Plastic surgery

PART V

AESTHETIC SURGERY

CHAPTER 46  BLEPHAROPLASTY

MARK A. CODNER AND RENEE M. BURKE

INTRODUCTION

The eyes are the focal point of the face and require detailed analysis before attempts at rejuvenation. The goal of blepharoplasty is to restore a more youthful appearance to the upper and lower eyelids while preserving their natural shape and appearance. Aging results in changes in the skin, muscle, fat, bone, and ligamentous attachments. One surgical technique is not suitable for all patients. For example, volume changes of the soft tissue can be addressed with soft tissue fillers or soft tissue transfer. Bone resorption can be addressed with bone fillers or implants to build up the underlying skeletal support. Distinct differences in surgical technique are applied to patients of differing gender and ethnicity. There are fundamental differences between blepharoplasty methods for men and women and for patients who are of Asian, African, or Occidental origin. Furthermore, patients who have signs of periorbital aging such as the tear trough deformity or malar bags require a unique surgical approach; traditional blepharoplasty techniques alone may exacerbate these findings.

Despite being one of the most commonly performed surgical procedures, blepharoplasty is a more complex and challenging procedure than has been traditionally appreciated. Complications are not only common but are noticeable, extremely bothersome to patients, and can be functionally devastating. One must be familiar with the nonsurgical as well as the surgical management of complications, including treatment of corneal irritation, ectropion, lid malposition, chemosis, and hemorrhage.

While blepharoplasty is aimed at the eyelids, the entire periorbital region requires evaluation and treatment. In upper blepharoplasty, goals include preservation, stabilization, and/or elevation of the brow and maintaining natural upper orbital fullness. Brow ptosis and eyelid ptosis are ideally corrected at the time of blepharoplasty.

During lower blepharoplasty, it is ideal to create a smoother transition between the junction of the lower lid and the cheek. Malar bags and descent of the malar fat pad may require treatment. Analysis of globe position relative to the inferior orbital rim and Hertel exophthalmometry to define the relationship of the globe to the lateral orbital skeleton are performed. To maintain the natural shape of the eyelids, treatment of tarsoligamentous laxity may be required with lateral canthal support via lateral canthopexy or canthoplasty.

SURFACE ORBITAL ANATOMY AND AGE-RELATED CHANGES

The distance from the medial to lateral palpebral fissure is 28 to 30 mm transversely and 8 to 10 mm vertically. While there is great individual variability, the lateral commissure is ideally positioned approximately 2 mm superior to the medial canthal angle, defining an upward lateral canthal tilt (Figure 46.1). The position of the lateral canthus, however, varies with age, family traits, race, and sex. In primary gaze, the upper eyelid margin forms a smooth arch with the highest point positioned superior to the pupil. With age, there is a gradual lateral shift of this apex as the tarsal plate migrates laterally due to weakening of the medial levator horn.

The upper eyelid crease is formed by the insertion of the levator aponeurosis into the dermis after it has penetrated the orbicularis oculi muscle. The lid fold is formed by excess skin and muscle that overhangs the crease. In the Occidental eyelid, the crease is approximately 7 mm above the lash margin at the midpupillary line in males and 8 to 10 mm in females. In the Asian upper eyelid, if a crease is present at all, it is approximately 4 to 6 mm above the lash margin. An absent crease results from the lack of levator insertion into the skin, causing preseptal fat to descend into the pretarsal space.

FIGURE 46.1. Surface anatomy. A. Surface anatomy of the upper eyelid, eyelid folds, and canthal tilt. B. Close-up of the upper lid showing the differences between the fold, crease, and pretarsal space.

With aging, numerous changes are observed in the orbital region and at the multiple levels. Loss of skin elasticity presents as periorbital rhytids and the eyelids become puffy due to orbital fat bulging through the weakened orbital septum. Furthermore, periorbital hollowing develops from atrophy of periorbital soft tissue. The combination of soft tissue loss and descent around the fixed points of the retaining ligaments creates an aged surface contour defined by a series of convexities and concavities. The eyelid bags accentuate the appearance of the deepening lid–cheek junction and vice versa. Brow ptosis is recognized by lateral upper eyelid hooding as well as a narrowed brow–eyelash distance. Brow ptosis accentuates the amount of loose skin in the upper lid. Vertical creases between the brows are commonly seen and are the result of corrugator and procerus activity.

EYELID ANATOMY

The eyelid is traditionally described as a bilamellar structure comprising an anterior lamella and a posterior lamella. The anterior lamella consists of skin and orbicularis oculi muscle; the posterior lamella includes the tarsoligamentous sling, which is comprised of the tarsal plate, medial and lateral canthal tendons, capsulopalpebral fascia, lid retractors, and conjunctiva. The septum originates at the arcus marginalis along the orbital rim separating the two lamellae and is therefore often referred to as the “middle lamella” (Figure 46.2).

The Anterior Lamella

The orbicularis oculi muscle lies posterior to the thin eyelid skin, originating from the medial canthus and the bone of medial orbit and inserting at the lateral canthus and lateral orbital rim. The orbicularis oculi muscle is divided into three components: the pretarsal, preseptal, and orbital divisions (Figure 46.3). The pretarsal portion of the orbicularis is superficial to the tarsal plate and functions to close the lid during involuntary blinking. The preseptal orbicularis assists in voluntary blinking and functions as part of the lacrimal pump mechanism for tear drainage. The pretarsal and preseptal orbicularis each have a deep and superficial component. The orbital orbicularis is the largest division of the orbicularis muscle, extruding well beyond the lids, and functions to protect the globe with forced eyelid closure.

FIGURE 46.2. Cross-sectional anatomy. A. Cross-sectional anatomy of the upper lid demonstrating the differences in crease position in Asian and Occidental patients. B. Cross-sectional anatomy of the lower lid demonstrating the anterior and posterior lamella.

FIGURE 46.3. Orbicularis oculi muscle. A. Divisions of the orbicularis oculi muscle and surrounding periorbital mimetic muscles. B. Innervation of the orbicularis oculi with contributions from the frontal, zygomatic, and buccal branches.

Orbicularis Muscle Innervation. The motor innervation to the orbicularis oculi muscle is multiple in nature with contributions from several branches of the facial nerve, including the frontal, zygomatic, and buccal branches (Figure 46.3). Cadaver dissection reveals a diffuse network of nerves innervating the orbicularis oculi. It is important to recognize that the buccal branches supply a plexus of nerve branches to the medial orbicularis in both the upper and lower eyelids that contribute to voluntary and involuntary lid closure (Figure 46.4). Therefore, proper lateral canthal anchoring and preservation of buccal innervation are important principles in avoiding lower lid malposition and problems with eyelid closure following lower lid blepharoplasty.

