VIDEO+

Refinements in Upper Blepharoplasty: The

Five-Step Technique
Rod J. Rohrich, M.D.
Nathaniel L. Villanueva,
M.D.
Paul N. Afrooz, M.D.
Dallas, Texas
Summary: Periorbital tissues are a keystone in facial beauty and a r­ epresentation
of youth. The aesthetically pleasing and youthful upper eyelids are full, with a
defined tarsal upper lid crease and with smooth, taut pretarsal and preseptal
skin. The upper blepharoplasty is a critical component of any facial rejuvena-
tion procedure. This five-step procedure provides key steps in the correction
of upper lid age-related changes and provides a reliable and reproducible
method of achieving excellent results. Furthermore, the addition of fraction-
ated fat restores volume and youthfulness of the upper lid, and also improves
the skin quality of the upper lid.  (Plast. Reconstr. Surg. 141: 1144, 2018.)

P
eriorbital tissues are a keystone in facial
beauty and a representation of youth. These
tissues are typically the first to exhibit signs
of aging because of the effects of animation, grav-
ity, and sun exposure. The upper eyelid is a critical
component of this anatomical region, and upper lid
blepharoplasty should be an integral component of
facial rejuvenation. The aesthetically pleasing and
youthful upper eyelids are full, with a defined tarsal
upper lid crease with only 2 to 3 mm of pretarsal
eyelid show and with smooth, taut pretarsal and
preseptal skin.1 The periorbital region and brow is
also smooth, without rhytides or redundancy, and
should be addressed with any rejuvenation pro-
cedure. Preoperative evaluation and planning is
critical for successful restoration of youthful upper
eyelids.2 Although the execution of upper blepha-
roplasty should not be identical in every patient,
varies with ethnicities, and should account for the
individual needs of each patient, there are principal
maneuvers that should be included in most upper
blepharoplasties to deliver an aesthetically pleas-
ing and youthful result. The senior author (R.J.R.)
has refined this procedure over the course of his
career, and has identified five key steps that should
be included in most female upper blepharoplasties.
PATIENT EVALUATION
The evaluation of a patient for upper bleph-
aroplasty should include a general history and
From the Dallas Plastic Surgery Institute; and the Depart-
ment of Plastic Surgery, University of Texas Southwestern
Medical Center.
Received for publication February 14, 2017; accepted
­August 7, 2017.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004439
physical examination. The periorbital examina-
tion should include visual testing, Schirmer test,
pupillary response, extraocular muscle function,
Bell phenomenon, palpebral fissure size and
shape, ptosis evaluation (marginal reflex dis-
tance-1), and volume and skin assessments.1–5
PREOPERATIVE MARKINGS
Preoperative markings are performed with
the patient in the upright position and in neutral
gaze. The brow is positioned appropriately before
marking. The supratarsal fold is located at 8 to
9 mm above the ciliary margin in women and 7 to
8 mm above the ciliary margin in men.4 A mark is
placed just inferior to this fold. The upper mark-
ing must be at least 10 mm from the lower edge
of the brow. Medially, the markings should not
extend beyond the medial canthus, and laterally,
depending on the amount of skin laxity, the shape
of the skin excision may be lenticular or trapezoid
in shape.
Disclosure: Dr. Rohrich is a volunteer member of
the Allergan Alliance for the Future of Aesthetics
and receives instrument royalties from Eriem Surgi-
cal, Inc., and book royalties from Taylor and Francis
Publishing. No funding was received for this article.
Video Plus content is available for this article. A
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on the Journal’s website (www.PRSJournal.com).

