Oculoplastic Surgery

Aesthetic Surgery Journal

Continuing Medical Education Article 2019, Vol 39(1) 10–28
© 2018 The American Society for
Aesthetic Plastic Surgery, Inc.
Blepharoplasty: Anatomy, Planning, Reprints and permission:
journals.permissions@oup.com

Techniques, and Safety DOI: 10.1093/asj/sjy034

www.aestheticsurgeryjournal.com

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Mohammed Alghoul, MD, FACS

Abstract
Blepharoplasty is one of the most commonly performed cosmetic surgical procedures. To date it remains the most powerful method of periorbital rejuve-
nation when compared to other nonsurgical modalities, especially in the aging face. Despite that, the procedure has its shortcomings that include a steep
learning curve, prolonged recovery, and potential for appearance and life-changing complications. Attaining successful outcomes relies on a solid under-
standing of facial topography, patient and technique selection, and, when appropriate, following a conservative approach. Modern blepharoplasty relies
on tissue conservation and volume enhancement rather than aggressive removal. This concept was conceived after the realization that older techniques
resulted in a hollowed appearance, which accentuated the aging process. It was further reinforced by advances in knowledge of periorbital anatomy
and aging changes. This Continuing Medical Education article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty
approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient’s anatomy.

Editorial Decision date: January 26, 2018; online publish-ahead-of-print February 21, 2018.

Learning Objectives Blepharoplasty is the surgical rejuvenation of the upper

The reader is presumed to have a basic understanding of
aesthetic eyelid surgical procedures. After studying this
article, the participant should be able to:
(1) Describe the periorbital anatomy and surface topogra-
phy of the youthful and aging eyes.
(2) Identify ideal candidates for aesthetic eyelid surgery
and patients at risks for postoperative complications.
(3) Recognize the various surgical techniques of upper
and lower blepharoplasty.
and lower eyelids. It is the fourth most common cosmetic
procedure performed in the United States according to the
2016 American Society for Aesthetic Plastic Surgery statis-
tics.1 Both upper and lower blepharoplasties are techni-
cally demanding operations that require careful planning
and meticulous execution to achieve optimal outcomes
and avoid complications. Numerous techniques have been
described for both upper and lower blepharoplasties, with
no comparative data supporting the superiority of one
technique over the other.2-16 Regardless of the approach

The American Society for Aesthetic Plastic Surgery (ASAPS)

members and Aesthetic Surgery Journal (ASJ) subscribers
can complete this CME examination online by logging on
to the CME portion of ASJ’s website (http://asjcme.oxford-
journals.org) and then searching for the examination by
subject or publication date. Physicians may earn 1 AMA
PRA Category 1 Credit by successfully completing the
examination based on the article.
Dr Alghoul is an Assistant Professor, Division of Plastic and
Reconstructive Surgery, Northwestern Feinberg School of Medicine,
Chicago, IL.
Corresponding Author:
Dr Mohammed Alghoul, Division of Plastic and Reconstructive
Surgery, Northwestern Feinberg School of Medicine, 675 N St. Clair
Street, Galter 19-250, Chicago, IL 60611, USA.
E-mail: mo.alghoul@gmail.com; Twitter: @DrMoAlghoul
Alghoul11

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Figure 1. Comparison of surface topography of the periorbital area between a youthful face (left) and an aging face (right).