FIGURE 46.4. Muscle contributions to the medial canthus. The complex origin of the deep and superficial heads of the canthal portion of the orbicularis muscle.

The Posterior Lamella and the Tarsoligamentous Structures

While the skin and muscle make up the anterior lamella, the tarsoligamentous sling creates the support structure for the posterior lamella (Figure 46.5). The tarsal plates constitute the connective tissue framework of the upper and lower eyelids. The upper lid tarsal plate is approximately 24 mm horizontally and 8 to 10 mm vertically at its widest dimension. Attachments of the upper lid tarsal plate include the pretarsal orbicularis and levator aponeurosis on the anterior surface, Muller’s muscle on the superior border, and conjunctiva on the posterior surface. The lower lid tarsal plate is approximately 24 mm in horizontal dimension and 4 mm in vertical dimension. Attachments to the lower lid tarsal plate include the pretarsal orbicularis, capsulopalpebral fascia, and conjunctiva. The tarsal plates of the upper and lower eyelid are attached to the orbit by the medial and lateral canthal ligaments and retinacular support structures.

The medial canthus is a complex support structure that forms the medial fixation point for the medial commissure. It consists of an anterior reflection, which inserts anterior to the lacrimal sac on the nasolacrimal crest, and a posterior reflection, which inserts deep to the lacrimal sac on the posterior lacrimal crest. The medial retinaculum is formed by several structures, including the deep head of the pretarsal orbicularis, orbital septum, and medial extension of Lockwood’s ligament, medial horn of the levator aponeurosis, medial rectus cheek ligaments, and Whitnall’s ligament. The medial retinaculum represents a fixed point maintaining medial canthal position, allowing the orbicularis muscles to act on lid position rather than medial canthal position (Figure 46.6).

The lateral canthus also functions as an integral fixation point for the lower lid. The lateral canthal ligament is formed by the fibrous crura, which connects the tarsal plates to Whitnall’s bony lateral orbital tubercle within the lateral orbital rim. In addition, the lateral retinaculum is formed by several ligamentous structures from the lateral horn of the levator aponeurosis, lateral rectus check ligaments, Whitnall’s suspensory ligament, and Lockwood’s inferior suspensory ligament. Although the lateral retinaculum represents the lateral point of fixation, there is some mobility of the lateral commissure to increase the visual field upon lateral gaze. This mobility predisposes the lateral canthus to laxity and medial migration with age or trauma compared with the immobile medial canthus.

FIGURE 46.5. Ligamentous attachments. A. Anatomy of the deep supporting structures of the posterior lamella, including the tarsoligamentous sling and the medial and lateral horns of the levator muscle. B. Axial view of the orbit demonstrating the anterior and posterior vectors of the medial and lateral canthus, respectively.

In addition to the tarsal plates and canthal ligaments, support structures in the upper and lower eyelid stabilize the tarsoligamentous sling. The superior transverse ligament of Whitnall is partially formed by the fascia of levator palpebrae superioris. Whitnall’s ligament inserts medially at the trochlea of the superior oblique and laterally at the lacrimal gland pseudocapsule and the frontal bone of the lacrimal sac fossa. The lower eyelid has an analogous inferior suspensory ligament, Lockwood’s ligament, which arises from the medial and lateral retinaculum and fuses with the capsulopalpebral fascia inserting on the inferior tarsal border. It functions to stabilize the lower lid on downward gaze, while the lower lid retractors cause depression of the lower lid to increase the inferior visual field during downgaze.

Retractors of the Upper and Lower Lids

The upper eyelid retractors include the levator palpebrae superioris muscle and Muller’s superior tarsal muscle. The levator muscle is striated muscle innervated by the oculomotor nerve (cranial nerve III). The levator muscle originates from the lesser wing of the sphenoid and inserts along the anterior surface of the tarsal plate. The levator muscle becomes aponeurotic 5 to 7 mm above the superior border of the tarsus and 10 to 14 mm below Whitnall’s ligament. The levator aponeurosis has a lateral horn that divides the lacrimal gland into orbital and palpebral lobes and inserts into the lateral orbital tubercle and lateral retinaculum as well as the capsulopalpebral fascia of the lower eyelid. The medial horn of the levator aponeurosis inserts into the posterior reflection of the medial canthal tendon. Together, the medial and lateral horns distribute the force of the levator muscle equally along the aponeurosis, causing the majority of lid elevation to occur centrally.

FIGURE 46.6. Anatomy of the orbital fat pads and the interpad septae that are addressed during blepharoplasty.

Muller’s muscle is smooth muscle, which originates from the posterior surface of the levator muscle and inserts into the superior tarsal border. Muller’s muscle is innervated by the sympathetic nervous system.

Upper lid ptosis can be caused by mechanical dehiscence of the levator aponeurosis, abnormalities of cranial nerve III, or loss of sympathetic nerve supply causing Muller’s muscle weakness (Horner’s syndrome).

The lower lid retractors include the capsulopalpebral fascia and the inferior tarsal muscle, which are closely applied. The capsulopalpebral fascia originates from the inferior rectus fascia and envelops the inferior oblique muscle. The capsulopalpebral fascia is analogous to the levator aponeurosis of the upper lid and the inferior tarsal muscle is analogous to Muller’s muscle.

The Orbital Septum and Orbital Fat Pads

The orbital septum separates the anterior and posterior lamella and helps maintain periorbital fat within the anatomic confines of the orbit. The orbital septum originates from the orbital rim at the arcus marginalis and is discontinuous at the medial canthus. In the upper eyelid, the septum fuses with the levator aponeurosis, several millimeters above the tarsal plate. In the lower lid, the septum fuses with the capsulopalpebral fascia below the tarsal plate. There are numerous fibrous structures that separate the central and nasal fat pads in the upper eyelid and the central and lateral fat pads in the lower eyelid. Appreciation of the anatomy of the septum is important particularly when surgical procedures such as resetting, tightening, and excising the septum are performed.

The periorbital fat pads are found posterior to the orbital septum (Figure 46.6). There are two main fat pads in the upper eyelid and three fat pads in the lower eyelid. The two upper fat pads are referred to as the central and nasal fat pads and are located in the preaponeurotic space just superficial to the levator aponeurosis. The interpad septum separates the central and nasal fat pads and is continuous with a septal fascial connection to the trochlea. The nasal fat pad is more fibrous and pale in color compared with the central fat pad. The medial palpebral artery is located in the medial fat pad and can cause significant bleeding during blepharoplasty. The central fat pad is superficial to the levator aponeurosis in the so-called preaponeurotic space and contributes to the fullness of the upper lid fold.

