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The Bespoke Upper Eyelid Blepharoplasty and Brow Rejuvenation

Maeve ODoherty, FRCS1 Naresh Joshi, FRCOphth1
Address for correspondence Maeve O Doherty, FRCS, Department of Oculoplastics, Chelsea Westminster Hospital, 369 Fulham Road, London SW10 9NH, United Kingdom (e-mail: maeveodoherty@gmail.com).
1 Department of Oculoplastics, Chelsea Westminster Hospital,

London, United Kingdom Facial Plast Surg 2013;29:264 272.

Abstract
Keywords

A blepharoplasty of the upper eyelids is one of the most commonly performed procedures in aesthetic plastic surgery. Aging changes in the upper third of the face can falsely project an appearance of tiredness, sadness, anger, or lack of interest. It is important to tailor upper eyelid blepharoplasty and brow rejuvenation to the individual. The goals for upper lid blepharoplasty include restoration of a naturally sharp and crisp tarsal fold and a pretarsal show. Evaluation of the upper eyelid must include an evaluation of the eyebrow. Brow ptosis should be corrected to achieve repositioning of heavy eyebrow skin, which may be compensated by frontalis contraction to keep the eyebrows above the orbital rim. Aging causes the eyebrow fat to descend over the upper lid, giving it a full appearance. Once the visual obstruction has been removed by eyelid skin resection, the brows may look even heavier because elevation is no longer needed for the visual eld. This results in a more aged appearance. 1,2 It is this individualized or bespoke approach to upper eyelid blepharoplasty and brow rejuvenation that forces us to structure this article based on patient presentation and how to address this in our surgical practice.

The upper eyelid can be divided into tarsal and orbital portions at the level of the supratarsal fold. In Caucasians, this skin crease is located 7 to 10 mm from the palpebral margin and results from a fusion of the levator aponeurosis, orbital septum, and fascia of the orbicularis oculi into the dermis. The deeper bers of this condensation inserts onto the anterior surface of tarsus. This area degenerates with age, which may lead to a high fold (Fig. 2A), with or without upper lid ptosis and/or skin laxity of the lid (Fig. 2B). Loss of crease attachments may cause the skin to rest toward or beyond the upper eyelid/lash margin, with a tendency to interfere with upper outer visual elds.1

Clinical Evaluation
The surgical approach must take into consideration the repositioning of underlying soft tissue and the redraping of skin. Evaluation of the upper eyelid must include an evaluation of the eyebrow. Brow ptosis should be corrected to achieve repositioning of heavy eyebrow skin, which may be compensated by frontalis contraction to keep the eyebrows above the orbital rim. Aging causes the eyebrow fat to descend over the upper lid, giving it a full appearance (Fig. 2B). Once the visual obstruction has been removed by eyelid skin resection, the brows may look even heavier because elevation is no longer needed for the visual eld. This results in a more aged appearance.2,3 The brows will be discussed in the latter section of this article.

Some Important Anatomical Concepts of the Eyelids

The pretarsal eyelid show is often only 2 to 3 mm in the aesthetically attractive eye (Fig. 1).

Issue Theme Periocular Aesthetic Rejuvenation; Guest Editor, Naresh Joshi, FRCOphth

Copyright 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0033-1349360. ISSN 0736-6825.

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blepharoplasty brow eyelid

Blepharoplasty of the upper eyelids is one of the most commonly performed procedures in aesthetic plastic surgery. In this article, we describe our approach to the patient with aging of the periorbita. At all times, the approach is tailored to the individuals needs, trying to achieve a natural result that will not in any way affect the function of the eyelid. Our current approach and techniques for upper eyelid blepharoplasty and brow lifting are described.

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Fig. 2 (A) The aged eyelid showing high skin crease and increased lid to brow distance. ( B ) The aged upper one-third showing brow ptosis. Fig. 1 The perfect eyelid and brow showing pretarsal lid show, lid to brow distance.