used, the goal of the operation should remain the same;
restoring a youthful and natural look to the eye and perior-
bital area. For upper blepharoplasty, the goal is to restore
the visibility of the pretarsal space with a well-defined
upper lid crease while restoring an attractive upper lid
fold volume, in proper proportion with the pretarsal space.
Lower blepharoplasty aims to create a smooth lower lid
surface with seamless transition into the cheek. As these
objectives are accomplished, the shape and dimensions of
the palpebral fissure should be maintained or improved.
Like other procedures in plastic surgery, the concept of
blepharoplasty has evolved over the years secondary to
increasing knowledge of periorbital anatomy, facial topog-
raphy, and the aging process. As a result, several surgical
techniques have been described in an effort to maximize
safety and improve the aesthetic results. The choice of par-
ticular blepharoplasty technique has been heavily debated
with several different schools of thought.3,6,8,11,12,14 The
fear of postoperative complications, especially with lower
blepharoplasty, has driven many surgeons towards more
conservative approaches sometimes at the expense of opti-
mizing aesthetics.14 This CME article will detail periorbital
surgical anatomy, preoperative planning, and varied bleph-
aroplasty approaches and techniques, with an emphasis
on safety and tailoring the procedure to the patient’s anat-
omy to attain the desired outcome.
UPPER AND LOWER EYELID ANATOMY
Knowledge of periorbital anatomy, topography, propor-
tions, and volume distribution are critical in surgical
planning. Both upper and lower eyelids should be assessed
in the context of the surrounding periorbital area. Changes
in the brow and cheek strongly influence the upper and
lower eyelids, respectively. It has become common prac-
tice to address both the lateral brow and cheek as part of
comprehensive periorbital rejuvenation.3,5,8,11,13,14,17-22
SURFACE TOPOGRAPHY
Ideally, the periorbital area should project anteriorly in
relationship to the globe. The reverse ratio results in aes-
thetically less attractive eyes as evidenced in patients with
prominent eyes, negative vector, and cheek and brow
deflation (Figure 1). A negative vector indicates that the
globe projects further than the malar eminence23 and is
often associated with lack of anterior cheek projection and
decreased soft tissue volume of the cheek. The upper eye-
lid is divided into two distinct spaces, the upper eyelid fold,
which is the space between the brow and upper lid crease,
and the pretarsal space, defined as the space between the
crease and the lash line.23 The ratio between both spaces
(fold:pretarsal ratio) and the difference in volume is what
determines upper eyelid aesthetics. This ratio differs from
medial to lateral and between males and females. We
have studied the upper eyelid topographical proportions
in attractive Caucasian female models and found that an
ideal fold:pretarsal ratio averages 1.87 medially and wid-
ens laterally to an average of 2.98, peaking at the lateral
limbus.24 These findings reflect the importance of lat-
eral brow vertical height and fullness, and the presence
of some degree of pretarsal show in females (Figure 1).
12
Figure 2. Illustration of layered anatomy of the upper and lower eyelids and periorbital area.
In males, on the other hand, pretarsal show is not as criti-
cal and upper lid fold height is more even across the width
of the palpebral fissure. The upper eyelid sulcus is the
space between the upper lid crease and the superior orbital
rim. Uniform fullness of the sulcus is created by the orbital
fat and directly contributes to the upper lid fold’s overall
volume. With aging, the fat content in the upper lid can
increase or decrease.25 Herniation of orbital fat can create
localized bulges that obliterate the sulcus. Loss of orbital
fat volume, on the other hand, deepens the sulcus and
creates a sunken, shadow-filled area under the brow and a
round hollowed upper lid (Figure 1).25,26 As a result of this
volume depletion, the supraorbital rim becomes visible
and the supratarsal crease may appear elevated.
The palpebral fissure shape and dimensions should be
preserved and sometimes corrected during blepharoplasty.
An aesthetically pleasing eye has an almond shape with
superior arc that peaks medially27 and a slight upward
inclination of the lateral canthal angle (positive canthal
tilt).3 The lateral canthal angle is sharp and crisp, with the
lateral commissure closely opposed to the globe, while the
medial canthal angle is slightly blunted and the commis-
sure separated from the globe, by the caruncle and plica
semilunaris. Assessment of the size and shape of the lat-
eral scleral triangle preoperatively and postoperatively is a
useful tool to assess the palpebral fissure shape and lower
lid malposition.23
The lower eyelid crease is less defined than the upper
eyelid crease, but similarly is considered a sign of youth and
reflects normal lower eyelid animation. Topographically,
the lower eyelid is divided into a pretarsal area, presep-
tal area, and the eyelid cheek junction. The pretarsal seg-
ment has a slight natural bulge that occurs with smiling
and animation reflecting normal function of the pretarsal
Aesthetic Surgery Journal 39(1)
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orbicularis. Orbicularis hypertrophy in some patients may
cause a noticeable bulge in that segment of the eyelid espe-
cially with squinting and smiling. The preseptal segment
of the lower eyelid is where the orbital septum and orbital
fat are located. Anterior protrusion of the fat compartments
in this segment results in distinct and well-localized bulges
(Figure 2). The eyelid cheek junction is the area defined by
a groove or a dark soft tissue depression known as the tear
trough. This trough accentuates the orbital fat protrusion
above and the upper cheek volume depletion below, result-
ing in a peak and valley visual effect and a dark shadow
in the lower eyelid. Volume deflation in the upper cheek
results in a central inverted triangular area of volume loss.28
An additional bulge may occur in the lateral cheek known
as the malar mound. This mound results from descent of the
prezygomatic space and is bordered superiorly by the lateral
orbicularis retaining ligament and inferiorly by the zygo-
matic cutaneous ligaments that form the midface groove.29
Finally, the lateral orbital area is a very important aes-
thetic component that is frequently overlooked. It is formed
by the merger of the lateral brow and upper lateral cheek
as they meet just lateral to the lateral canthus. Graduated
fullness from the lateral brow to the upper lateral cheek
complements the results of blepharoplasty and closes the
circle in periorbital rejuvenation.
PERTINENT SURGICAL ANATOMY
The eyelid is a complex structure that varies in its lay-
ered composition depending on the anatomic segment.
The pretarsal segment extends from the lash line to the
margin of the tarsal plate and is bilamellar. The anterior
lamella is composed of skin and pretarsal orbicularis while
the tarsus and conjunctiva make the posterior lamella. The
Alghoul13
importance of the pretarsal segment is that it harbors the
pretarsal orbicularis (blink muscle) and the tarsoligamen-
tous sling that are critical for lid function and support.
The pretarsal orbicularis must be preserved in both upper
and lower blepharoplasties by making the access incisions
through the muscle (when indicated) at the junction of
the pretarsal and preseptal orbicularis. The preseptal seg-
ment constitutes the remaining lid proper where the bulk
of blepharoplasty surgery takes place, and is composed
of the above bilamellar structure separated by the orbital
septum and orbital fat. The preseptal orbicularis is loosely
adherent to the underlying orbital septum through the sub-
orbicularis oculi fascia creating the preseptal space,29,30 a
commonly used dissection plane in blepharoplasty. The
preseptal orbicularis can be trimmed, when indicated in
both upper and lower blepharoplasty. The orbital orbicu-
laris defines the area of the eyelid-brow and eyelid-cheek
junctions, in the upper and lower eyelids, respectively. It is
separated from the preseptal orbicularis by the orbicularis
retaining ligament (Figure 2).31 In lower blepharoplasty,
release of the orbicularis retaining ligament allows mobi-
lization, suspension, and tightening of the preseptal and
orbital orbicularis.12 The orbital orbicularis extends over
the brow, lateral orbit, and cheek and overlies deep fat
compartments. The orbicularis oculi muscle is responsible
for eyelid tone and closure and is innervated by zygomatic
and buccal branches of the facial nerve.32 It is believed that
the inner canthal orbicularis, the main blinking muscle, is
innervated by the buccal branch of the facial nerve that
passes lateral to medial in a plane deep to the muscles
of facial expression. Injury to this branch during aggres-
sive dissection to release the medial tear trough can result
in blink impairment.32 Both the pretarsal and preseptal
orbicularis are almost devoid of superficial fat while the
orbital orbicularis is covered with the superficial infraor-
bital fat compartment (Figure 3).33,34
The orbital septum is a fibrous structure that originates
from the arcus marginalis and inserts on the inferior edge
of the tarsal plate in the lower eyelid.30 In occidental upper
eyelid, it inserts on the levator aponeurosis at the level of
the upper tarsal edge. The orbital septum is located deep
to the orbicularis oculi muscle, is thicker laterally, and
acts as an anterior barrier to orbital fat herniation.30 The
lateral extension of the orbital septum forms the superfi-
cial lateral canthal tendon that can be used as an anchor
structure in lateral canthopexy.35 The capsulopalpebral
fascia (CPF) and the accompanying smooth muscle fibers
comprise the lower lid retractors. The CPF originates from
the inferior rectus muscle and its head wraps around the
inferior oblique muscle to ultimately insert on the inferior
edge of the tarsal plate. The orbital septum in the lower
eyelid is adherent to the CPF for 3 to 5 mm inferior to the
lower tarsal edge. Therefore, a transconjuctival preseptal
approach should be performed through this area of fusion,
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Figure 3. Cadaver dissection of an injected head (a 62-year-
old male) showing the superficial fat compartments of
the periorbital area. The arrow marks the junction of the
preseptal and orbital orbicularis in the lower eyelid, which
corresponds to the eyelid-cheek junction. Notice how
the bulk of the infraorbital superficial fat compartment is
overlying the orbital portion of the orbicularis.
while a postseptal approach that preserves the orbital sep-
tum should be performed inferiorly, approximately 6 mm
or more below the edge of the tarsus.8,30
The orbital fat is located deep to the septum and is par-
tially separated into compartments, nasal and central in the
upper eyelid and nasal, central, and lateral in the lower
eyelid.23 The central upper eyelid fat is also known as the
preaponeurotic fat and is located anterior to the levator apo-
neurosis, medial to the trochlea and lateral to the lacrimal
gland.3,4,23 The nasal fat compartment is located deeper and
is superficial to the trochlea. It has a characteristic whitish
color and is separated from the central fat compartment
by an extension of Whitnall’s ligament called the interpad
septum (Figure 4C).23 There are two vascular structures
that can be injured during manipulation of the nasal fat
pad, one is the medial palpebral artery located medially
and a branch of the superior ophthalmic vein located deep
to the pad. Eisler’s fat pad is a small fat pad that can be
used as a landmark for its proximity to Whitnall’s tuber-
cle (Figure 5E).23 In the lower eyelid, the medial and cen-
tral fat compartments are separated by the inferior oblique
muscle while the central and lateral compartments are sep-
arated by the arcuate expansion of Lockwood’s ligament
(Figure 6C). Release of this latter structure results in the
ability to mobilize both the central and lateral compart-
ments as one unit. The deep fat compartments are located
deep to the orbital orbicularis and are divided into the ret-
ro-orbicuaris oculi fat (ROOF) compartment in the upper
lid-brow junction and the medial and lateral suborbicularis
fat compartments (SOOF) in the lower lid-cheek junction.
These compartments are targets for augmentation through
fat blending and fat grafting (Figure 2).
14 Aesthetic Surgery Journal 39(1)

