Blepharoplasty

Dr. Ateesh Borole Deptt of Plastic Surgery

Definition
Cosmetic surgical procedure aimed at improving the appearance of eyes Goals- to improve the appearance of eyes while maintaining the natural shape of eyes

Youthful eye appearence

Slight upward tilt of intercanthal axis (from medial to lateral) In a relaxed forward gaze Vertical height of aperture should expose at least three quarters of the cornea with the upper lid extending down 2 mm below the upper limbus (the upper margin of cornea) The lower lid ideally covers 0.5 mm of the lower limbus Ratio of distance from lower edge of eyebrow (at the centre of the globe) to open lid margin : visualized pretarsal skin should 3 to 1

Anatomy- Upper Eyelid

Anterior lamellae -Skin -Orbicularis oculi muscle Posterior lamellae -conjunctiva -tarsus -levator aponeurosis -Muller`s muscle

Lower lid anatomy

Capsulopalpebral fascia & Inf. Tarsal muscle replace LPS and Muller muscle

Eyelid fat
Behind orbital septum and levator aponeurosis sling Extension of orbital fat Upper eyelid fat- 2 pockets Long thin middle - central Globular nasal Lower eyelid- 3 pockets - Nasal, middle and lateral

Blood Supply
Rich anastomosis between internal and External Carotid Arteries Medial and lateral palpebral arteries- marginal arcade along eyelid margin in each eyelid Upper eyelid in addition- peripheral arcade in between levator aponeurosis and Muller`s muscle

Characteristic aging changes

Forehead wrinkles Temporal brow droop Upper lid skin excess Lower eyelid double convexity Deepening of nasolabial folds Tear trough deformity

Indications of blepharoplasty
Dermatochalasis : -Excess fold of skin of upper lid -Skin hangs over the ciliary margin -Skin fold does not contain fat ,orbicularis may or may not be included -Usually occurs from middle age onwardsaging process

Indications of blepharoplasty
Blepharochalasis Characterised by intermittent edema of upper lid Leads to relaxation and atrophy of eyelid tissues May be unilateral

Indications of blepharoplasty
 Hypertrophy of the orbicularis oculi muscles : -Ridge of bulging muscle running horizontally along the lower lid below the ciliary margin

Contraindications to Surgery
Main contraindication inability to meet pts goals Dry eyes & blinking abnormalities relative contraindications

Aim of blepharoplasty
To correct a functional problem-Diminution of visual field, ptosis or involutional changes of the lower lids (senile ectropion). To improve patients appearance

Goals of surgery
-Symmetry -Aperture length & height -Limited scleral exposure -Supratarsal fold -Eyebrows -Scar

Periocular physical examination

Eyebrow position & contour Supraorbital ridge Superior sulcus & skin fold Upper eyelid position Prolapsing fat in both lids Redundant skin & muscle in lower lid Inferior orbital rim

Examination And Planning

Brow elevation Four finger test Modified snap test Eyelid distraction test - <6mm

Brow elevation test

Modified Snap test

Examination And Planning

Medical and ophthalmologic history Ocular examination
Visual acuity Extraocular muscles Globe Retina Tear film- Schirmer`s test

Photographs

Simple skin excision blepharoplasty: Indications

-No compensated brow ptosis -So much compensated brow ptosis or pseudoptosis that the cascading of the lid skin over the lid margin causes visual obstruction in spite of maximal brow elevation -Brows unattractively elevated with or without prominent horizontal creasing of brow

Upper eyelid surgery

Traditional blepharoplasty: technique
Extra skin marked Skin and muscle excised Fat excised through opening in septum

Effects on eyebrow
-The visual incentive to elevate the brow either disappears or reduces -Frontalis muscle relaxation -Brow ptosis occurs (Medial brow drops more than lateral)

Anchor blepharoplasty
Objectives: -Crisp, secure, and aesthetically pleasing eye folds -Minimal, if any, skin excision of eyelid skin -Limited lateral excision of upper eyelid scar -Easy access for adjustment of the levator aponeurosis and or fat reduction

Markings
Determination of amount of visualized pretarsal skin desirable (2-4 mm) Vertical height of tarsus measured centrally (9-10 mm) Vertical height of the tarsus + 2mm (for stretched skin and required inward curvature) - lower border of the skin excision Medial 1/3 incision drifts to the lid margin ending 3 to 4mm above it Laterally incision not beyond orbital rim minimizing any visualization

Markings paper clip invagination technique

Paper clip estimation of skin excision
Wire paper clip used to invaginate skin to level of superior margin of tarsus X = amount of the pretarsal skin required to be visualized Y = amount that overhanging skin impinges on desired amount of pretarsal skin Amount of skin to be removed =2Y+1 mm

Invagination blepharoplasty
Skin excision done separate from orbicularis removal About 1 to 2 mm slice of orbicularis removed in proportion to skin removed Tenting up of muscle avoided accidental sectioning of underlying orbital septum and aponeurosis
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Invagination blepharoplasty
Differentiate between aponeurosis and orbital septum
Sling descends lower laterally in eyelid and migrates cephalad nasally Parallels the eye in the open not the closed posture Pressing on globe forces fat to bulge anteriorly making septal recognition and opening without injury to aponeurosis easier Fat removed and hemostasis achieved.

