Laser-induced skin contraction is usually not long-
lasting; the postoperative decrease with the CO2
laser ranges from an average of 42% 1 month
postoperatively to 36% on average at 6 months. With
erbium laser treatment the skin contraction is less
Fig. 7. A 42-year-old woman before (top), 5 days (middle)
and 3 months after (bottom) trichloroacetic acid 25% peel
for skin rejuvenation.
but is more stable.28 With the advent of new-
generation ultra-pulse CO2 lasers, the skin can be
successfully resurfaced with minimal risk or side
effects.131
Laser resurfacing of the lower eyelid skin and
periocular skin is done with the ultra-pulse CO2
laser. After each pass with the laser, debris should be
removed using saline-soaked gauze, and the area
dried with dry gauze. One pass usually suffices for
the pre-tarsal skin, whereas 2 3 passes should be
applied for the pre-zygomatic skin and lateral crow’s
feet area. After laser application the treatment area
should be covered with a moist dressing. 115
436 Surv Ophthalmol 53 (5) September--October 2008
The Er:YAG laser is also used to treat periocular
skin deformities. In many cases, skin resurfacing by
CO2 or Er:YAG yields good results even without
lower eyelid surgery. Combined use of Er:YAG and
CO2 lasers was recently described (Derma-K).90
Because the eyelid skin is only 0.25 mm thick, two
passes with decreasing power of the CO2 laser are
adequate for its removal. To avoid ectropion, the
triangle below the lateral corner of the eye must be
approached with restraint. An occlusive dressing
with polyurethane film is applied. Epithelialization
occurs after 6 to 7 days. Erythema lasts for several
weeks after resurfacing with the CO2 laser and for
only 2 weeks with the Er:YAG laser. This is because
the Er:YAG laser does not cause thermal damage; on
the other hand, it does not induce collagen
shrinkage, and deep wrinkles are therefore more
successfully treated with the CO2 laser. Promising
results have been obtained with the CO2/Er:YAG
combination laser, with post-treatment erythema of
3 weeks. Sun protection of the treated area is
mandatory for 6 months.90
Possible complications include persistent ery-
thema, allergic dermatitis, mild post-inflammatory
skin hyperpigmentation, hypopigmentation, and lid
retraction.18
INTENSE PULSED LIGHT
Intense pulsed light, a non-coherent light pro-
duced by a flash lamp, has been used in recent years to
treat photodamaged skin. By using filters with
different cutoff values, it is possible to select the
desired wavelength; long waves that reach the deep
dermal collagen tighten the skin, improving its
texture. Vascular and pigmented lesions are treated
by photodermal damage either through hemoglobin
absorption or melanin-pigmented lesions. Thermal
damage is avoided by controlling the duration of light
pulses and the interval between them, the latter must
be shorter than the thermal relaxation time in the
target lesion in order to ensure its destruction.31
Intense pulsed light was recently shown to be effective
and safe for treating senile pigmentation, telangec-
tasias, and rosacea, as well as for improving skin
texture in facial and non-facial rejuvenation. Com-
plications can include redness, blisters, swelling, scar
formation, and hyperpigmentation.34,124,132
LASER HAIR REMOVAL (PHOTOEPILATION)
Selective laser thermolysis is currently the treat-
ment of choice for hair removal. By using a laser beam
with a defined wavelength and pulse duration to
specifically target the melanin, it is possible to
selectively destroy the chromophore while protecting
the surrounding tissue. Patients require a minimum
BEN SIMON AND MCCANN
of three treatments at 1.5- to 2-month intervals for
body hair and five or six treatments for facial hair. The
reported success rate at 6 months is 60 95%.74 Lasers
used for hair removal include long-pulsed alexan-
drite, long-pulsed diode, and long-pulsed Nd:YAG;
the first two appear to be more effective than the last.8
In addition, larger spot size appears to be more
effective for hair removal, probably because it delivers
more total energy per pulse and results in increased
penetration.91 Possible side effects include pain,
hyperpigmentation, blister or erosion, folliculitis,
and hypopigmentation.8
Other methods of hair removal include shaving,
waxing, electrolysis, and chemical epilation.
BOTULINUM TOXIN
Botulinum toxin is one of the most powerful
toxins known in toxicology. It acts via parasympa-
thetic acetylcholine inhibition (chemodenervation),
which prevents fusion of the acetylcholine-filled
vesicle with the plasma membrane, thereby also
preventing the release of acetylcholine into the
synaptic cleft. The exotoxin produced from Clostrid-
ium botulinum temporarily paralyzes the mimic facial
musculature.7
Botulinum toxin was first used in 1973 and 1979
for the treatment of strabismus, and in 1985 the
indication was extended to blepharospasm and
dystonia.7,112--114 Aesthetic indications were added
after patients noticed that treatment in the brow
area produced a relaxed, unworried appearance
(Figs. 8--10 ).15,113,128 Three commercial botulinum
toxin preparations are currently available: Botox
(botulinum toxin type A [C. botulinum type A
toxin]; Allergan, Irvine, CA), Dysport (type A
toxin haemagglutinin complex; Ipsen, Maiden-
head, Berkshire, UK), and botolinum toxin type B,
available as Myobloc (injectable solution; Elan
Pharmaceuticals, South San Francisco, CA).44,47
Botulinum toxin, used alone or in combination
with other modalities of facial rejuvenation, such as
chemical peel, laser resurfacing, dermabrasion, or
soft tissue augmentation, offers safe and effective
treatment of upper face wrinkles. It has also been
used in surgery for facial rejuvenation.47
Dynamic changes are caused by muscle hyperto-
nicity and are manifested as lines or rhytids of the
forehead and glabellar areas. Improvement after
intramuscular injection of botulinum (type A or B)
first appears after 24 72 hours, reaches a peak by 1
month after injection, and lasts usually for 3 4
months, but might persist for 6 8 months or
longer.17,86 Previous botulinum toxin treatment
might extend the efficacy of additional BTX in-
jections because of attendant muscle atrophy; it was
COSMETIC EYELID AND FACIAL SURGERY 437