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Figure 4. (A) Skin markings of upper blepharoplasty in a 73-year-old woman, showing the crease and the lateral extent of
the ellipse, which is marked parallel to the lower blepharoplasty lateral canthal incision. Ideally the distance between the two
should be 10 mm although many time this distance ends up being shorter. (B) Open-sky technique showing the upper incision,
dissection through the orbicularis oculi muscle (OO) and septum (S) exposing the preaponeurotic fat pad (PF). (C) Upper lid
orbital fat showing the preaponeurotic (central) fat pad (PF) and the paler nasal fat pad (NF). (D) The preaponeurotic fat after
it was mobilized and draped across the upper lid fold for volume augmentation.

The orbicularis retaining ligament is an osseocutane-
ous septum that separates the eyelids from the cheek and
brow and is responsible for nasojugual and palpebromalar
grooves (Figure 6B).28,29,31 The medial aspect of this liga-
ment is sandwiched between the maxillary origin of the
preseptal and orbital orbicularis and it ends at the medial
scleral limbus. This segment of the ligament is known as
the tear trough ligament (Figure 2).28 As it travels later-
ally it turns into a pure bilamellar septum that increases
progressively in length and fuses with the lateral orbital
thickening. This segment of the ligament is known as the
orbicularis retaining ligament.28 It is critical to differenti-
ate the orbicularis retaining ligament from the arcus mar-
ginalis. The latter is a distinct fibrous thickening seen at
the orbital rim from the confluence of the orbital septum
with the periorbita and periosteum.30 The arcus marginalis
is encountered and released through a transconjunctival
postseptal approach, and the result of this release is con-
necting the orbital fat with a preperiosteal or subperios-
teal plane on the anterior rim while leaving the septum
undisturbed.8,11,36 On the other hand, a transconjuncti-
val preseptal approach and the transcutaneous approach
usually open the septum and encounter and release the
orbicularis retaining ligament while leaving the arcus
undisturbed,13 except in cases where they transition into
a subperiosteal plane, necessitating the release of arcus
marginalis (Figure 7).36
The lateral canthal fixation is anatomically accom-
plished through three structures that attach to the lateral
orbital rim at different levels. The lateral palpebral raphe
is formed by the pretarsal and preseptal orbicularis and is
located immediately under the lateral canthal skin.37 The
superficial lateral canthal tendon is a continuation of the
orbital septum sandwiched between the muscle and the
Alghoul15

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E F

Figure 5. Lateral canthoplasty in steps in a 73-year-old woman. (A) Lateral canthotomy. (B) Inferior cantholysis. (C)
Estimating the degree of shortening and tightening. (D) Vertical bites through the cut end of the tarsal plate with double-armed
suture. (E) Deep periosteal bite in the lateral orbital rim close to the location of Whitnall’s tubercle, the white arrow is pointing
to Eisler’s fat pad, and (F) recreating the lateral canthal angle with a gray-line stitch.

lateral canthal tendon and inserts anteriorly on the peri- that originates from the upper and lower tarsal plates
osteum of the lateral orbital rim.35,37 The lateral canthal and inserts on Whitnall’s tubercle which is positioned 2
tendon (lateral retinaculum), is the deepest attachment to 4 mm inside the lateral orbital rim.23,37,38 It receives
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Figure 6. Skin muscle flap lower blepharoplasty in a 73-year-old woman. (A) A stair-step incision starting as a subciliary
skin incision 1 to 2 mm below the lash line followed by a muscle incision preserving 4 mm strip of PTOO. (B) Dissection in
the preseptal plane or space showing the LFP and CFP separated by the arcuate expansion of Lockwood ligament, the black
arrow is pointing to the orbicularis retaining ligament and the white arrow is pointing to the lateral orbital adhesion. (C) White
arrow pointing at arcuate expansion of Lockwood ligament. (D) Mobilization of the orbital fat as pedicled flaps that can be
advance over the orbital rim. (E) Redraping of the orbital fat in the preperiosteal plane. (F) Marking the lateral wedge of skin
and muscle that are trimmed in the skin-muscle flap technique. (G) The excess skin is estimated only after excision of the
tissue laterally and orbicularis suspension. (H) Skin is conservatively trimmed, notice the elevation of the marked line that was
originally placed at the tear trough. CFP, central fat pad; LFP, lateral fat pad; PSOO, preseptal orbicularis oculi muscle; PTOO,
pretarsal orbicularis oculi muscle; OF, orbital fat; S, septum; SOOF, suborbicularis oculi fat.