Preoperative Markings
Preoperative markings are critical in assessment of the patient and are made with the patient sitting upright and in neutral gaze. The brow should be elevated to the proper position before any marks are made. The supratarsal fold is located at 8 to 10 mm above the ciliary margin in women and at 7 to 8 mm in men. A mark should be made on this fold (Fig. 3A). The upper marking must be at least 10 mm from the lower edge of the brow and not include any thick brow skin. The use of a pinch technique with a nontoothed forceps for redraping the skin is helpful (Fig. 3B). The index of safety is much higher laterally (one can remove more skin) and becomes more critical as the incision proceeds medially. The incision may need to be extended laterally with a larger excision, but extension lateral to the orbital rim should be avoided if possible to prevent a prominent scar (Fig. 4). Similarly, the medial markings should not be extended medial to the medial canthus for larger resections because extensions onto the nasal side wall result in webbing. If excessive skin is present medially, an additional triangle of skin maybe resected. It is important to ensure that the preoperative markings, especially medially, disappear when the eye is open in the primary position. This ensures that any unsightly scars will be avoided. The amount of fat to

The Standard Upper Eyelid Blepharoplasty Surgical Technique in the Older Patient
Two to three milliliters of a premade mixture of 4 mL of Lignospan (Novocol Pharmaceutical of Canada; 2% lignocaine with 1:80,000 adrenaline), 4 mL of bupivacaine, and 2 mL of dexamethasone (8 mg) is injected subcutaneously using a 30gauge needle by rst pinching the skin and then rolling the orbicularis off the skin to ensure that the injection is just subcutaneous. The speed of injection is crucial in avoiding patient discomfort. Proxymetacaine topical anesthetic drops are also instilled, and a corneal shield (made of soft rubber) is used in all eyelid procedures to avoid inadvertent damage to the cornea. Incisions are made using a Colorado microdissection needle. The skin, without muscle, is dissected off the underlying tissue maintaining rigorous hemostasis (Fig. 5A, B). Once the skin has been removed, a strip of orbicularis is then removed using the Colorado needle. The upper onethird to upper one-half of muscle is removed (Fig. 6A, B). If lateral brow elevation is required, more orbicularis muscle is removed at the lateral corner. If preseptal muscle is left under the skin excision, especially when large resections are

Fig. 3 (A, B ) Pinch test technique with a nontoothed forceps. Starting with the natural skin crease.

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The skin of the upper eyelid is the thin and mobile and integral to the functioning of the eye, so to avoid lagophthalmos, the excision must be conservative, especially in the nasal half.

be resected should be determined preoperatively, with the patient in upgaze, downgaze, and medial and lateral ranges of motion, with photographic documentation. In the rare instances that fat removal is required, with the patient prone, cross-hatching is used to indicate the amount and region of fat to be removed as this can become dif cult to assess after local in ltration and in the supine position.

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deemed necessary, a small incision is made through the septum, into the medial compartment of the eyelid. The fat is teased out and resected using a clamp, cautery, and curved scissors. This fat usually contains white fat. It is rarely necessary, in my experience, to remove fat from the central and lateral fat pads, though lacrimal gland repositioning is often required and will be described later. If a lateral canthopexy is required as part of a lower lid blepharoplasty procedure, it is done at this time. An incision is made laterally to expose the lateral orbital rim. A stab incision is created at the lateral canthus and a 50 Prolene (Ethicon, Somerville, NJ) suture is placed through the stab at the lateral canthus and secured to periosteum on the inside of the lateral orbital rim at the level of the upper limbus (Fig. 7A, B). It is important that this suture disappears within the stab incision. It is also important to place this suture within the orbital rim to avoid tenting the lower lid anteriorly away from the eye. Once hemostasis is obtained, the incision is closed with 60 Prolene suture. In cases where reformation of skin crease is necessary, the sutures should include the subcutaneous aponeurotic/septal tissue. Figs. 8 and 9 show pre- and postoperative appearances of a blepharoplasty in an older patient.

Fig. 4 The preoperative markings for blepharoplasty.

Fig. 5 (A, B ) Skin-only excision with Colorado needle.

undertaken, there will be muscle over muscle when the nal closure is performed. This redundancy can cause a heavier, fuller lid postoperatively and interfere with the creation of a clean, distinct supratarsal fold. If fat removal has been

Upper Lid Blepharoplasty in the Young Patient

The surgical approach is exactly as described for the older patient; however, we do not remove the orbicularis muscle in these patients. See pre- and postoperative photos in Fig. 10.

Fig. 6 (A, B ) Upper one-third orbicularis excision.

Fig. 7 (A, B ) Lateral canthopexy suture done through blepharoplasty incision in a combined upper and lower lid blepharoplasty.

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Fig. 8 (A, B ) Skin septum skin sutures and orbicularis resection allows an eyelid show in the presence of a large amount of skin excess.

Fig. 9 (A, B ) Blepharoplasty with skin orbicularis and deep skin crease reformation suture to hold up folded skin in low brow position.