Fig. 8. A 26-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to corrugators and
procerus muscles. Note marked improvement in frowning appearance.

also noted that repeated injections prolong the
clinical effect.33,76 Among the many cosmetic in-
dications are lateral canthal lines (crow’s feet),
horizontal forehead lines, brow ptosis, orbicularis
oculi hypertrophy and periocular skin wrinkling,30
facial asymmetry, masseteric hypertrophy to reduce
a prominent mandibular angle,2 neck rejuvenation10
(platysmal bands), and decollete folds.7 Because of
asymmetric results, cosmetic indications that include
nasolabial folds and platysma and mouth frown are
still a subject of controversy. As our understanding of
the anatomy and combined mentalis and depressor
anguli improves, the results of treatment are likely to
be increasingly satisfactory.16
Systemic complications are rare because clinical
dosages of botulinium toxin are measured in nano-
grams, and as it is injected locally into the muscle, very
little enters the systemic circulation. Complications
can be classified as local, regional, or systemic.124
Possible systemic complications are thirst, flu-like
illness, and mild urticarial rash, as well as potentiation
of neurological diseases such as myasthenia gravis
and amyotrophic lateral sclerosis. Rare reports in-
clude anaphylaxis and respiratory arrest.21,79 Patients
with human albumin allergy should avoid treatment
with botulinum toxin. Possible regional complica-
tions are unwanted weakness or paralysis adjacent to
the point of injection, such as droopy eyelid, brow
ptosis or elevation, diplopia in the periocular area
from inadvertent orbital injection, lip drooling and
asymmetry in the perioral area, dysphagia (after deep
neck muscle injection), reduction in facial expres-
siveness, and a mask-like appearance.11,15,16 Local
effects can include erythema, rash, ecchymosis, and
hematoma.124
Contraindications for botulinum toxin injection
include pregnancy and lactation, neuromuscular
diseases, peripheral neuropathy, and use of medica-
tions such as quinine, calcium channel blockers,
penicillamine, or aminoglycoside antibiotics.47
FILLERS
Attempts have been made over the years to
augment facial soft tissue for aesthetic and re-
constructive purposes. Fillers are used for the
treatment of deep wrinkles and non-dynamic
furrows.67,77,107 They are also useful for correction
of facial, bony, and soft tissue defects of congenital
or traumatic origin, and in patients suffering from
scleroderma, Romberg disease, facial wasting, or
AIDS-associated lipodystrophy.14,77,78 Many mate-
rials have been used, including organic particles
such as autologous fat, sea coral, and injectable
bovine collagen. The latter, along with inorganic
liquid silicone gel, have been used increasingly in
recent years. None of the proposed materials has
proved entirely satisfactory because of migration,
host immune response, or transitory cosmetic
improvement.104 Autologous fat is not permanent