There are three fat pockets in the lower eyelid: central, nasal, and lateral. The nasal compartment in the lower eyelid is similar to its counterpart in the upper eyelid. The inferior oblique muscle commonly visible during blepharoplasty separates the nasal and central fat compartments. The central and lateral fat compartments are also separated by an interpad septum as well as a fascial extension from Lockwood’s ligament, the arcuate expansion. The arcuate expansion of Lockwood’s ligament should be preserved during lower lid dissection to maintain lateral lid support. Since the nasal and central fat pads envelope the inferior oblique muscle, aggressive fat transposition techniques that suture the fat below the rim can result in diplopia from impaired inferior oblique function. The lateral extent of the lateral fat pocket includes the lateral retinaculum and lateral canthal tendon.

The Lacrimal Gland

The lacrimal gland lacks a true capsule and is divided into the orbital and palpebral lobe by the lateral horn of the levator. The orbital lobe is positioned in the fossa glandulae lacrimalis, which is a shallow fossa in the frontal bone at the superolateral orbit. The smaller palpebral lobe is connected to the orbital lobe by an isthmus posterior to the lateral horn of the levator. Lacrimal gland ptosis is caused by dehiscence of Sommering’s ligaments, which are the fibrous interlobular septa that connect the gland to the orbital rim fossa. Fullness in the lateral aspect of the upper eyelid is often caused by lacrimal gland ptosis. Lateral to the lacrimal gland is a separate compartment, just above Whitnall’s tubercle, called Eisler’s pocket. Eisler’s fat pad is a small accessory fat pad located in Eisler’s pocket, which serves as a useful anatomical landmark for Whitnall’s tubercle. The location of this fat pad is clinically useful during placement of the lateral canthoplasty suture.

The Conjunctiva

The most posterior layer of the eyelid is the conjunctival lining, which continues over Tenon’s capsule. The palpebral portion of the conjunctiva is closely adherent to the posterior surface of the tarsal plate and the lid retractors. At the fornix, the conjunctiva is termed bulbar conjunctiva and overlies the globe up to the corneoscleral limbus. Small accessory glands are located within the conjunctiva creating the aqueous portion of the tear film.

Forehead Anatomy

In the superior and lateral orbit, the forehead is more firmly attached to the underlying periosteum. Specifically, there is fibrous fusion between the orbicularis fascia and the underlying periosteum and deep temporal fascia. These attachments are released to mobilize the forehead for browlifting. The frontalis muscles are brow elevators and are continuous with the galea aponeurotica and the occipitalis posteriorly. The frontalis muscles insert into the dermis above the supraorbital rim and are responsible for transverse forehead furrows.

FIGURE 46.7. Lower eyelid anatomy. A. The septum and osteocutaneous supporting ligaments of the lower lid, including the lateral orbital thickening, the zygomaticofacial ligament, and the orbitomalar ligament. B. The cross-sectional relationship of the orbitomalar ligament and the orbicularis oculi. SOOF, suborbicularis oculi fat.

The orbital orbicularis oculi, depressor supercilii, oblique and transverse heads of the corrugator supercilii, and procerus muscles act in synergy to depress the medial brow and produce glabellar furrows. Motor innervation to the frontalis and superior orbicularis oculi is by the frontal (temporal) branches of the facial nerve. The brow depressors receive motor innervation from the buccal and zygomatic branches in addition to the frontal branches.

Midfacial Anatomy

Knowledge of anatomy in this region allows understanding of the changes seen in the lower eyelid/cheek junction. Mendelson described the prezygomatic space. The upper border of the prezygomatic space is formed by the orbitomalar ligament (also called the orbicularis retaining ligament), a structure that arises from a thickened area of periosteum inferior to the inferior orbital rim inserts on the deep surfaces of the orbicularis muscle (Figure 46.7). The orbitomalar ligament along with the origin of the orbicularis from the bone below the infraorbital rim is responsible for defining the tear trough and its lateral continuation, the lid–cheek junction (Figure 46.8). The lower border of the prezygomatic space is framed by the zygomatic ligaments. From the skeletal plane, these osteocutaneous ligaments radiate outward to insert into the dermis of the cheek. This prezygomatic space is triangular in shape with the apex being nasal. Malar mounds are the result of edematous fat in the prezygomatic space.

The malar fat pad, a totally separate structure, is a subcutaneous fat pad that contributes to the fullness of the midface. Elevation of the malar fat pad and/or correction of malar mounds requires a more aggressive subperiosteal midface lift.

PREOPERATIVE EVALUATION

Visual acuity is measured and documented in all patients prior to blepharoplasty. Ocular motility is then assessed by testing the six cardinal positions of gaze. Since diplopia can result from injury to the inferior or superior oblique muscles during blepharoplasty, it is important to establish a pre-op baseline. Visual field testing is performed in patients with upper eyelid ptosis and upper eyelid skin folds that interfere with the visual axis. Finally, standard photographs are taken for three reasons: preoperative planning, intraoperative reference, and for reviewing with the patient postoperatively.

Upper Orbit and Brow

An organized sequential assessment of the orbit, including the upper lid and brow, is performed. The brow is evaluated in a relaxed posture for ptosis, symmetry, and, most importantly, shape. Traditional teaching indicates that the female brow should arch above the supraorbital rim with a peak above the lateral limbus. In males, the brow should be lower and more horizontal, traversing the supraorbital rim. The modern trend, however, is to concentrate on brow shape more than its height. As a general rule, only the lateral brow requires lifting. Signs of lateral brow ptosis include lateral upper eyelid hooding and descent of the tail of the brow. Glabellar wrinkling can be treated with botulinum toxin (Chapter 43) or surgical manipulation, including open coronal lifting, endoscopically, or via transpalpebral corrugator resection. Transpalpebral corrugator resection is a good alternative to more invasive procedures and can improve the glabellar frown lines. No surgical treatment of glabellar creases can compete with botulinum toxin, however, as long as it is administered every 3 to 4 months.

Upper eyelid fold asymmetry may be due to upper lid ptosis, upper lid retraction, an asymmetry in the amount of tissue in the upper lid, or asymmetrical brow position. In patients presenting with upper lid ptosis, it is important to identify the etiology on history and clinical evaluation. The differential diagnosis includes congenital ptosis, acquired aponeurotic dehiscence, myogenic ptosis including myasthenia gravis, neurogenic ptosis including Horner’s syndrome, and mechanical ptosis secondary to tumor or trauma.

