A thorough working knowledge of periorbital and eyelid anatomy (discussed in Chapter 9) is essential for successful blepharoplasty. In addition, just as the brow and glabellar areas affect the upper eyelids, the midfacial structures influence the position, tone, contour, and function of the lower eyelid and must be considered in surgical planning.
Surgical preparation involves marking excess skin for excision prior to infiltration of local anesthetic. The surgeon can determine the amount of skin to be excised by grasping the upper eyelid skin with toothless forceps and identifying the amount of redundancy (pinch technique). To avoid excessive skin removal, the surgeon usually leaves at least 20 mm of skin remaining between the inferior border of the brow and the upper eyelid margin (Fig 12-26).
Upper blepharoplasty begins with the surgeon incising along the lines marked on the upper eyelid. The surgeon removes skin and then may selectively remove orbicularis and a conservative amount of orbital fat to reshape the upper eyelid. Adjunctive procedures to reform the eyelid crease and reposition the lacrimal gland may be necessary.
Lower blepharoplasty can be accomplished through a transconjunctival incision or a transcutaneous, infraciliary incision (Video 12-10). The transconjunctival incision offers a lower rate of postoperative eyelid retraction and absence of an external postoperative scar (Fig 12-27). The preoperative evaluation defines the location and extent of lower eyelid fat prolapse and thus determines the boundaries of surgical excision. The surgeon should be aware of the location of the inferior oblique muscle, which is between the medial and central fat pads. As in the upper eyelid, the medial fat pad of the lower eyelid is less yellow than the lateral fat pads. The central fat compartment is separated from the lateral fat compartment by the arcuate expansion of the inferior oblique muscle; removal or incision of this arcuate expansion may improve access to the lateral fat pad. The surgeon can remove or reposition the fat. Horizontal tightening or resuspension (see Fig 12-2) is often performed with lower blepharoplasty.
Lower blepharoplasty. Reproduced with permission from Korn BS, Kikkawa DO, eds.
Video Atlas of Oculofacial Plastic and Reconstructive Surgery. Philadelphia: Elsevier/Saunders; 2011.
Figure 12-27 Photos taken before (A) and after (B) lower eyelid blepharoplasty through a transconjunctival approach.
(Courtesy of Bobby S. Korn, MD, PhD.)
After structural alteration of the lower eyelid (eg, fat removal, fat transposition, midface resuspension, horizontal eyelid tightening), skin removal can be performed. When skin resection is necessary, an infraciliary incision is used to remove only the skin, while preserving the underlying orbicularis muscle. It is important to note that aggressive skin removal during lower blepharoplasty increases the risk of lower eyelid contour abnormalities, retraction, and ectropion. This risk can be minimized with conservative skin removal and lower eyelid tightening.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.