Lacrimal Gland Prolapse

The lacrimal gland can be found in the lacrimal fossa. In some patients prolapse of the gland leads to a lateral fullness that can be misinterpreted as prolapsed fat (Fig. 11A). The technique for lacrimal gland repositioning is simple; the most dif cult part is the visualization, identi cation, and separation of the gland itself. The procedure is often incorporated with blepharoplasty, the approach described previously. The skin is opened as for

blepharoplasty and a strip of skin is removed. The lateral orbital fat pad is exposed by opening the septum. The prolapsed lacrimal gland can be visualized on the undersurface of the lateral fat pad (Fig. 12A). The orbital rim should also be identi ed at this stage. Using a 60 double-ended Vicryl (Ethicon) suture, the undersurface of the lacrimal gland capsule is grasped and sutured in two bites to the inner surface of the orbital rim. When the suture is pulled, the gland retracts backward behind the suture (Fig. 12B). Two to three sutures can be placed in this manner.

Fig. 10 (A, B ) Pre- and postoperative blepharoplasty in a young patient without muscle excision.

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Fig. 11 (A) Prolapsed lacrimal gland preoperatively. (B ) Post lacrimal gland repositioning.

Fig. 12 (A, B ) Lacrimal gland repositioning suture.

Minimally Invasive One-Suture Blepharoptosis Repair

Before placing protective corneal shields, the position of the midpupil is marked on the upper lid margin. A maximum of 1 mL of our standard premade mixture is injected subcutaneously. We normally perform all ptosis procedures under sedation so we rarely require more than 1 mL. In a combined blepharoptosis procedure, the ptosis is performed rst. A lid crease incision is made using a Colorado microdissection needle. The anterior surface of the tarsus is exposed and cleaned. The orbital septum is opened horizontally 1 cm across the central upper eyelid. This exposes the preaponeurotic fat, which is then retracted gently to expose a small portion of the aponeurosis. The aponeurosis alone or with Mller muscle is then dissected off the tarsus for a short

distance of 2 to 4 mm so that access to the aponeurosis from its undersurface is possible. A double-armed 60 Prolene suture is used to take a 3- to 4-mm horizontal bite across the upper one-third of the tarsus in line with the preoperative mark on the upper eyelid (ensuring that this is not full thickness through the tarsus by checking the conjunctival surface). Each end of the suture is then brought through the aponeurosis from the posterior surface to the anterior surface at the desired height and a small bow is tied to assess height and contour (Fig. 13A, B). Once the contour and height are satisfactory, the bow is cut, the unattached end is pulled through, and the suture is secured in the standard manner. Further anesthesia is administered and the skin is then resected as per a normal blepharoplasty and the orbicularis muscle strip is also removed. The wound is closed with 60 Prolene sutures including four to ve skin crease reformation

Fig. 13 (A, B ) One-suture ptosis repair.

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Fig. 14 (A, B ) A fresh plum showing good skin quality and volume comparable to the youthful brow. (C, D ) A prune comparable to the aging brow; both have experienced volume change leading to a shriveled-up appearance.

sutures. These are created by including a small bite of the aponeurotic tissue in the skin suture.

Postoperative Care
Preservative free ocular lubricants are prescribed four times per day for 2 weeks. Chloramphenicol ointment is used topically on the eyelid incision and in the eye for 2 weeks at night. The sutures are removed at 10 days. Contraindications to surgery include patients with psychological issues, dry eyes, uncontrolled in ammatory skin conditions such as eczema and psoriasis, multiple redo surgeries, and in situations where removing skin would lead to lagophthalmos.

the brow to the forehead periosteum through a posthairline approach or through an upper blepharoplasty incision; tissue excision techniques directly above the brow and tissue excision higher in the forehead creases are also possible. The common technique of endoscopic browlift will not be discussed in this article. Alternatives to the standard practice will be highlighted. Any surgical technique must be tailored to the individual patients needs and acceptability.

Nonsurgical Browlift
Botulinum toxin is used whenever nonsurgical browlift is required. The ideal application for botulinum toxin A use in browlift would be a young patient with isolated ptosis of the lateral brow who desires nonsurgical treatment. The primary advantage of this technique is that it is an of ce-based

Our Approach to the Brow

Elevation of the ptotic brow and forehead complex has long been recognized as integral to upper facial rejuvenation. The aging changes of the brow can be classi ed into two main characteristics. 1. De ationarycharacterized by volume loss (Fig. 14 A to D) 2. Positionaleither high or low depending on the level of overaction of the frontalis muscle (Fig. 2A, B) The ideal brow position has been described repeatedly.46 There are also a variety of eyebrow shapes depending on fashion. Although the brow position becomes lower with age from the effects of gravity and the depressor muscles of the brow, the youthful brow can also be quite low (Fig. 1). Often laxity of the tissues and volume de ciency confer to the aging appearance (Fig. 2A). Many techniques have been described for elevating the brow and forehead.713 These include techniques to suspend

Fig. 15 Excessive nonsurgical browlift with botulinum toxin.