On physical examination, the levator function is measured by stabilizing the eyebrow and measuring lid margin excursion. Congenital ptosis is present from birth and is characterized by poor levator function. The measured excursion is generally less than 4 mm and often requires correction by means of a frontalis suspension procedure with a silicone, suture, or fascia sling. In acquired ptosis, levator function is most often normal with an excursion of 10 mm or greater. The eyelid crease is typically high in these patients as the dermal anchor of the levator fibers forming the crease has been disrupted. This can be corrected by Mullerectomy, by Fasanella-Servat, or with the authors’ preferred technique of tarsolevator advancement through the blepharoplasty incision. The cover test is recommended in cases of minimal unilateral acquired ptosis to rule out subclinical ptosis on the other side. The ptotic lid is covered with an eye pad for 5 minutes. Due to Hering’s law of equal innervation, subclinical ptosis in the “normal” lid will be unmasked resulting in a ptotic position of the “normal” lid. In that case, bilateral tarsolevator advancement is performed.

FIGURE 46.8. Tear trough and cheek fat pads. A. Surface anatomy of the tear trough deformity and midfacial aging. B. Three-dimensional anatomy of malar bags created by edematous soft tissue that is surrounded by the orbicularis oculi, the malar periosteum, and the zygomaticocutaneous and orbitomalar ligaments. C. Three fat compartments in the periorbital region include the orbital, SOOF (suborbicularis oculi fat), and malar fat pads.

Excess of skin and preaponeurotic fat is evaluated as well as lacrimal gland prolapse, excess ROOF (retro-orbicularis oculi fat), and bony fullness or resorption. If lacrimal gland prolapse is identified, lacrimal gland suspension is added to the blepharoplasty. Excess ROOF or brow fat may be removed in a conservative manner lateral to the supraorbital nerve. This procedure may be combined with a browpexy to raise and suspend the lateral aspect of the brow. Significant bony fullness in the region of the lateral orbital rim can be contoured using a burr. Modern teachings have recognized that the youthful upper orbit is characterized by fullness, not emptiness. Bony or soft tissue deficiency resulting in an A-frame deformity can be corrected with fillers or fat transfer. Fat grafting in addition to a fat-conserving blepharoplasty should be considered if the orbit has become skeletonized with age or by previous surgery.

Floppy eyelid syndrome, while uncommon, may be present in large, burly males who present for blepharoplasty. The syndrome is characterized by upper eyelid eversion during forced lid closure and may be addressed by shortening the lid laterally. This requires resection of a portion of the lateral tarsal plate along with a canthoplasty of the upper eyelid. If a floppy upper eyelid is not corrected, post blepharoplasty complications including an overriding upper eyelid during eyelid closure, persistent chemosis, and lid separation from the globe may occur.

Lower Orbit and Midface

The lower eyelid is evaluated for excess skin, muscle, orbital fat, malar bags, lateral canthal descent or disinsertion, lower lid laxity, and scleral show. The lateral canthal position is ideally 2 mm superior to the medial canthal position, and a line drawn from the medial to lateral canthus indicates the canthal tilt. A positive canthal tilt is one where the lateral canthus is positioned superior to the medial canthus. A negative canthal tilt may indicate descent of the lateral canthus from disinsertion, laxity, or the presence of a prominent eye. This orbital morphology may also be present as a hereditary trait. The lower lid tone is evaluated in two ways: 1) the distraction test wherein the lid is distracted from the globe (lid distraction greater than 6 mm indicates significant lid laxity); 2) the snap test wherein the lid is retracted caudally and allowed to snap back (slow return indicates poor lid tone). Poor lid tone and/or laxity may necessitate lid shortening and lateral canthoplasty (Chapter 32). Inferior malposition of the lower lid, or scleral show, is a major “red flag.” Scleral show may be caused by prominent eyes, lower lid laxity, poor infraorbital support, or a combination of the above, and it places that patient at high risk for postoperative complications.

The globe position relative to the bony orbital rim is evaluated. Patients with a negative vector relationship have a prominent eye with poor vertical support of the lower lid; on lateral view, the anterior aspect of the globe projects anterior to the underlying soft issue over the infraorbital rim. A positive, or normal, vector is when the globe does not project beyond the infraorbital rim and overlying soft tissue. Hertel exophthalmometry is used to assess globe prominence relative to the lateral orbital rim. Normal globe prominence is in the range of 16 to 18 mm. Patients with enophthalmos have a measurement less than 16 mm and with exophthalmos have measurements greater than 18 mm. Both prominent and deep-set eyes are at increased risk for complications, and the degree of prominence influences the level at which the lateral canthus will be anchored during lateral canthoplasty. Lateral canthal anchoring in prominent eyes requires supraplacement. Canthal anchoring in deep-set eyes requires no overcorrection but does require more significant internal placement to avoid anterior malposition. Furthermore, primary lower lid spacers and infraorbital rim implants may be considered in patients with prominent eyes to correct the poor globe support.

Dry Eye

Contact lens intolerance is another “red flag” and indicates high risk for postoperative eye dryness. These patients are further evaluated using a Shirmer’s test. The conjunctiva is anesthetized in the inferior lateral fornix with Tetracaine eye drops. Any excess tear film is then blotted away and a Shirmer’s strip is placed in the lateral fornix while the patient is asked to gaze straight ahead. Decreased tear production is identified by less than 10 mm of wetting after a 5-minute period. A poor Bell’s phenomenon also predisposes patients to significant postoperative corneal dryness. Patients with dry eyes should have no skin excision and consideration is given to lateral canthal anchoring. At a minimum, a temporary tarsorrhaphy suture is placed to limit the corneal exposure during the postoperative edematous phase. Liberal use of perioperative lubrication is advocated, and postoperative insertion of punctal plugs may be needed in refractory cases.

Systemic Conditions

In addition to anatomical findings, certain medical conditions increase the risk of complications following blepharoplasty. The history is directed toward identification of eyelid inflammatory disorders, Graves’ disease, benign essential blepharospasm, and dry eye syndrome.

Additionally, blepharoplasty technique must be deferred or conservative in nature to minimize the risk of corneal dryness and/or lid malposition.

Blepharochalasis is a specific disorder of eyelid tissue distinct from dermatochalasis caused by repeated episodes of extreme periorbital edema. This condition is rare and is seen in women who have eyelid edema exacerbated during their menstrual cycle. Chronic stretching of the eyelid skin and septum results in blepharochalasis or chronic puffy eyelids.

The most common cutaneous inflammatory disorders that affect the eyelids are rosacea and pemphigus. Patients with rosacea often have decreased tear film production, which causes corneal dryness and possible ulceration from exposure following blepharoplasty. Pemphigus is an autoimmune disorder that leads to chronic inflammatory changes of the conjunctiva and ocular adnexa. Scar contracture of the conjunctival fornix may occur causing foreshortening and lid malposition. In addition to patients with rosacea and pemphigus, patients with known history of sarcoidosis are at increased risk for healing complications following blepharoplasty. Noncaseating granuloma formation in blepharoplasty incisions has been reportedly caused by sarcoidosis of the surgical scar.