contributions from the lateral horn of the levator apo-
neurosis and Whitnall’s ligament superiorly, Lockwood’s
ligament inferiorly, and the check ligament of the lateral
rectus muscle on its deep surface.23,37-39
PREOPERATIVE EVALUATION
The goal of preoperative evaluation is to identify medi-
cal history and anatomical features that increase the risk
of postoperative complications. History of poorly con-
trolled hypertension, bleeding disorder, and certain med-
ications and herbal supplements can increase the risk of
bruising and bleeding.40 History of prior cosmetic and
reconstructive periorbital procedures should be obtained.
The presence of dry eye symptoms and predisposing risk
factors for dry eye syndrome must be carefully evalu-
ated, as upper and lower blepharoplasties cause transient
impairment in eyelid closure mechanics, and can result
in worsening of symptoms postoperatively.41-43 Patients
with history of dry eyes or inability to tolerate contact
lenses should undergo a Schirmer test, which relies on
the degree of wetting of a filter paper strip placed at the
lateral commissure. Wetting of less than 5 mm distance
over a period of 5 minutes is considered diagnostic of
dry-eye syndrome.40,42 The presence of a normal Bell’s
phenomenon, manifested as upward rolling of the globe
Alghoul17
E F
G H
Figure 6. Continued
when attempting to open a closed eye should be docu-
mented.40 Absence of Bell’s phenomenon, although is not
a contraindication for blepharoplasty, should steer the
surgeon towards a more conservative approach. History
of recent ocular or corneal surgery should be elucidated.
It is advisable to wait for 6 months after laser-assisted in
situ keratomileusis (LASIK) to allow for restoration of nor-
mal corneal sensitivity prior to eyelid surgery, as LASIK
causes blunting of the normal blink reflex temporarily.44
The patient’s specific cosmetic complaints should be veri-
fied while looking in the mirror. Evaluation then proceeds
with careful analysis of periorbital topography and signs
of aging. Standardized preoperative photographs are taken
in 6 views that include a front, lateral, three quarters, and
a close-up view of the eyes. In addition, photographs of
the eyes closed in repose and of the eyes open with the
globe in upward gaze, help in evaluation of the amount of
excess skin in the upper lid and excess orbital fat in the
lower lid, respectively. Finally, a photograph of the eyes in
animation (squinting) helps verify the size and function
of the pretarsal orbicularis and accentuates the tear trough
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deformity.28 Pictures will often reveal asymmetries that
are not clear on examination, especially with ptosis that is
more apparent when the patient relaxes in front of a cam-
era. Three-dimensional photographs allow more accurate
measurements of periorbital volumization procedures.45
The surgical plan should be determined after discussing
the patient’s goals and desired outcome and it should be
customized depending on the presenting features.
Upper Eyelids
There are three important features that need to be evaluated
in the upper eyelid: (1) the presence of a well defined and
visible crease; (2) the degree of pretarsal show; and (3) the
height, volume, and contour of the upper eyelid fold. The
marginal reflex distance-1 (MRD-1), defined as the distance
between the corneal light reflex and the upper eyelid mar-
gin, should be determined first to rule out a concomitant
blepharoptosis, which should be addressed at the time of
blepharoplasty. In Caucasian females, the crease has a gentle
arch, averages 8 to 10 mm in height from the lash line at the
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Figure 7. (A) An illustration of a sagittal view of the lower lid showing the two main approaches to lower blepharoplasty; the
dashed line is the plane of dissection for the skin-muscle flap preseptal approach transitioning into a supraperiosteal plane,
and the dotted line is the plane of dissection for the transconjunctival post septal approach transitioning into a subperiosteal
plane. (B) The skin-muscle flap approach releasing the orbicularis retaining ligament and advancing the orbital fat over the
orbital rim in a supraperiosteal plane leaving arcus marginalis intact. (C) The transconjunctival approach releasing arcus
marginalis and advancing the orbital fat over the orbital rim in a subperiosteal plane, and therefore indirectly releasing the
orbicularis retaining ligament by releasing its periosteal origin.

midpupil, and should be visible through its full length from
medial to lateral canthi. The degree of desired pretarsal show
varies among patients and can be determined by examining
old photographs. Caution should be practiced with patients
who present for upper blepharoplasty who have full visibility
of their crease and pretarsal space. A traditional upper bleph-
aroplasty in this patient population can result in increased
pretarsal show, which can be unattractive. The youthful
upper eyelid fold has a smooth surface with a progressive
gradual increase in height and volume from medial to lat-
eral where it blends with the lateral orbital area (Figure 1).2
This progressive increase in height and volume in females is
determined by the position of the temporal brow and retro-or-
bicularis oculi fat. It is for this reason that a temporal brow lift
can be complementary to upper blepharoplasty (Figure 8). In
non-Asian males, the crease (averaging 7-8 mm in height)46
is straighter and the upper lid fold is more uniform in height
and volume with less emphasis on the visibility of the pre-
tarsal space. Contour irregularity of the upper eyelid fold can
result from excess skin, localized bulge created by herniating
orbital fat, or a prolapsed lacrimal gland. Finally, the need for
fat grafting to create a smooth, full, and convex upper eyelid
fold should also be determined.
Lower Eyelids
The lower eyelid position is evaluated including the pres-
ence of scleral show or bowing of the lateral lower lid
Alghoul19

resulting in rounding of the lateral canthal angle.3,40 These

features along with the presence of a negative vector place
the patient at a high risk for post lower blepharoplasty
retraction.40,47,48 The presence of a negative vector causes
the lower lid to travel at an upslope to cover the globe,
which creates a mechanical disadvantage that can be fur-
ther deteriorated by surgical disruption of ligamentous and
volume support of the lower eyelid.48 If the patient is sus-
pected of having a prominent globe, a Hertel exophthal-
mometer can be used to measure the corneal projection
relative to the lateral orbital rim. Normal range is defined
to be between 15 and 17 mm and patients with prominent
eyes (>18 mm) are at higher risk for postoperative lower

