All about Eyelid Surgery (Blepharoplasty) Cosmetic Surgery , Blepharoplasty cost, Clinics, Videos, Blepharoplasty before and after pictures, photos, complications and Prices.
Aesthetic eyelid surgery is intended to brighten and refresh the eyes. By removing baggy skin, an ellipse of muscle and protruding fat, the surgeon has a chance to erase the signs of periorbital aging and endow a youthful appearance. Functional eyelid surgery is largely geared towards correcting congenital or acquired ptosis, ectropion (eversion of the eyelid) and epiblepharon (inversion of eyelashes against globe). While aesthetic and functional eyelid surgery may be nosologically divided, both have a role in every operation.
Eyelid surgery must be preceded by a sound knowledge of the anatomy and a thorough understanding of the deformity to be corrected. Moreover, patient selection may be as important as the technical aspects of resecting/resuspending the periorbital tissues or controlling the lateral canthus. Goals for eyelid surgery include the creation of crisp upper lids, correction of fatty protrusions without hollowing the eyes, reestablishment of lower lid tone, control of the lateral canthus, preservation of aperture length and height, avoidance of scleral show and lagophthalmos, and correction of deep groves, all while maintaining the illusion of symmetry.
The palpebral fissure (aperture of the eye) measures 12-14 mm vertically and 28-30 mm horizontally. The eye is almond-shaped with the lateral canthus slightly more superior than the medial canthus: typical superior elevations at the lateral canthus are 2 mm for men and 4 mm for women. The distance from the lateral canthus to the orbital rim is about 5 mm. The upper lid fold in Caucasians is approximately 8-11 mm. The lower lid crease is about 5-6 mm. The high point of the brow is superior to the lateral limbus. The upper lid rests 2 mm below the superior limbus of the iris and the lower eyelid rests at the inferior limbus.
The skin of the eyelid is less than 1 mm thick. With aging and loss of elasticity, wrinkling and sagging of the eyelid occurs. Beneath the skin and subcutaneous tissues lies the orbicularis oculi muscle, which is divided into an outer orbital portion and an inner palpebral portion. The palpebral portion is further subdivided into preseptal and pretarsal parts. Collectively, the orbicularis oculi closes the eye, shortens and milks the canniliculi, and expands the lacrimal sac.Beneath the orbital and preseptal portions of the orbicularis oculi is the preseptal fat, known as the retroorbicularis oculi fat (ROOF). This fat pad lies over the orbital rim extending outward toward the tail of eyebrow. Resecting the ROOF decreases the heaviness of the lateral brow and upper lid, but the ROOF isn’t the primary culprit in baggy upper lids. The orbital septum lies deep to the orbicularis. It hangs from the
superior orbital rim and joins the levator aponeurosis at the superior border of the tarsal plate. Weakening of the septum with aging, hereditary predisposition, or trauma may cause protrusion of the orbital fat.
The upper lid contains two fat pads:
medial and central (the lateral space is occupied by the lacrimal gland).
The medial and central compartments are separated by the superior oblique muscle.
The medial fat pad is lighter in color (similar to butterscotch), firmer in consistency, and usually
requires more local anesthesia during resection than the central compartment.
The medial compartment also contains the terminal branch of the ophthalmic artery; we find that attending surgeons will take an extra second to ensure that this vessel is satisfactorily coagulated during fat resection.
The upper lid tarsus is a fibrous plate that is approximately 10 mm wide in the central upper lid, narrowing medially and laterally. The tarsal plates extend from the lateral commissure to the punctum, and it contains numerous meibomian glands that empty into the ciliary border.
There are two muscles responsible for opening the upper eyelids:
the levator muscle (primary lid elevator) and Müller’s muscle.
The levator muscle originates at the apex of the orbit, just superior to the superior rectus. At the
orbital aperture, it is supported by Whitnall’s ligament, which functions to translate the horizontal force of this muscle into the posterior and vertical motion necessary for lid elevation.
The levator muscle becomes aponeurotic as it passes Whitnall’s ligament.
The anterior interdigitation of the aponeurosis with the orbicularis muscle fibers leads to the formation of the supratarsal fold. Müller’s muscle originates from the posterior aspect of the levator aponeurosis and travels inferiorly, closely adherent to the conjunctiva, to insert on the superior border of the tarsus. Müller’s muscle is sympathetically innervated. The conjunctiva is the inner most layer of the upper lid.