Undiagnosed hyperthyroidism may present with puffy eyelids. Preoperative evaluation includes free T4, thyroid circulating antibodies, as well as consideration for endocrine consultation. Ocular manifestation of Graves’ disease often includes upper and lower lid retraction, diplopia, exophthalmos, and puffy eyelids. Standard blepharoplasty techniques must be avoided in patients with significant thyroid eye disease. Another periorbital disorder associated with increased risk of complications is benign essential blepharospasm. This is an involuntary spastic disorder of the orbicularis oculi muscle, frequently contributing to redundant upper eyelid skin. Blepharoplasty is avoided because improvement in symptoms after surgery is unlikely. Current management is nonoperative with orbicularis oculi muscle injections of botulinum toxin.

Patients who have had recent laser in situ keratomileusis (LASIK) surgery for vision enhancement should avoid blepharoplasty for at least six months in order to allow the corneal incision adequate time to heal to avoid complications of dryness after blepharoplasty.

OPERATIVE TECHNIQUE

Upper Lid Markings

Preliminary markings are made while in the preoperative area to ensure that the eventual scar will lie in the upper lid crease. The markings are completed on the operating room table. The upper eyelid crease is marked at the level of the midpupillary line. In women, this is 8 to 10 mm superior to the lash margin and roughly 7 mm above the lash margin in men (Figure 46.9). The marking is tapered caudally at the nasal and lateral lid margins following the gentle curve of the upper lid crease. The nasal aspect of the marking should not extend medial to the caruncle, to avoid webbing or the development of epicanthal folds. At the lateral canthus, the lateral marking should be 5 to 6 mm above the lash line. The lateral extension should be hidden in a skin tension line and not extend past the lateral orbital rim. The superior margin is marked, preserving 10 to 15 mm of skin between the lower border of the eyebrow and the upper lid marking, at the level of the lateral canthus. The superior mark is drawn parallel to the contour of the lower marking. The marks are then tapered nasally, to reduce the amount of skin and muscle to be excised, as over-resection in this area is poorly tolerated and may result in lagophthalmos in addition to a poor aesthetic outcome.

FIGURE 46.9. Upper blepharoplasty markings. A. Upper blepharoplasty distances are shown and (B) the points to consider during the markings.

In the Asian eyelid, one must determine if a single eyelid fold (absent crease) or a double eyelid fold (single crease) is desired. It is also important to define the desired location of the crease, as this is typically lower than in the Caucasian upper eyelid. A distance of 4 to 6 mm above the lid margin is usually used depending on the patients’ desires. A plan is made to limit the amount of skin and preaponeurotic fat excision since this can lead to an unnaturally high crease and supratarsal hollowness. Furthermore, the epicanthal fold is usually preserved unless the change is specifically requested by the patient. Proper communication with the patient regarding the desired outcome is of utmost importance as the aesthetic goals of Asian blepharoplasty are different from those achieved by standard techniques.

Special attention is given to the presence of eyebrow and lid fold asymmetry. Asymmetric brow positions are extremely common. If asymmetry is due to unilateral bow ptosis, the upper eyelid markings should closely approximate one another and a browlift should be planned to lift the lower brow. However, if the lid folds are asymmetric due to eyelid asymmetry or ptosis, the markings should aim to establish symmetry and correct the underlying ptosis. Symmetry can be improved by removing different amounts of skin and muscle from each eyelid and equalizing the distances from the lid margin to the inferior incision and from the brow to the superior incision.

Lower Lid Markings

The lower lid is first marked with a single point at the level of the lateral canthus. If a skin incision is planned, a line is extended inferiolaterally for approximately 6 to 10 mm within a prominent skin tension line. Roughly 10 mm of skin is preserved between the lateral extension of the upper and lower blepharoplasty incisions. If the incisions are placed too close together, postoperative webbing or distortion can occur. The nasal extension of the marking parallels the lid margin approximately 2 to 3 mm below the eyelashes.

Anesthesia

Blepharoplasty can be performed under local anesthesia with sedation, MAC, or general anesthesia. Local anesthesia consisting of lidocaine 1% with epinephrine 1:100,000 is injected using a 27-gauge needle into the upper eyelid, lateral canthus, lower eyelid, and inferior orbital rim. If midfacial dissection is planned, the injected area is extended to include the bony malar prominence at the level of the periosteum avoiding the infraorbital neurovascular bundle. Care is taken to avoid injury to the marginal arterial arcades and the deep orbital structures to reduce the risk of eyelid or retrobulbar hematoma.

Upper Lid Blepharoplasty

Using a scalpel, upper lid skin is excised as marked preoperatively. A strip of orbicularis oculi muscle is excised exposing the orbital septum. The septum is opened along the length of the incision. This technique is described as an “Open Sky” approach to the preaponeurotic space (Figure 46.10). Care is taken to preserve the interpad septum separating the central and nasal fat pads. Over-resection of fat in this area will result in a hollow “A-frame” or peaked arch deformity of the supratarsal crease. Preservation of fat at the interpad septum will maintain a symmetrical gentle arch below the new upper lid fold. When fat excision is indicated, it can be performed by direct sculpting with the needle tip cautery, which allows greater precision and visualization of the medial palpebral artery. Clamping, resecting, and cauterizing fat should be discouraged since this can result in uncontrolled bleeding. Inadequate cauterization can result in bleeding from the nasal fat pad. Poor visualization and indiscriminate cauterization within the deep nasal orbit has contributed to injury to the trochlea and the superior oblique muscle. Patients with injury to the superior oblique muscle will exhibit diplopia and head tilt toward the side of the superior oblique injury following blepharoplasty. Fat preservation should be considered to avoid creation of a hollow more aged-appearing orbit.

FIGURE 46.10. Removal of preaponeurotic central fat pad and exposure of levator aponeurosis. Reprinted from McCord CD, Codner MA. Eyelid and Periorbital Surgery. St. Louis, MO: Quality Medical Publishing; 2008.

Inadvertent surgical disinsertion of the levator aponeurosis during upper blepharoplasty may result in postoperative acquired ptosis. To minimize this risk, some surgeons perform supratarsal fixation of the pretarsal skin muscle to the levator aponeurosis as a routine part of upper blepharoplasty using a horizontal mattress suture of 6-0 Vicryl at the midpupillary line.