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lid malposition.3,40 Lower eyelid laxity and tone are exam- Video 1. Watch now at https://academic.oup.com/asj/
ined through “distraction” and “snap back” tests.3,40,48 article-lookup/doi/10.1093/asj/sjy034
A lower eyelid that can be distracted >8 to 10 mm away
from the globe constitutes an abnormal distraction test
and indicates increased lower lid laxity.47,48 An abnormal
elevating the crease in patients who desire more pre-
snap back test on the other hand, defined as a slow return
tarsal show have been described.2 On the other hand,
of a pulled down lower eyelid to a normal position that
if an upper lid crease is abnormally high as in tarso-
may require a blink, indicates both increased laxity and
lavator dehiscence, or ill defined, then marking the
decreased muscle tone.40,47,48 Finally, the presence of lower
crease should rely on measurements or the height of
eyelid malposition should be evaluated, investigated, and
the tarsal plate, which can be determined by everting
documented prior to surgery.
the lid.
Unacceptable cosmetic appearance of the lower eye-
2. Does the fat need to be removed, redistributed, or
lids can be due to one or more of the following: (1) dark
enhanced with grafting? If fat grafting is needed then
shadows due to skin pigmentation and contour irregular-
a decision is made whether it’s done concomitantly or
ity resulting from the tear trough depression and overlying
at a different stage depending on the extent of intraop-
bulging orbital fat; (2) orbicularis oculi muscle laxity or
erative dissection.
hypertrophy; (3) skin excess; and (4) volume loss at the
3. Does the patient require a temporal brow lift, or just
eyelid cheek interface. These components are not present
brow volume enhancement?
in all patients and they vary in severity, therefore the sur-
gical plan should be tailored to each patient based on their
presenting anatomy and risk for developing postoperative
“Open Sky”Technique
complications. The location and extent of each abnormal-
The “open sky” technique described by McCord,23 relies on
ity should be examined in the upright sitting position and
the excision of a myocutaneous segment of skin, orbicularis
the extent and severity of anterior lamellar changes should
oculi, and orbital septum to expose the preaponeurotic and
be evaluated to determine the best approach to address the
nasal fat pads. Intraoperative skin markings are detailed in
anterior lamella.
Video 1. The lateral extent of the marked skin excision is
determined in an upright position while the patient’s tail
SURGICAL TECHNIQUES of the brow is manually elevated and depressed assess-
ing where the skin redundancy can be trimmed without
Upper Blepharoplasty creating a dog ear. The lateral point should preferably
stay medial to the tail of the brow,46 and if it were to be
Upper blepharoplasty has evolved over the years from a
extended laterally as in cases with extensive dermatocha-
debulking procedure to a more balanced, volume-preserv-
lasis, then it should be marked in a natural upper crow’s
ing approach.2-4,26,46,49,50 Regardless of the technique used,
feet line (Figure 4A). The upper limit of excision is marked
the following points have to be addressed:
on the upper lid fold at least 10 mm from the junction of
1. Does the patient have a visible and nondisplaced the brow-upper lid skin.3,23 This distance can be increased,
crease? If so, then the incision should be marked and and therefore shortening the vertical length of the excised
made in that crease instead of creating a crease that skin, according to the desirable degree of pretarsal show.
purely relies on measurements. However, making the The lines are connected with a gentle curve that tapers
incision slightly lower than the existing crease,49 and nasally to avoid excessive skin excision in that area. The
20
incisions should not extend nasal to the medial canthus.46
Skin infiltration with a local anesthetic is performed after
marking the crease and it can facilitate drawing on an oth-
erwise redundant skin. Pinching the area of marked skin
with forceps allows for making adjustments before com-
mitting to the marked pattern.51 Incisions are made pre-
cisely, beginning with the crease. The upper fold incision
is deepened through the orbicularis oculi muscle exposing
the orbital septum while maintaining meticulous hemo-
stasis. Gentle pressure applied on the globe (retropulsion)
allows preaponeurotic fat to bulge forward and the orbital
septum is incised. The preaponeurotic fat is trimmed or
redistributed along the length of the sulcus (Figure 4D).
The nasal fat pad is located next, freed from the surround-
ing connective tissue, and excised or blended with cen-
tral fat pad as necessary.4 Following management of the
orbital fat, the skin-muscle flap is excised at the level of
the crease, beveling the scissors away from the crease to
prevent disruption of the levator aponeurosis attachment
to the tarsal plate. Transpalpebral browpexy or reposition-
ing of the lacrimal gland can be performed as needed.
Closure involves approximation of the skin and muscle in
one or two layers. The addition of a supratarsal fixation as
suggested by McCord can theoretically help stabilize the
crease by reattaching the pretarsal orbicularis to the leva-
tor aponeurosis with a 6-0 absorbable suture.3,23
Other Techniques
A variety of other techniques have been previously reported
in the literature to preserve the upper eyelid volume by
conserving the orbicularis oculi and orbital fat.2,4,46,49,52
Skin markings are performed in a similar fashion and rely
more on skin pinch while the brow is stabilized in posi-
tion. After the skin is excised, the preseptal orbicularis
can be incised or a window can be made in the muscle
and septum as needed to address the preaponeurotic cen-
tral fat and nasal fat pads.4 The temporal septum is also
opened as needed to address a prolapsed orbital lobe of
the lacrimal gland.53 After the fat pads are mobilized, they
can be redraped across the sulcus or blended together to
augment the upper lid fold and sulcus volume.54 The nasal
fat pad can also be adequately mobilized and redraped
while taking care not to injure any vascular structures or
the tendon of the superior oblique muscle.4 Mobilizing the
central or preaponeurotic fat pad has also been described
to augment the lateral upper lid fold.50 The retro-orbicula-
ris oculi fat can be sculpted as needed,23 however, it is bet-
ter to preserve the brow volume and reposition it instead.
Repositioning the ROOF has been advocated through sur-
gical techniques that secure the cut edge of the preseptal
orbicularis to the arcus marginalis.21 When the orbicual-
ris oculi muscle is left untouched, plicating the muscle by
incorporating it in skin closure helps define the upper lid
crease and enhance the upper lid fold convexity.26,49
Aesthetic Surgery Journal 39(1)
Adjunct procedures for upper blepharoplasty include
lacrimal gland suspension, transpalpebral browpexy, fat
grafting, and transpalpebral corrugator resection. The
incidence of lacrimal gland prolapse has been reported
to be 15% in the general population55 and higher in the
aging population.53 In order to expose the gland, the tem-
poral orbital septum is opened and the central fat pad is
mobilized. Several techniques have been described for
repositioning of the orbital portion of the lacrimal gland
including suturing the capsule of the gland to superior
orbital rim periosteum,56 suturing Whitnall’s ligament57 or
the anterior surface of the lateral horn of the levator over
the gland to the superior orbital rim periosteum,23 or the
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use scarring induced by cautery to reposition mild gland
prolapse.53 If the lateral horn of the levator is placated to
arcus, it is critical to place the upper lid on downward
traction prior to suture placement to prevent postopera-
tive lagophthalmos. Transpalpebral internal browpexy is
mainly a brow-stabilizing procedure that fixes the lateral
brow to the deep temporal fascia lateral to the temporal
fusion line. Modifications were described of the internal
browpexy using Endotine device (Coapt Systems, Inc.,
Palo Alto, CA) over the bony portion of the superior orbital
rim, medial to the temporal fusion line for more lifting.19
Lower Blepharoplasty
There are two popular approaches to surgical rejuve-
nation of the lower eyelid: the transconjunctival and
skin-muscle flap blepharoplasties. The main distinguish-
ing feature between the two is that the transconjunctival
approach does not violate the orbicularis oculi muscle
and the orbital septum can also be left intact. Therefore,
it relies mainly on skin-only excision to address the
anterior lamella, when indicated. The skin muscle flap
technique on the other hand relies on mobilization and
tightening of the orbicularis oculi muscle through sus-
pension,58 which resembles a SMAS facelift. The term
transcutaneous can indicate a variety of modifications of
the skin-muscle technique but does not always involve
orbicularis suspension.
Skin-Muscle Flap Lower Blepharoplasty
As the name indicates, this technique provides access to
the orbital fat through an anterior approach.6 A stair-step
incision is made in the skin immediately inferior to the lash
line and is extended a few millimeters laterally beyond the
lateral canthus (Figure 6A). The lateral extension is marked
in an upright sitting position in a natural crow’s feet line
if possible (Figure 4A). One must err on marking the lat-
eral extension pointing slightly superiorly as it tends to drift
inferiorly postoperatively, which results in an inferior aes-
thetic result. After the skin incision is made starting later-
ally, dissection is deepened through the orbicularis oculi
Alghoul21