LOWER EYELID BLEPHAROPLASTY
The lower eyelid is often described as being composed of three lamellae. The anterior lamella consists of the skin, orbicularis oculi (orbital, preseptal and pretarsal) muscle, and preseptal suborbicularis oculi fat (SOOF).
lamella is the orbital septum. The septum is a continuation of the orbital periostium that extends from the inferior orbital rim (arcus marginalis) to the inferior border of the tarsus. It provides the anterior border of the medial, middle and lateral fat compartments. Although these compartments are more imaginative than anatomic, the inferior oblique (most commonly injured during blepharoplasty) separates the medial and middle compartments; the arcuate expanse divides the middle from the lateral fat pad. The medial fat pad tends to be whiter than the middle and lateral pads.
The posterior lamella is composed of the tarsus, lower lid retractors and the conjunctiva. The lower lid tarsal plate is only about 4.5 mm wide at the mid-pupil. The lower eyelid retractor system originates as a fascial extension of the inferior rectus muscle (capsulopalpebral head). This fascial system splits to encapsulate the
inferior oblique muscle and then reunites to form a dense fibrous sheet (capsulopalpebral fascia) that inserts onto the inferior tarsal border.
The inferior tarsal muscle is the smooth muscle analog of the upper lid Müller’s muscle. The inferior tarsal muscle originates in the inferior fornical area and extends toward the inferior tarsal border but does not insert on the tarsal border as does its counterpart in the upper eyelid. The inferior tarsal muscle provides sympathetic innervation to the lower eyelid, and interruption of its innervation results in a slightly elevated
position of the lower eyelid margin, as observed in Horner syndrome. Otherwise, the inferior tarsal muscle has little pathologic significance.
There are a number of anatomic differences between Asian and Caucasian eyelids.
In the Asian upper eyelids, the skin and subcutaneous fat tend to be thicker.
The ROOF is heavier. The orbital septum is weaker and thinner and it tends to drape below the upper border of the tarsal plate. The levator aponeurotic dermal extensions are weak or nonexistent. The paucity of levator-dermal extensions is responsible of the low-lying or absent supratarsal fold. Epicanthal folds cover the medial angle and lacrimal caruncle. Trichiasis is caused by the overhanging upper eyelid skin pushing down on the eyelashes. Collectively, these features give the Asian eyelid more fullness, a lower lid crease and a narrower palpebral fissure.
Medially, the superficial heads of the upper and lower pretarsal muscles join to form the medial canthal tendon. This tendon is firmly attached to the anterior lacrimal crest. The superficial heads of the preseptal muscles attach to the medial canthal tendon.The deep heads of the preseptal and pretarsal muscles attach to the posterior lacrimal crest, just behind the lacrimal sac. Laterally, the upper and lower pretarsal muscles join to form the lateral canthal tendon, which inserts just posterior to the orbital tubercle. The upper and lower preseptal muscles join laterally to form the lateral palpebral raphe, which is attached to the skin.
BLEPHAROPLASTY – PREOPERATIVE CONSIDERATIONS
During the complete medical history, one should inquire about a history of diabetes, hypertension, coagulopathy, hypothyroidism, hyperthyroidism, renal disease, cardiopulmonary disease or glaucoma; each of these diseases can have a role in eye symptomatology and effect postoperative recovery. Patients with a history of collagen vascular diseases, such as scleroderma, systemic lupus erythematous, periarteritis
nodosa, Wegener’s granulomatosis, Stevens-Johnson syndrome, rosacea, rheumatoid arthritis, or secondary Sjögren syndrome have a higher risk of postoperative dry eye syndrome. Finally, elicit an ophthalmologic history. This includes previous eyelid surgery, eyelid trauma, eyelid infection, eyelid allergy, eyelid swelling, the use of glasses or contact lenses, and changes in visual fields and/or visual acuity.
The physical examination first includes looking at the full face. Note facial appearance, asymmetry and wrinkles. Examine the periorbital area for crow’s feet, fine wrinkles (at rest and with smiling), and the appearance of the globes, infraorbital rims, cheeks and malar bags.
Assess for negative vector (in the lateral view: anterior most projection of the globe, the lower eyelid margin and the malar eminence).
A negative vector is one which angles posteriorly and indicates an absence of support for the lower lid). Patients with a negative vector are at higher risk for postoperative dryness. Note any pseudoherniated orbital fat and hypertrophied orbicularis muscle.
Pressure on the upper eyelid and globe causes pseudoherniated orbital fat in the lower eyelid to be more evident. Having the patient look upward can help to delineate the lower eyelid fat pockets. Examine the eyelids for discoloration, hypertrophied skin and skin lesions. Excessive skin produces a crepe-like quality in the lower eyelid skin. Also, note the position of the lacrimal gland, in particular whether or not it has fallen from the lacrimal fossa. Assess for Bell’s phenomenon.