The ROOF pad should be evaluated, and conservative resection of the brow fat pad can be performed. Ptosis of the orbital lobe of the lacrimal gland may be present and is corrected with suspension of the lacrimal gland into the lacrimal sac fossa (Figure 46.11). The lateral horn is placed on traction and the levator aponeurosis is sutured to the arcus marginalis with 6-0 Vicryl suture just at the level of the lacrimal gland to prevent future lacrimal gland ptosis. The levator aponeurosis is placed on downward stretch to eliminate the risk of postoperative lagophthalmos. Resection of the lacrimal gland can cause postoperative dry eye syndrome and is not recommended.

If lateral brow ptosis is present, a browpexy can be performed through the upper blepharoplasty incision. The orbicularis and ROOF are dissected just superficial to the periosteum along the lateral third of the eyebrow, lateral to the supraorbital nerve, exposing the periosteum and the temporalis fascia. Internal browpexy is performed using 4-0 Prolene interrupted mattress sutures between the orbicularis just deep to the dermis at the level of the inferior brow margin and the underlying periosteum and temporalis fascia. The inferior margin of the brow at the level of the lateral limbus should be sutured 10 to 15 mm above the lateral orbital rim depending on the desired position.

The incision is closed with interrupted 6-0 nylon suture lateral to the lateral canthus. The remainder of the incision is closed with a running nylon suture, which can be placed in an intradermal fashion or in a simple, running fashion.

FIGURE 46.11. Demonstration of lacrimal gland ptosis. Reprinted from McCord CD, Codner MA. Eyelid and Periorbital Surgery. St. Louis, MO: Quality Medical Publishing; 2008.

Asian Upper Lid Blepharoplasty. A low crease incision typically 4 to 6 mm above the lash line is made. A conservative amount of skin is excised and minimal preaponeurotic fat is removed. To create a dynamic fold, multiple three-point sutures are placed through the junction of the upper tarsal margin, levator insertion, and dermis of the upper skin margin.

Lower Lid Blepharoplasty

Approaches to the lower lid differ widely. Some experienced surgeons never make a subciliary incision, preferring to use the transconjunctival plus skin pinch approach, while others make a subciliary incision routinely. If a skin incision is planned, it is initiated lateral to the canthus exposing the underlying orbicularis oculi muscle. The orbicularis oculi muscle is divided with electrocautery lateral to the canthus. Scissors are used to incise the remainder of the lower lid skin incision along the lid margin with a second stair-step incision through the orbicularis preserving a 5 mm strip of pretarsal orbicularis muscle (Figure 46.12). Electromyelogram analysis has revealed normal function of the pretarsal muscle strip after use of the skin muscle flap with minimal risk of denervation. The skin muscle flap is then dissected anterior to the septum to the infraorbital rim. The orbitomalar ligament is encountered several millimeters below the infraorbital rim and is divided. A tear trough deformity may be improved by release of the medial origin of the orbicularis oculi from the bone. Once the orbitomalar ligament is released, the SOOF (suborbicularis oculi fat) becomes visible and preperiosteal dissection is performed approximately 10 mm below the orbital rim preserving the zygomaticofacial nerve. Release of the orbitomalar ligament allows elevation of the SOOF with the skin muscle flap. Orbital fat can be removed in a conservative fashion from all three lower lid compartments (Figure 46.12). Care is taken to avoid injury to the inferior oblique muscle between the nasal and central fat pads. The inferior oblique muscle is the most common extraocular muscle injured during blepharoplasty. The arcuate expansion of Lockwood’s ligament between the central and lateral fat pad should be preserved for additional support to prevent further herniation of periorbital fat. Alternative procedures are considered including arcus marginalis release with fat repositioning, or fat grafting to the orbital rim.

Transconjunctival Lower Blepharoplasty. The orbital fat can be removed by a transseptal approach that divides the conjunctiva, capsulopalpebral fascia, and septum, or by a retroseptal incision through the conjunctiva and capsulopalpebral fascia that leaves the septum intact. We reserve transconjunctival fat removal for young patients with congenital fat excess and minimal laxity, as well as for African-American and Asian patients. The transconjunctival approach has the advantage of leaving the orbicularis muscle intact, which minimizes the risk of complications. In addition to removing fat, the transconjunctival approach can be combined with a “pinch” skin excision and/or fat redraping.

Lateral Canthal Anchoring

The degree of lower lid laxity is reevaluated intraoperatively by placing anterior traction on the lower eyelid and using caliper measurement to determine the amount of lid distraction from the globe. Lid distraction of 1 to 2 mm indicates minimal lid laxity, while measurements of 3 to 6 mm of lid distraction indicate moderate laxity of the lower eyelid. Some surgeons believe that a lateral canthopexy should be used to correct both minimal and moderate lid laxity to provide long-lasting lower eyelid support and preserve the natural shape of the eyelid (Figure 46.13). When the lid can be distracted greater than 6 mm away from the globe, significant lid laxity is present. The consensus is that lateral canthal anchoring is necessary.

FIGURE 46.12. Lower blepharoplasty technique. A. Lower blepharoplasty markings of the skin muscle flap with preservation of innervation from the zygomatic and buccal branches of the facial nerve. B. Sagittal view demonstrating the stair-step technique that preserves pretarsal orbicularis muscle. C. Removal and redraping of fat from the nasal, central, and lateral orbital fat compartments.

FIGURE 46.13. Lateral canthoplasty. A. Lateral canthoplasty is performed by placing a suture through the incised edge of the tarsal plate. B. Placement of the canthoplasty suture demonstrates slight vertical overcorrection in patients with prominent eyes. C. The canthoplasty suture is placed posteriorly to the lateral orbital rim to ensure that the lid follows the curve of the globe.

The objective of lateral canthopexy (Chapter 32) is to suture the tarsal plate and lateral retinaculum to the periosteum of the lateral orbital rim, thereby tightening the lower lid tarsoligamentous sling. A nonabsorbable horizontal mattress suture is used to incorporate the tarsal plate and lateral retinaculum. The suture is placed inside the lateral orbital rim periosteum from deep to superficial, allowing the lateral canthus and lower lid to be tightened posteriorly and superiorly and pulling the lower lid margin against the globe. The vertical position of the lateral canthal fixation suture depends on the amount of eye prominence, the amount of lower lid laxity, and the preoperative shape of the lower eyelid. Care is taken to maintain the preoperative shape of the lower eyelid, avoiding overcorrection or alteration in the preoperative canthal position. The position of the lateral canthal suture is most commonly at the horizontal midpupillary line. However, patients with prominent eyes require supraplacement of the canthal support suture with overcorrection and minimal tightening to avoid “clothes-lining” of the lower lid below the inferior limbus. Conversely, patients with deep-set eyes require more posterior placement of the canthopexy suture taking care to avoid overcorrection in a superior direction. The downward force of the prominent globe on the lower lid will cause descent of the lid margin following lateral canthopexy; however, this force does not exist in patients who have deep-set eyes.