1144 www.PRSJournal.com
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 141, Number 5 • Refinements in Upper Blepharoplasty
SURGICAL TECHNIQUE
Subcutaneous injection of 3 to 5 ml of 1% lido-
caine with 1:100,000 epinephrine with a 27-gauge,
1½-inch needle is performed 7 minutes before
incision. (See Video, Supplemental Digital ­Content
1, which demonstrates a five-step upper blepharo-
plasty, available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for Ovid
users, available at http://links.lww.com/PRS/C722.)
Step 1: Lowering the Supratarsal Fold
The first step of the technique is critical for
the restoration of a youthful upper lid crease. The
incision is usually placed 1 mm inferior to the
current supratarsal lid crease or 7 mm above the
ciliary margin with a no. 15 blade. Laterally, this
incision takes a lazy-S–shaped course, falling into
a lateral orbital skin crease, to allow greater skin
excision of the lateral upper lid, where most of
the redundancy is found.
Step 2: Skin Excision
The shape of the skin excision is dependent
on the age of the patient and the amount of skin
redundancy.2 Using the presurgical markings,
the upper incision is made approximately 10 mm
from the brow at a vertical point directly above the
lateral limbus with a no. 15 blade and the skin is
excised with fine curved scissors. (Note: if there
is excess fat in the medial fat compartment, the
deep fat is excised.)
Step 3: Lateral Orbicularis Window
Most patients with lateral fullness have laxity
and redundancy of the lateral orbicularis oculi
Video. Supplemental Digital Content 1 demonstrates a five-step
upper blepharoplasty, available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for Ovid users, available
at http://links.lww.com/PRS/C722.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
muscle. Depending on the amount of redundancy,
using fine curved scissors, a minimal portion of
the orbicularis muscle is excised. This also further
defines the supratarsal fold. Of note, if perform-
ing a concomitant lower blepharoplasty, the lateral
canthopexy is performed during this step. The can-
thopexy is performed with a single 5-0 Vicryl (Ethi-
con, Inc., Somerville, N.J.) suture grasping the
lower lateral retinaculum and passed though the
periosteum of the inner upper orbital rim just lat-
eral to the lateral limbus. The suture is tensioned
depending on the laxity of the lower lid, and the lat-
eral canthus should be placed close to the patient’s
youthful eye appearance, which can be determined
using old photographs of the patient.
Step 4: Differential Skin Closure
Hemostasis is obtained with a pinpoint insulated
cautery. The skin is reapproximated in a differential
manner because of the inherent difference in thick-
ness between the brow and lid skin. A running sub-
cutaneous 6-0 Prolene (Ethicon) suture is placed,
taking a deep path on the lid skin and a superficial
path on the brow skin to compensate for the dif-
ference in skin thickness. This is followed by inter-
rupted simple 6-0 nylon sutures placed in a similar
differential manner, with superficial passes of the
needle in the thicker brow skin and deeper bites
in the thinner lid skin. The differential closure has
provided further camouflaging of the incisions in
the senior author’s (R.J.R.) experience.
Step 5: Volume Restoration
Finally, volume restoration of the upper orbit
is performed using fractionated fat. The fat is
1145

harvested at the beginning of the case from the
medial thighs and centrifuged at 1200 rpm for 1
minute as described previously.6 The fat is then
passed between two syringes through a small
Tulip Emulsifier (Tulip Medical Products, San
Diego, Calif.) 50 times. Then, using a 14-gauge
needle, a small stab incision is made in the upper
lateral brow and the fractionated fat is injected
into a submuscular plane in the upper lid and
just above the periosteum near the orbital rim
using an 18-gauge, 1½-inch blunt cannula (Mic-
rins; Eriem Surgical, Lake Forest, Ill.). This step
improves the volume of the upper lid, and the
stem cells in the fractionated fat may provide
dermal regeneration, which has been noted by
the senior author in clinical follow-up.7,8 Further-
more, the fractionated fat has a minimal propen-
sity for lumps.
CONCLUSIONS
The upper blepharoplasty is a critical com-
ponent of any facial rejuvenation procedure.
This five-step procedure provides key steps in the
correction of upper lid age-related changes and
provides a reliable and reproducible method of
achieving excellent results. Furthermore, the
addition of fractionated fat restores volume and
youthfulness of the upper lid and also improves
the skin quality of the upper lid.
1146
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • May 2018
Rod J. Rohrich, M.D.
Dallas Plastic Surgery Institute
9101 North Central Expressway, Suite 600
Dallas, Texas 75231
rod.rohrich@dpsi.org
Twitter: @DrRodRohrich
Instagram: @Rod.Rohrich
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