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Figure 8. (A) Preoperative photograph of a 54-year-old woman with bilateral brow ptosis, lateral hooding, lower lid anterior
lamellar changes with minimal orbital fat herniation. (B) Postoperative result 8 months after bilateral upper blepharoplasty
and lower skin-muscle flap blepharoplasty with canthopexy. (C) Postoperative result at 18 months and after additional cheek
fat grafting. In addition to that, she also underwent bilateral endoscopic temporal brow lift and transpalpebral corrugator
resection in addition to fat grafting to the medial and lateral SOOF. Notice the improvement in her upper lid aesthetic
proportions enhanced by the brow lift, and the smooth lower lid surface as a result of anterior lamellar tightening.

muscle until the lateral orbital rim periosteum is identified.
A small double prong skin hook is then used to pull on
the incision edge laterally keeping the lower lid under ten-
sion and the skin incision is placed precisely 0.5 to 1.0 mm
under the lash line. After the skin is separated from the
orbicularis oculi, the muscle incision is extended pre-
serving 4 millimeters of pretarsal orbicularis (Figure 6A).
Dissection proceeds in a preseptal plane until the inferior
orbital rim is reached. In this plane, the tear trough liga-
ment and the orbicularis retaining ligaments are identified
and are released in continuity with the lateral orbital adhe-
sion (Figure 6B). It is this complete release of the retaining
ligament and lateral adhesion that frees the muscle and
allows mobilization of the orbital portion of the orbicula-
ris6,12,59 along with its overlying subcutaneous fat compart-
ment (infraorbital fat) superiorly.33 This maneuver is what
defines the skin-muscle flap technique, as it redrapes and
lifts the orbicularis taking the soft tissue redundancy later-
ally where the majority of trimming occurs (Figure 6F).6,58
After releasing the tear trough and the orbicularis retaining
ligaments, the area of the SOOF is exposed and dissection
proceeds in a supraperiosteal plane for 5 to 10 millimeters.
If a midface lift is intended at the same time, dissection
can be extended further either in a supraperiosteal plane
spreading through the prezygomatic and premaxillary
spaces12,29 or in a subperiosteal plane. If a midface lift is not
planned, then the extent of dissection is judged by adequate
release of the depression created by the retaining ligaments
and the size of the pocket created for fat redraping. Fat
excision or redraping (see below) is performed through a
septal incision or partial excision (Figures 6D and E). After
the orbicularis is redraped, a triangular skin and muscle
excision is performed laterally and inset is performed after
lateral canthal tightening. Conservative subciliary skin
and muscle excision is performed after lateral inset of the
orbicularis flap (Figure 6G). Proper inset of the skin-muscle
flap is probably one of the most challenging steps of this
technique for several reasons; there is a substantial dog ear
that has to be chased while maintaining a relatively short
incision, sewing the orbicularis back together can create a
step off that has to be leveled, and finally imprecise inset of
the skin near the lateral canthus can result in postoperative
webbing. Given the nature of the stair-step incision, careful
trimming of the preseptal orbicularis is necessary to avoid
overlap and unintentional augmentation of the pretarsal
orbicularis.6,12,16
There are several advantages of the skin-muscle flap bleph-
aroplasty; it provides unparalleled exposure for fat redrap-
ing, it is a powerful technique for tightening of the anterior
lamella (Figures 8-10) especially in patients with orbicularis
oculi laxity, and it elevates the infraorbital superficial fat
compartment, which helps with blending of the eyelid-cheek
junction (Figure 6H). On the other hand, the skin-muscle flap
technique is considered by some an aggressive approach with
higher incidence of postblepharoplasty lower eyelid retrac-
tion.48 There is more scarring involved in the anterior and
middle lamella by violating the muscle and septum in addi-
tion to partial denervation of the muscle which weakens the
anterior support of the lower lid.48 Although EMG studies
have refuted this hypothesis by showing normal innervation
22 Aesthetic Surgery Journal 39(1)

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Figure 9. (A) Preoperative photograph of a 70-year-old woman with bilateral lower lid anterior lamellar changes, surface
irregularities, asymmetry, minimal fat herniation on the right, and volume loss at the eyelid-cheek junction. (B) Postoperative
results 18 months after bilateral lower blepharoplasty using the skin-muscle flap approach, lateral canthopexy, and fat grafting
the deep medial cheek and SOOF compartments. Notice the improved symmetry and smooth eyelid-cheek transition. The
patient declined upper blepharoplasty.

of the pretarsal orbicularis through preservation of the medial

buccal branch of the facial nerve,32 there is possibly some
loss of tone that occurs postoperatively that takes some time
to recover. This loss of tone in addition to increased postop-
erative swelling can prolong the recovery of the procedure.
Although the skin muscle-flap technique achieves excellent
results, it can be unforgiving in inexperienced hands and if
lateral canthal anchoring is not mastered.39,60,61 This is espe-
cially true in patients at high risk of postoperative retraction
like those with negative vector (Figure 11).47,48

Transconjunctival Lower Blepharoplasty

A transconjuctival incision provides access to the orbital
fat through a posterior approach and leaves the orbicu-
laris muscle and septum undisturbed, although there are
reported transconjuctival techniques that involved some
form of orbicularis tightening.8,17 An incision is made in
the conjunctiva 5 to 6 mm inferior to the tarsus to avoid the
zone of fusion between the capsulopalpebral fascia and the
orbital septum. This allows direct posterior access to the
Video 2. Watch now at https://academic.oup.com/asj/
article-lookup/doi/10.1093/asj/sjy034
orbital fat while staying in a postseptal plane. A preseptal
dissection can also be performed if the transconjunctival
incision were to be made within 5 mm of the tarsus (Video 2).
The incision in the capsulopalpebral fascia can be made
Alghoul23

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Figure 10. (A) Preoperative photograph of a 43-year-old woman with bilateral upper lid dermatochalasis and “tired look” as
a result of bilateral lower lid tear trough deformity and medial orbital fat herniation. (B) Postoperative photograph 16 months
after bilateral upper blepharoplasty and bilateral skin-muscle flap lower blepharoplasty, fat transposition, fat grafting to the
cheek, and canthopexy. Notice the postoperative increase in pretarsal show and worsening hollowing despite that this was a
skin only removal indicating the need for volume enhancement with fat grafting. The lower lids are smooth with elimination
of the tear trough deformity and the “tired look.”