Patients who have significant lid laxity with lid distraction greater than 6 mm probably require lateral canthotomy and canthoplasty. Lateral canthoplasty is performed by selective canthotomy of the inferior limb of the lateral canthal tendon followed by cantholysis, which allows mobilization of the lower lid. Two to 3 mm of full-thickness lid margin is resected to correct significant lid laxity. A 4-0 nonabsorbable suture is placed through the edge of the tarsal plate from inferior to superior ensuring vertical alignment while controlling lash rotation. The mattress suture is then placed inside the lateral orbital rim periosteum at the appropriate level. The suture is tied with a surgeon’s knot until the desired amount of tension is achieved, allowing 1 to 2 mm of lid distraction away from the globe (Figure 46.11). Over-tightening of the lateral canthoplasty is avoided. The lateral commissure is then reconstructed with a 6-0 plain catgut suture placed in the gray line to prevent postoperative lateral canthal webbing. In order to recreate a normal appearing lateral commissure, the suture is placed in the posterior aspect of the upper lid gray line and the anterior aspect of the lower lid gray line to allow the upper lid to slightly overlap the lower lid in a normal anatomical relationship.

Following lateral canthal support, the skin muscle flap is redraped in a superior lateral vector, and a triangle of excess skin and muscle is resected according to the amount that overlaps the lateral extent of the lower blepharoplasty incision. The orbicularis muscle flap is then resuspended to the lateral orbital rim at the level of the lateral canthus using a 4-0 Vicryl suture placed as a three-point quilting suture from the incised edges of skin and muscle to periosteum along the inner aspect of the lateral orbital rim to recreate the normal concavity associated with the lateral orbital raphe. Similarly, interrupted absorbable sutures are placed in the lateral cut edge of the orbicularis flap to the lateral orbital rim periosteum and temporalis fascia to properly resuspend the orbicularis under appropriate tension. Resuspension of the orbicularis provides additional lower lid support as well as elevation of the SOOF overlying the inferior orbital rim. Minimal skin and muscle are resected parallel to the lower lid margin to minimize the risk of lid malposition. A small strip of orbicularis is removed from the undersurface of the skin muscle flap to avoid a redundant layer overlying the preserved pretarsal orbicularis, thereby completing the tension-free stair step with a 6-0 fast absorbing catgut suture.

Postoperative Care

Frequent moisturizing with wetting drops, ophthalmic lubricating, and intermittent forced lid closure helps prevent exposure-related desiccation. The head should remain in an elevated position and iced gauze or ice packs applied to the periorbital region for 24 hours. Ophthalmic antibiotic ointment is applied along the suture line as well as on the globe to prevent or to reduce evaporative tear film loss after surgery. Patients are asked to avoid the use of eyelid makeup on the suture lines and the use of contact lenses for 7 to 10 days following surgery.

If significant chemosis is present at the end of the case, the use of a Frost suture or temporary tarsorrhaphy is considered. A 6-0 nylon suture is placed in the lower lid margin lateral to the limbus and either suspended to the eyebrow or sutured to the upper eyelid along the gray line. These techniques will minimize corneal exposure in the immediate postoperative period. All sutures, including the Frost suture, are removed 5 to 7 days after surgery.

Persistent postoperative chemosis can be treated with continuous use of ophthalmic ointments in addition to ocular decongestants (Neo-Synephrine, 2.5%) and steroid eye drops (Tobradex). If the chemosis persists into the second postoperative week, second-line steroid drops may be used (FML Forte Liquifilm or Pred Forte) along with patching the eye closed for 24 to 48 hours, and applying gentle pressure from an Ace wrap to reduce the swelling. If chemosis persists beyond 2 weeks, and especially if significant lagophthalmos is present, conjunctivotomy with possible tarsorrhaphy is performed and oral steroids (Solumedrol dose pack) may be given. Ophthalmic steroid eye drops are contraindicated in patients with glaucoma or for more than 2 weeks due to the risk of elevated intraocular pressure. Surgeons who perform the more limited transconjunctival fat removal and pinch skin excision do so because, among other things, chemosis does not occur.

Complications

This chapter focuses on the most common complications, including ectropion, lid malposition, chemosis, and the need for reoperation. The most devastating complication after blepharoplasty is visual loss, which has been reported from periorbital filler injection due to intra-arterial injection and embolization to the central retinal artery (Figure 46.14). Although rare, the estimated incidence of visual loss with blepharoplasty is 0.04% and may be caused by retro-orbital hemorrhage compromising central retinal arterial circulation or by direct globe perforation with a needle, instrument, or laser. Management of retro-orbital hematoma includes immediate surgical decompression with lateral canthotomy and cantholysis in the recovery room or emergency room followed by surgical exploration, administration of mannitol, acetazolamide, and oxygen. Diplopia can also occur following blepharoplasty; it is usually caused by edema and is temporary. Permanent diplopia can occur from thermal or surgical injury to the inferior oblique or superior oblique muscles from electrocautery or direct clamping or excision. Strabismus surgery may be required for patients who do not improve with conservative management. In the upper lid, ptosis may occur from failed recognition of a preexisting condition or from levator injury during surgery. To minimize this risk, supratarsal fixation of the pretarsal skin muscle to the levator aponeurosis is considered.

FIGURE 46.14. Blindness from injectable agents. Diagram showing the anatomy that results in embolization from the supratrochlear artery to the central retinal artery.

Signs of corneal irritation require ophthalmological evaluation, including a slit lamp examination with the use of fluorescein eye drops. Liberal use of Tobradex ophthalmic ointment on the cornea three to four times a day with patching at night is the first line of treatment. Bandage contact lenses can also be considered. Lid malposition may contribute to lagophthalmos and corneal exposure, which can be managed with vertical lower lid massage and steri-strip tape support to the lower lid. Timing of reoperation should be in the immediate 2-week postoperative period if ectropion or severe lid malposition is attributable to technical failure of the canthopexy suture. This can save the patient weeks of conservative management and discomfort. If mild lid malposition gradually occurs after the initial 2-week postoperative period, conservative management should continue for 2 months to avoid operating during the 6-week postoperative period when there is poor tissue compliance due to the peak proliferative phase of healing. Furthermore, a significant number of patients will improve without reoperation after this timeframe. Lower lid ectropion or persistent lid malposition following a 2- to 3-month period of conservative management may require surgical intervention, including placement of a posterior lamella spacer graft and lateral canthoplasty with possible drill hole to fix the lateral canthus.