Fig. 9. A 30-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to orbicularis muscle for
lower eyelid orbicularis hypertrophy and crows feet. Note marked improvement in lower eyelid and lateral canthal area.
438 Surv Ophthalmol 53 (5) September--October 2008 BEN SIMON AND MCCANN

Fig. 10. A 48-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to orbicularis muscle
for crows feet.

and its fate is unpredictable. The effect of soft tissue ophthalmic procedures is to improve or preserve
augmentation using fillers typically lasts 6 months. vision. The success of the surgery can be readily
The search for newer and better materials led to the measured with visual acuity.
introduction of polyacrylamide, which was consid- The goals of cosmetic surgery are more varied and
ered biologically inert; however, recently reported success must be defined on a patient-by-patient
severe granulomatous reaction to polyacrylamide basis. The most common goal of cosmetic surgery is
casts doubt on this assumption.23 A filler commonly to reverse anatomical changes that occur in the face
used in the United States is an injectable bovine with aging. Just as a successful ophthalmologist must
collagen preparation. Other common fillers include understand the anatomy and physiology of vision
PMMA (polymethylacrylate), microspheres, silicone a successful cosmetic surgeon must understand the
oil, polylactic acid microspheres, and dextran micro- anatomy and physiology of facial aging. The success-
spheres. Recently, hyaluronic acid filler (Restylane; ful cosmetic surgeon must be able to listen to
non-animal stabilized hyaluronic acid; Medicis Aes-
thetics, Scottsdale, AZ) was approved by the FDA.
Long-term retention of its effect has been demon-
strated in a mouse model using Restylane mixed with
cultured human dermal fibroblasts (Fig. 11).136
In a recent investigation of human host response
to intradermal injection of various soft tissue fillers,
all of the examined substances appeared to be
clinically and histologically safe, but all showed host
inflammatory reaction from encapsulated fibrous
tissue, granulomatous reaction with giant cells, and
chronic foreign body reaction.77 A less severe
inflammatory response was obtained with polyme-
thylacrylate particles, polyacrylamide, polyvinylhydr-
oxide microspheres, and calcium hydroxylapetite.
Other fillers have also had destructive inflammatory
effects on soft tissues.82--84
Other possible complications of soft tissue aug-
mentation include blindness and cutaneous necro-
sis from treatment in the glabellar area30,125 and
arterial embolization following hyaluronic acid in-
jection (Restylane).100,111

Summary Fig. 11. A 56-year-old man, before (upper image) and 6

months after Restylane injection for lower eyelid tear
In many ways cosmetic surgery is very different trough deformity, note marked improvement achieved
from the rest of ophthalmology. The goal of most with no incisional surgery.
COSMETIC EYELID AND FACIAL SURGERY
a patient’s concerns about how their appearance has
been altered by age, understand the underlying
anatomical and physiological changes that cause
these changes, describe to the patient what sort of
success they might expect in reversing these
changes, and then master and stay current on
a number of rapidly evolving techniques.
It is a truly fascinating and challenging area of
ophthalmology. For those who embrace the disci-
pline it can be very rewarding.
Method of Literature Search
Medline and Medical Subject Headings search
(1966--2007) was conducted using the following
terms: eyelid, ptosis, blepharoplasty, eyelid bags, forehead,
face-lift, midface-lift, neck-lift, rhytidectomy, browlift, chem-
ical peel, blepharoplasty, facial implants, fat transfer,
liposuction, botulinum toxin, fillers, Restylane, chemical
peel, cosmetic surgery, aesthetic surgery. The search was
limited to English language publications. All manu-
scripts’ abstracts were examined. Publications were
included if they studied any aspects of cosmetic eyelid
and facial surgery with emphasis on new surgical
techniques and new cosmetic procedures. Compara-
tive prospective studies were preferred; case-series
were also included if they studied an important aspect
of a specific cosmetic procedure. Abstracts identified
were assessed for eligibility. If the abstract was unclear
the full-text of the article was obtained and assessed.
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The authors reported no proprietary or commercial interest in
any product mentioned or concept discussed in this article.
Reprint address: Guy J. Ben Simon, MD, Goldschleger Eye
Institute, Tel Hashomer, Israel 52621.