horizontally along the same line with conjunctiva, or sep-
arately as a vertical split to preserve the retracting function
of the muscle. There have been no reported complications,
however, from dividing the CPF horizontally. Staying in
the postseptal plane until the inferior orbital rim is reached
leads to the posterior aspect of the arcus marginalis, so this
plane continues naturally into a subperiosteal plane unless
an incision is made at the inferior border of the septum
above the arcus marginalis to continue in a supraperiosteal
plane. A subperiosteal dissection is performed with a per-
iosteal elevator taking care not to injure the infraorbital
neurovascular bundle, which is clearly visualized.8,11,36
The tear trough and orbicularis retaining ligaments are not
directly severed as their periosteal origin is elevated, there-
fore there is more emphasis on “arcus marginalis release”
in this type of procedure than on orbicularis retaining lig-
ament release. The end effect should be similar as the tear
trough area of depression is elevated and separated from
bone. A preseptal dissection is preferred by others13 as it
provides better access to release the palpebral part of the
orbicularis oculi, tear trough ligament, orbital part of the
orbicularis oculi, and the orbicularis retaining ligament.
After the fat is redraped, lateral canthal tightening can be
performed when indicated and the conjunctival incision
is closed or left to heal by secondary intention. The skin
is addressed through a separate incision when indicated.
Different techniques were described for skin excision
including a “pinch”7 and a skin only flap.8,17 In a “pinch”
blepharoplasty, the skin is pinched with forceps creating a
vertical skin pillar that is excised and closed while avoid-
ing any everting tension on the lid margin. A skin only flap
on the other hand separates the skin from the orbicularis
oculi down to the inferior orbital rim and redrapes the skin
(Supplemental Figure 1).
Fat Transposition and Fat Grafting
First described by Loeb62 in 1981, using the orbital fat as
pedicled grafts to augment the eyelid-cheek junction has
become a popular and reliable technique. The orbital
fat can be accessed through a preseptal or a postseptal
approach and is redraped in a subperiosteal or suprape-
riosteal plane.6,8,9,11,13,14,16,17,36,63 In a preseptal approach,
the orbital septum is opened or partially excised and the
fat is mobilized by lysis of the fibrous connective tissue
that restricts it (Figure 6D). The use of a needle-tip electro-
cautery on a low current facilitates this dissection, which
is continued until the fat pedicles are completely freed and
redraped over the inferior orbital rim without creating any
tension on the lower lid (Figure 6E). The septal reset tech-
nique, described by Hamra,64 involves incising the inferior
border of the septum and advancing the septum along with
the orbital fat over the orbital rim where it is secured.16,64,65
The most common orbital fat redistribution is the use of
the nasal and central fat compartments to augment the area
of the tear trough with its accompanying central triangu-
lar depression at the eyelid cheek junction, while excising
the lateral fat compartment.3,6,8,9,11,13 Fat transposition has
been reported with and without anchoring to periosteum or
to skin.6,8,11-13,36 The use of excised orbital fat as free grafts
has been also reported with good outcomes.13,15
Fat grafting has become an important adjunct proce-
dure that is being performed more frequently with both
upper and lower blepharoplasties. This is attributed to
24 Aesthetic Surgery Journal 39(1)

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Figure 11. (A) Preoperative oblique view of a 41-year-old woman with a prominent tear-trough deformity and medial orbital
fat herniation. The patient has negative vector and scleral show at baseline. (B) Postoperative photograph 3 years after
bilateral lower blepharoplasty, skin-muscle flap approach, with release of the tear trough ligament and medial and central
orbital fat transposition, and lateral canthopexy with over correction. Notice the improvement in her tear trough and lower lid
contour with preservation of the lower lid position.

several recent topographical and anatomical studies that
advanced our understanding of periorbital aging and its
relationship to soft tissue deflation, and facial fat com-
partments of the face.22,33,34,66 The purpose of fat graft-
ing is to blend the eyelid-cheek junction and to improve
both the anterior and lateral brow and cheek projection,
enhancing periorbital aesthetics. In the upper lid, fat
grafting improves the volume of the upper eyelid sulcus,
the upper lid fold, and the brow.18,26 This has a favorable
effect on the position of the brow and the upper eye-
lid fold to pretarsal space ratio. The main target areas in
the upper lid are sulcus both medially and laterally and
the lateral brow fat compartment (retroorbicularis oculi
fat, ROOF). In lower blepharoplasty, fat grafting the deep
medial fat compartment improves the anterior cheek pro-
jection and the inverted V defromity, while fat grafting
the lateral and medial SOOF helps improve the lateral
cheek projection and blend the eyelid cheek junction,
respectively.22,33,34 The main challenge with concomi-
tant fat grafting and blepharoplasty is trying to perform
grafting in a plane that has not been violated, in order
to comply with Coleman’s fat grafting principles.67 This
becomes more challenging when the tear trough and the
orbicularis retaining ligaments are released, opening up
both the medial and lateral SOOF compartments. One
possible advantage of subperiosteal dissection is the pres-
ervation of the preperiosteal plane, where fat grafting can
be performed concomitantly. The use of both micro and
fractionated (fracto) fat grafting have been reported for
blending the eyelid junction.18,22
term canthopexy indicates lateral tightening of the lower
lid without a canthotomy or cantholysis, while canthop-
lasty is lid tightening in the presence of canthotomy and/
or cantholysis (Figure 5). Lateral canthoplasty allows for
lid shortening in cases of severe lower lid laxity, in addition
to reshaping and repositioning of the lateral canthal angle,
while canthopexy is merely a splinting procedure that
maintains the posture of the lid and relaxes with time.60
Canthopexy is more frequently applied in the setting of aes-
thetic blepharoplasty and canthoplasty is reserved to cases
where lower lid horizontal shortening is indicated. Several
canthopexy techniques have been described, each differ in
the lower lid tissue being captured with suture including
tarsus,6 inferior or lateral retinaculum,38,39 or superficial lat-
eral canthal tendon (Video 2).35 They all, however, anchor
to the periosteal lining of the lateral orbital rim.6,8,11,35,38,39
Although the term “canthopexy” has also been used to
describe anchoring the orbicularis to periosteum,8 this
maneuver is more in line with orbicularis suspension. To
date there is no consensus on the routine use of lateral
canthal tightening with lower blepharoplasty, perhaps due
to the fact that blepharoplasty techniques vary in approach,
dissection, and amount of tissue removal. This is further
confounded by publications showing low rate of lower lid
malposition with selective68,69 or no canthopexy70 even
with skin-muscle flap blepharoplasty. It should be noted
however, that a lateral canthal tightening procedure is
required in the following situations: (1) a skin-muscle flap
blepharoplasty; (2) patients with negative vector; and (3)
patients with moderate to severe lower lid laxity.