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Invagination blepharoplasty
Pretarsal extension of aponeurosis incised across lid with scissors just above level of lash origin Filmy pretarsal connective tissue excised better fixation Residual fat, and orbicularis muscle on pretarsal skin flap excised better fixation
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Invagination blepharoplasty
Dermis of pretarsal skin flap attached to superior aspect of tarsus & to free edge of aponeurosis The skin is closed

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Invagination blepharoplasty
Advantages:
crisp, precise & well defined eyelid crease that persists indefinitely

Disadvantages:
-time consuming -greater surgical skill & expertise -encourages greater frontalis relaxation

Complications
Asymmetry Extrusion of anchoring vicryl suture Prolonged edema and hemorrhage Retrobulbar hemorrhage blindness Lagopthalmos Corneal exposure

Traditional lower lid blepharoplasty

Modified lower lid blepharoplasty

Lower eyelid surgery

Problems in traditional blepharoplasty:
Failure to diagnose & restore reduced lower eyelid tone Require concomitant lid support Design is commonly incorrect Not addressing the deep grooves (nasojugal groove & tear tough deformity) Excess removal of orbital fat resulting in hollowedout eyes

Traditional lower lid blepharoplasty with modification :

Minimal skin excision Lateral canthopexy Forehead lifting-Corono-canthopexy. Peel or Laser resurfacing with transconjunctival or transcutaneous fat reduction Suborbital malar implant (tear trough deformity)

Lateral canthopexy
Surgical lifting or tightening of lateral canthus Periosteum, bone or temporal fascia

Lateral canthopexy & canthoplasty

Canthopexy into periosteum

Canthopexy into bone

Canthopexy into bone

Double layer in bone canthopexy

Transconjunctival blepharoplasty
Preferred in pts without excess skin and with good canthal position Minimizes post-op lower lid retraction For mild wrinkles can be combined with light chemical peel With lid skin excision.

Transconjunctival blepharoplasty

Fat repositioning in lower lid blepharoplasty

Useful in older pts with hollows over the orbital rim Dissection done in the subperiosteal plane inferior to orbital rim Dissected fat with pedicle rotated over orbital rim into pocket

Complications
Lid retraction Asymmetry Retrobulbar hemmorhage

Post operative care

Cold compresses for 3 hrs postoperatively Head end elevation to 45 degrees Check for vision disturbances for the 1st 24hrs Suture removal after 6 days

Tear trough deformity

Bony groove evident on cheek contour becomes more prominent as midface tissues age Ability to place side of finger into bony furrow under the nasojugal groove suggests a potential benefit from a tear trough implant

Tear trough deformity

Treatment Fat injection Filler injection Implant insertion

Forehead muscles causing creases

Frontalis - horizontal creases in the forehead Procerus Horizontal wrinkles at the root of the nose Corrugator muscle Vertical glabellar furrows during contraction

Temporal brow droop

Browplasty choice of surgery

Elevate the entire brow Direct browplasty Midforehead browplasty Pretrichial browplasty Coronal browplasty Endoscopic

Lift temporal brow - Direct temporal - Transblepharoplasty Do blepharoplasty alone

Direct brow lift

Advantages Easy to do Correction of asymmetries Disadvantages Visible scarring Hypoaesthesia of forehead

Temporal brow lift

Lifts only temporal brow Useful in cases with isolated temporal droop

Midforehead browplasty

Transblepharoplasty browpexy
Mild brow ptosis Unilateral brow ptosis Disadvantages Dimpling of skin

Pretrichial, coronal browlifts

Access to entire brow Scar camouflage Direct excision of redundant skin Disadvantages Risk for alopecia Alteration of hairline Numbness of scalp

Endoscopic browlifts
Preservation of scalp ennervation Preferential lateral brow elevation Disadvantages Steep learning curve

Summary
Simple dermatochalasis upper lid blepharoplasty Dermatochalasis with indistinct fold invagination blepharoplasty Dermatochalasis with brow ptosis blepharoplasty + brow lift Lower lid laxity lower lid blepharoplasty + canthopexy Only prolapsing fat pads with little excess skin transconjunctival blepharoplasty

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