FIGURE 46.15. Blepharoplasty results. A. A middle-aged male patient before and after upper and lower blepharoplasty with fat excision and release of orbitomalar ligament to blend lid–cheek junction. B. A younger female patient before and after lower blepharoplasty with fat transfer for correction of tear trough deformity. C. An older female patient before and after upper and lower blepharoplasty. Reprinted from McCord CD, Codner MA. Eyelid and Periorbital Surgery. St. Louis, MO: Quality Medical Publishing; 2008.

Infectious and inflammatory complications are rare following blepharoplasty and can be differentiated according to the time of presentation. Hypersensitivity reactions in the perioperative period can occur as a reaction to preservative drops containing benzalkonium chloride or ointment containing neomycin and usually resolve with discontinuation of the offending agent, antihistamines, and cold compresses. Inflammatory reactions to suture material may occur during the first 2 weeks after surgery. Sutures in the skin for more than 7 days may result in epithelialized tracks and subsequent formation of subcutaneous epidermoid cysts, which can be unroofed with local anesthesia and an 18-gauge needle. Finally, minor cellulitis around the incision can be treated with oral antibiotics; however, atypical infections should be considered.

Symptoms of visual impairment or pain with ocular movement require a thorough evaluation, including a computed axial tomography, to rule out deep orbital cellulitis with possible extension to the cavernous sinus, which requires treatment with emergent surgical debridement and intravenous antibiotics. Erythema and nodules presenting 2 to 6 weeks after blepharoplasty include suture abscesses, pyogenic granulomas, and foreign body granulomas. These lesions are treated with excisional biopsy to confirm the diagnosis . Additional, low-dose, oral steroids may improve inflammatory reactions as long as infection has been excluded. Patients presenting with erythema or signs of infection more than 6 weeks after surgery should be considered to have atypical infections, the majority of which are caused by mycobacteria or fungus. Drainage from these lesions should be sent for special stains (acid-fast and KOH prep), culture, and sensitivity. Patients should be placed on broad-spectrum antibiotics (Ciprofloxacin, Avelox, or Zyvox), with the addition of oral clarithromycin for 6 weeks if there is culture confirmation of mycobacteria. Though rare, noncaseating granulomas can occur after blepharoplasty and present as nontender, inflammatory processes appearing more than 6 weeks after surgery. The differential diagnoses include chalazion, dermoid cysts, and cutaneous sarcoidosis. If there is no drainage for culture, incisional or excisional biopsies may be performed in the subacute phase. Once the subacute phase subsides, which can take up to a year, the lesion may be safely excised. If cutaneous sarcoidosis is suspected, the workup should include serum angiotensin-converting enzyme level, chest radiography, and possibly a rheumatology referral.

Outcomes

Emphasis is placed on maintaining the preoperative shape of the palpebral fissure with particular attention to maintaining lower eyelid position (Figure 46.15). In this author’s opinion, lateral canthal support, most commonly with lateral canthopexy, represents an important step in the technique to maintain lid shape and reduce the risk of lower lid malposition or postoperative round-eye syndrome. The trade-off that should be discussed with patients prior to surgery is that the lower lid may appear tight for 2 to 3 weeks after surgery. The natural S-shaped curve to the lower lid and palpebral aperture is preserved following completion of the healing process.

Complications associated with lateral canthoplasty include canthal webbing or asymmetry, which requires surgical revision. The risk of frank ectropion is reduced when conservative skin excision and lateral canthal support are performed in routine combination. In addition to minimizing the risk of complications, maximizing the aesthetic result is directly related to safe management of periorbital fat, the orbicularis muscle, SOOF, and release of the periorbital ligaments. Elevation of the skin muscle flap and release of the orbitomalar ligament mobilize the SOOF, which is elevated with the orbicularis muscle. Using the orbicularis muscle as a sling with secure lateral orbital fixation is the key to maximizing the aesthetic appearance of the infraorbital region. The posterior lamella (tarsoligamentous sling) has a more posterior point of periosteal fixation than the anterior lamella (skin muscle flap). Similarly, key principles for upper blepharoplasty include fat preservation with conservative removal of the skin, muscle, and fat to avoid a hollow upper lid sulcus and supratarsal fixation to avoid acquired post-blepharoplasty ptosis. Browlifting procedures should be considered as an adjunct to blepharoplasty.

CONCLUSION

Blepharoplasty has evolved over the past decade from the routine removal of skin, muscle, and fat to a sophisticated surgical procedure that is individualized for each patient. The current techniques are aimed at not only improving age-related changes but also modifying periorbital changes associated with ethnicity, gender, and ligamentous attachments. The adjacent anatomical areas should be addressed by techniques that improve the forehead and midface.

Suggested Readings

1.  Carraway JH. Lower lid blepharoplasty with fat grafts for correction of the tear trough. In: Codner MA, de Castro C, Boehm KA, eds. Techniques in Aesthetic Plastic Surgery: Midface Surgery. Philadelphia, PA: Saunders Elsevier; 2009:47-58.

2.  Codner MA, Day CR, Hester TR, Nahai F, McCord C. Management of moderate to complex blepharoplasty problems. Perspect Plast Surg. 2001;15(1):15-32.

3.  Codner MA, Locke MB. Applied anatomy of the eyelids and orbit. In: Nahai F, ed. The Art of Aesthetic Surgery Principles and Technique. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2011:807-830.

4.  Codner MA, Mejia JD. Lower eyelid blepharoplasty. In: Nahai F, ed. The Art of Aesthetic Surgery Principles and Technique. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2011:907-940.

5.  Hamra ST, Choucair RJ. Orbital aging and harmony in orbital rejuvenation. In: Codner MA, de Castro C, Boehm KA, eds. Techniques in Aesthetic Plastic Surgery: Midface Surgery. Philadelphia, PA: Saunders Elsevier; 2009:93-104.

6.  Hirmand H, Codner MA, McCord CD, Hester TR, Nahai F. Prominent eye: operative management in lower lid and midface rejuvenation and the morphologic classification system. Plast Reconstr Surg. 2002;110:620.

7.  Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthalmic Plast Reconstr Surg. 1996;12:77.

8.  Knize DM. The superficial lateral canthal tendon: anatomic study and clinical application to lateral canthopexy. Plast Reconstr Surg. 2002;109:1149.

9.  McCord CD, Codner MA. Involutional entropion and ectropion. In: McCord CD, Codner MA, eds. Eyelid and Periorbital Surgery. St. Louis, MO: Quality Medical Publishing; 2008:627-654.

10.  McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconstr Surg. 1998;102:2471-2479.

11.  Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873.

12.  Pacella SJ, Codner MA. Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show. Plast Reconstr Surg. 2010;125:709-718.

13.  Ramirez OM, Santamarina R. Spatial orientation of Motor Innervation to the lower orbicularis oculi muscle. Aesthet Surg J. 2000;20(2):107-113.

14.  Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg. 2008;122:579-585.