Lateral Canthal Tightening OUTCOMES AND COMPLICATIONS

The need for lateral canthal tightening after lower blepharo- To date, there are no standardized outcome measures
plasty remains a controversial topic between proponents of for either upper or lower blepharoplasty. The majority of
routine6,11,12,14,47,48,59 and selective8,36,68,69 application. The studies and case series reported in the literature mainly
Alghoul25
focus on reporting complications and need for revision.
Only a few studies utilized some form of objective evalu-
ation or aesthetic score calculation.14,68,69,71 The FACE-Q
eye module has been developed as a patient reported out-
come measure but hasn’t been widely adopted yet due to
its recent introduction.72 Postoperative complications after
blepharoplasty include hematoma, asymmetry, lagoph-
thalmos, lower lid malposition, scleral show, dry eyes,
frank lower lid ectropion, lateral canthal webbing, and
chemosis. The most devastating complication after bleph-
aroplasty is blindness that can occur as a result of globe
injury, retrobulbar hematoma, and/or fat grafting.46,73
Reported complications and reoperation in the literature
are generally low6,8,9,11-13,59,68,69 but probably do not reflect
common practice as they are often published in series
of experienced surgeons. The duration of postoperative
recovery after blepharoplasty is underreported and per-
haps underestimated.
Postoperative bruising and ecchymosis is expected in
the early postoperative period and is minimized by appli-
cation of cold compresses for 48 hours.42 Peribulbar hema-
toma usually occurs due to bleeding from the orbicularis
oculi muscle, and although it is not vision threatening, it
can result in increased inflammation, scarring, and lower
lid malposition. Retrobulbar hematoma is the most serious
complication after blepharoplasty and should be treated
emergently, as it can lead to vision loss due to compres-
sion of the neurovascular structures.46
Postblepharoplasty lower eyelid retraction (PBLER) is
one of the most feared complications after lower blepha-
roplasty. Risk factors that predispose to PBLER include
excessive skin or muscle resection, scarring of the middle
lamella, and failure to recognize and address lower eyelid
laxity.40,47,48,61 Other patient-related risk factors include the
presence of negative vector that is usually associated with
lack of adequate volume support in the cheek and reduced
orbicularis function.48 Management of PBLER is mainly
through prevention by applying proper lateral canthal tight-
ening techniques, which include canthopexy with overcor-
rection in patients with prominent eyes and negative vector,
and canthoplasty with lid shortening in patients with severe
lower eyelid laxity.6,38,39,47,61 Customizing procedure selec-
tion to the patient’s anatomy is also critical to avoid PBLER,
as in avoiding skin-muscle transcutaneous approaches in
patients with negative vector who predominantly require
treatment of orbital fat herniation and a tear trough deform-
ity in the absence of anterior lamellar laxity. Another critical
consideration is in avoiding over resection of skin, muscle,
or fat as this will result in scarring and vertical shortening of
the lid and reduction in soft tissue support.
Chemosis is a bulbar conjunctival swelling that can
occur with varying severity, mainly in the setting of lower
blepharoplasty.74 Multiple etiologies have been associated
with the development of chemosis including inflammation,
exposure, and lymphatic disruption.42,43,74 A recent ana-
tomical study of the periorbital lymphatic drainage by
Shoukath et al described the presence of a deep lymphatic
drainage system that drains the conjunctiva and passes
deep to the preseptal orbicularis piercing the orbicularis
retaining ligament laterally at its junction with lateral
orbital thickening.75 These findings are suggestive that any
procedures involving deep lateral dissection can theoret-
ically increase the incidence of chemosis. The incidence
of reported postoperative chemosis ranges between 0% to
12.1%, with one series reporting an incidence of 34.5%.43
The data from previously published case series suggest
higher incidence of chemosis with the skin muscle flap
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compared with transconjunctival approach especially with
the routine use of lateral canthal tightening.75 There is
no evidence supporting that lateral canthoplasty is asso-
ciated with higher incidence chemosis when compared
to lateral canthopexy.6 A cyclic relationship can develop
between exposure and chemosis leading to the propaga-
tion of the latter. As the formation of conunctivocalasis
and blister formation impairs eyelid closure, this leads to
further conjunctival exposure, desiccation, and inflamma-
tion.42,74 Treatment strategies include frequent lubrication
of the conjunctiva with wetting drops, topical antibiotic
ointments with steroids, and vasoconstrictive agents such
as 2.5% ophthalmic phenylephrine. These measures are
usually effective in treating mild chemosis. If chemosis
develops intraoperatively, a lateral tarsorrhaphy suture
and/or plication of the redundant conjunctiva at the for-
nix can be helpful in preventing further propagation. In
more severe cases, firm patching of the eye for 24 to 48
hours can be effective. The patient should be instructed
to keep the eye closed under the patch. In cases of severe
refractory chemosis, a snip conjunctivotomy to release the
fluid is recommended, combined with firm patching and
systemic anti-inflammatories.41,42,74
Dry eyes syndrome after blepharoplasty occurs in
patients with predisposing risk factors and is reported to
persist longer than 2 weeks in 11% of patients.41 The pre-
senting symptoms include dry eyes, irritation, and foreign
body sensation, which develop as a result of decreased tear
film production or increased evaporation.41,42 After bleph-
aroplasty, the precision of the blink mechanism is affected
due to swelling, lagophthalmos, and sometimes transient
muscle denervation. In addition, there is a decreased
production of the lipid component of the tear film by
the Meibomian glands, which leads to increased evap-
oration.41-43 Management of dry eye syndrome is mainly
through prevention by avoiding or staging the procedure
in patients with history of dry eyes, and using conserva-
tive surgical approach in high-risk patients. Postoperative
management include continued lubrication with wetting
eye drops until the symptoms resolve, treatment of inflam-
mation with topical antibiotics and steroid ointment, and
26 Aesthetic Surgery Journal 39(1)

minimizing exposure.40-43 Support of the lower lid with
taping during the healing phase and early treatment of
chemosis are critical especially if symptoms persist longer 7.
than two weeks. Surgical correction of lagophthalmos due
to skin or muscle over resection, and lower lid malposition 8.
should be undertaken when it becomes clear that those
9.
changes are irreversible. The use of punctal plugs and an
ophthalmology referral can be considered in patients with
prolonged or refractory symptoms.
10.
CONCLUSION
11.
support: a comprehensive 10-year review. Plast Reconstr
Surg. 2008;121(1):241-250.
Rosenfield LK. The pinch blepharoplasty revisited. Plast
Reconstr Surg. 2005;115(5):1405-1412; discussion 1413.
Massry GG. Comprehensive lower eyelid rejuvenation.
Facial Plast Surg. 2010;26(3):209-221.
Goldberg RA. Transconjunctival orbital fat repositioning:
transposition of orbital fat pedicles into a subperiosteal
pocket. Plast Reconstr Surg. 2000;105(2):743-748; discus-
sion 749.
Pacella SJ, Nahai FR, Nahai F. Transconjunctival bleph-
aroplasty for upper and lower eyelids. Plast Reconstr Surg.
2010;125(1):384-392.
Sullivan PK, Drolet BC. Extended lower lid blepharoplasty

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Upper and lower blepharoplasties are effective and safe
cosmetic surgical procedures that require knowledge of
periorbital anatomy and carful preoperative planning. The
choice of approach should be tailored to the patient’s needs
and preoperative risk factors. Volume preservation and
enhancement rather than excessive tissue removal define
modern blepharoplasty. Mastering certain techniques such
as canthal anchoring and fat grafting help prevent postop-
erative complications and refine outcomes.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Disclosures
The author declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The author received no financial support for the research,
authorship, and publication of this article.
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