The Schirmer’s I test may be performed by placing a 5 x 35 mm strip of #41 filter paper between the lower lateral lid and globe for 5 minutes. This test measures both basic and reflexive tear production. Less than 10 mm of moisture on the paper suggests that the patient may be at risk for postoperative dry eyes. The Schirmer’s II test measures only basic tear secretion by blocking reflex secretion with a topical anesthetic.
The snapback test is performed by grasping the lower eyelid skin and pulling the lid away from the globe. The rapidity with which the lid snaps back against the globe gives an estimate of the probability of postoperative ectropion.
Begin the procedure by marking the lower border of the skin resection with the patient in the upright position. This curvilinear line is usually located 10 mm above the lid margin in the natural eyelid crease. The upper border of the skin resection is usually estimated by a pinch test; there should be 15-18 mm of skin between the upper border of the skin resection and the eyebrow. Infiltrate local anesthetic evenly throughout the upper eyelid. Excise the skin and achieve hemostasis with pinpoint electrocautery. Resect a sliver of orbicularis oculi muscle to reveal the preaponeurotic fat. The preaponeurotic fat is resected as desired, and the orbital septum is opened in defined points at the medial and central fat pads or along its length. Excess orbital fat is estimated by applying gentle pressure to the globe. This excess fat is resected
with care taken to ensure hemostasis. The skin then is reapproximated, and the procedure is complete.
LOWER LID BLEPHAROPLASTY, SUBCILIARY
At the start of the subciliary blepharoplasty approach, a Frost suture can be placed in the gray line lateral or medial to the limbus to facilitate retraction and protect the
globe. Alternatively, a lubricated corneal shield may be inserted. An incision is made just lateral to the lower lid margin. A scissors is used to develop a subcutaneous plane across the subciliary margin and complete the skin incision. Care is taken to protect the lashes. A skin-only or skin-muscle flap can be created to gain access to the orbital fat. If a skin-only flap has been elevated, the orbicularis is opened by incisions over
the medial, central and lateral compartments. If a skin-muscle flap is chosen, all three fat compartments are in plain view. The inferior oblique muscle is identified between the medial and middle fat pads, and it is protected easily.
The lateral compartment is slightly higher than the middle and should be identified carefully because it is the most common compartment to be overlooked. After resecting the orbital fat, a conservative skin excision is performed and the skin is closed.
LOWER LID BLEPHAROPLASTY TRANSCONJUNCTIVAL
Two approaches to transconjunctival blepharoplasty are used: retroseptal and preseptal. The retroseptal approach is taken by incising from the caruncle to the lateral canthal area at a level half way between the inferior margin of the tarsal plate and the fornix. A traction stitch can be placed through the upper conjunctiva.
The orbital fat pads can be assessed and excess fat resected to the level of the orbital rim. Once the fat is resected, some surgeons will close the transconjuctival incision with absorbable sutures, but most will realign the incision without suturing.
In the preseptal approach, the incision is made through the conjunctiva below the tarsus, and a dissection plane is developed between the orbicularis muscle and the orbital septum. The orbicularis is opened by incisions over the medial, central, and lateral compartments, and the fat is resected. Closure is the same as above.
There are many techniques to suspend the lateral border of the lower tarsal plate. Classically, the lateral canthus is sutured to Whitnall’s tubercle, which is located about 1 cm inside the lateral orbital rim. The purpose of any type of lateral tarsal suspension is to simply tighten the lower lid, improve its coaptation against the globe, and reduce the incidence of postoperative ectropion.
A small composite wedge resection of the lateral lower lid is an alternative to lateral suspension procedures. This procedure is designed to take up slack in the lower lid and improve lid position. However, some surgeons argue that wedge resection shortens the aperture of the eye and causes a rounding of the lateral palpebral
BLEPHAROPLASTY, EYELID SURGERY, POST OPERATIVE CARE
The patient should stay in an observational area after surgery for at least 1-2 hours. Ice water-soaked gauze compresses should be applied continuously for 24-48 hours to decrease swelling, as well as to reduce postoperative pain. Additionally, the patient’s head should be elevated greater than 45˚ to decrease edema and the collection of sanguinous fluid. Ocular lubrication with artificial tears should be prescribed, particularly if the patient has a preexisting history of dry eyes or if postoperative lagophthalmus is present. The patient should avoid any strenuous activity. Stitches are removed in clinic in 3-7 days.