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Fig. 16 (A) Crenated brow lift, intraoperative. (B ) Crenated brow lift results, 8 weeks postoperatively.

Crenated Direct Browlift Technique

In older patients where brow descent is evident and all planes of tissue are lax (anterior lamellae slippage from the periosteum), we favor the direct browlift. However, the technique is modi ed, the crenated browlift, to disguise the scar. Mark the full length of the superior border of the brow adjacent to the uppermost brow hairs. Pull the brow up to its intended postoperative height and hold the marker pen at this point. With the pen held steady above the forehead skin, allow the

Pretrichial Browlift
Pretrichial denotes an incision in front of the hairline. In younger patients with a lateral brow ptosis, a pretrichial small incision browlift (browpexy) is offered. This is effective especially in those with a low hairline laterally. The amount of skin to be resected is determined with the patient sitting up; usually 1 cm of the line of pull required is drawn on the forehead. The area is in ltrated with anesthetic. Skin and subdermal tissue are incised and resected (Fig. 18A, B). Super cial subdermal plane dissection is carried downward with care. The facial nerve lies at a slightly deeper plane. A deep 40 Prolene suture is used to elevate the undermined forehead section to the superior deep temporalis fascia (Fig. 19A, B). The skin is sutured using 50 Prolene interrupted sutures. This technique elevates and reorients the ptotic lateral brow (Fig. 20A, B).

Postoperative Care
Sutures are removed at 10 days postoperatively. Chloramphenicol ointment is applied topically twice per day to the incisions. Massage to the area is avoided for the rst 2 weeks.

Fig. 17 Well-healed direct crenated browlift scar at 1 year.

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outpatient procedure with minimal patient morbidity. The procedure has limitations including temporary ef cacy with the need for repetitive treatments, minimally uncomfortable injections, and sometimes unpredictable results. Maas and Kim noted that more ef cacious results were found in younger patients.14 As a consequence of injection to depressor muscles in the glabellar region, the medial brow becomes elevated due to unopposed action of the frontalis muscle. However, excessive injection to the depressor muscles can result in overelevation of the brow, resulting in an unaesthetic, surprised look (Fig. 15).15 The paralysis of the lateral depressor orbicularis elevates the lateral eyebrow. A titrated paralysis of the two zones can determine the shape of brow elevation.

brow to drop back to its ptotic position and mark the forehead skin at the level of the pen. Repeat this maneuver at several points along the brow to outline the amount of skin, subcutaneous tissue, and muscle to be resected. Join the line of these marks to form an ellipse as usual, then form zigzag pattern, dipping just into the brow hairs to form a crenated effect (Fig. 16A). The surgical procedure is similar to that described for any direct browlift. Close the wound in two layers. Use a 50 absorbable suture at the apex of one edge to the valley of the opposing edge to close the deep layers. The suture should pass close the epidermis and the knot should be placed deeply. Close the skin with a 50 mono lament suture. These are placed at right angles to the linear edges. This zigzag hides the scar. The postoperative scar is almost imperceptible after a few months (Fig. 16B, 17).

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Fig. 18 (A) Crescent-shaped post hairline incision site. The arrow shows the direction of pull. ( B ) Sutured pretrichial browlift.

Fig. 19 (A, B ) Fixation to deep temporalis fascia.

Fig. 20 (A, B ) Pretrichial lift reorients crow s-feet upward.

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5 Miller PJ, Wang TD, Cook TA. Rejuvenation of the aging forehead

Conclusion
Blepharoplasty is a highly successful aesthetic surgical procedure that requires careful preoperative planning and examination of the patients concerns and desires. Standard resections of fat and muscle have been replaced with conservative and careful resections of only redundant soft tissue. Ptotic soft tissues are relocated rather than resected. The eyelid must always be considered in conjunction with the eyebrow, and correction of periorbital aging may require brow repositioning as well. Careful perioperative technique, meticulous hemostasis, and attentive postoperative management of blood pressure will prevent most complications.

and brow. Facial Plast Surg 1996;12:147155

6 Daniel RK, Tirkanits B. Endoscopic forehead lift. Aesthetics and

analysis. Clin Plast Surg 1995;22:605618

7 Paul MD. The evolution of the brow lift in aesthetic plastic surgery.

Plast Reconstr Surg 2001;108:14091424

8 Hudson DA. A paradigm shift for plastic surgeons: no longer

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