The most concerning postoperative complication is a retrobulbar hematoma (bleeding posterior to the orbital septum). The incidence is about 0.04%. This complication is more likely to occur in hypertensive patients with intraoperative hypertension. Thus, adequate pain control during the procedure becomes equally as important as precise cauterization of vessels. Significant retrobulbar hemorrhage will lead to visible protrusion of the globe initially and then to a rapid increase in intraocular pressure to greater than 30 mm Hg (normal = 10-20 mm Hg). As the intraocular pressure approaches diastolic levels, the risk of total vision loss increases dramatically. Clinically, the signs and symptoms include acute pain, proptosis, chemosis and opthalmoplegia. The globe and lid may become hard to palpation.
Acute orbital hemorrhage is a medical and surgical emergency. An emergency ophthalmology consult should be obtained, but treatment should not be delayed. Treatment includes immediate suture removal, wound exploration and lateral canthotomy. Mannitol, acetazolamide and steroids may be administered to reduce
intraocular pressure. Anterior chamber paracentesis and bony orbital decompression are rarely used.
Diplopia in the early postoperative period is not uncommon. It may be caused by edema or anesthesia infiltration of the extraocular muscles. Long-lasting diplopia is extremely rare and may be caused by damage to the inferior oblique muscle, which is especially vulnerable during the transconjunctival approach.
Management is supportive.
Post-blepharoplasty ptosis occasionally occurs secondary to edema and ecchymosis.
In these cases the ptosis is temporary and usually resolves after 2-3 weeks.
However, the most frequent cause of postoperative ptosis is the failure to recognize it preoperatively. Early postoperative asymmetry is best managed by time and gentle massage of the higher crease. Ptosis lasting longer than 3 months requires reexploration.
The incidence of scleral show is reported to be as high as 15% in some series.
Many surgeons suggest the principle cause of lower eyelid malposition is unrecognized laxity in the tarsoligamentous sling. In addition to scleral show, ligamentous laxity tends to cause rounding of the lateral palpebral fissure. Treatment is conservative with massage therapy for 2-3 months. The round eye appearance may improve slowly with time and gentle upward massage. Lateral canthopexy can be done if
symptoms persist. It is important to remember that minimal skin should be excise in a lower blepharoplasty.
Although ectropion is one of the most commonly discussed complications of lower blepharoplasty, its incidence is estimated to occur in less than 1% of patients.
The best treatment is prevention by attention to lower lid laxity and conservative skin and orbicularis excision. Ectropion is usually treated by massage therapy and taping for at least 3 months. If the ectropion persists, tightening procedures or skin grafts can be performed.
Lagopthalmos is the inability to completely close the eyes. It occurs immediately after surgery due to swelling and local anesthesia impairment of orbicularis oculi function. Lagopthalmos requires treatment with eye lubricants to protect the cornea and reduce irritative symptoms. Persistent lagopthalmos is probably related to the amount of skin excised from the upper lid and not the amount of muscle excised. In most cases, lagopthalmos resolves as the wound matures.
Mild dry eye syndrome secondary to lagopthalmos is a common transient problem.
However, it can produce corneal ulcerations that may threaten vision. All patients should be provided with ocular lubricants.
PEARLS AND PITFALLS
It is important to identify ptosis preoperatively. Possible causes of ptosis include trauma, chronic progressive external ophthalmoplegia, Horner’s syndrome, myasthenia gravis, levator dehiscence and upper lid tumors. Pseudoptosis is excess skin that causes hooding and depression of the upper lid. Pseudoptosis can be differentiated from true ptosis by elevating the excess skin with a cotton-tipped applicator.
Ptosis, particularly asymmetric ptosis, should be highlighted for the patient preoperatively.
Operative correction is dictated by the cause of ptosis.
Preoperative testing for dry eyes (e.g., Schirmer’s tests) may have a poor positive predictive value. The best predictors of postoperative dry eyes are abnormal ocular history or abnormal orbital anatomy.
Abnormal ocular anatomy includes: scleral show, lagopthalmos, lower lid hypotonia, proptosis, exopthalmos and maxillary hypoplasia.
Patients with one or more of these anatomic findings should be provided with additional preoperative warnings and postoperative ocular protection.
Although ectropion is uncommon, the surgeon must have a high preoperative index of suspicion. Ectropion may be prevented by a variety of lateral canthal tightening procedure. The senior author prefers a Kunt-Simonowsky lid shortening procedure for lower risk patients and a lateral canthopexy for higher risk patients.
Correcting an ectropion is more difficult than preventing an ectropion.
HOW MUCH DOES BLEPHAROPLASTY COST
The average cost of blepharoplasty is $4,000 and $6,000, and this price normally does not include pre and post-operative care and medication.
BLEPHAROPLASTY BEFORE AND AFTER – PICTURES, PHOTOS AND VIDEO