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UPPER LID BLEPHAROPLASTY
UPPER LID BLEPHAROPLASTY
Upper lid blepharoplasty with en bloc excision of upper lid skin, orbicularis oculi muscle, and/or orbital fat is the gold standard for the correction of dermatochalasis, and there are records of it being performed as far back as 2000 years ago.48 There are variations described for the ideal skin marking for upper lid blepharoplasty.49โ51 One large retrospective series of over 400 patients aimed to determine the optimal blepharoplasty markings to avoid lateral skin excess, medial fullness, and an incision that is beyond the orbital rim.52 The group concluded that the medial extent of the
incision should end 6 mm lateral to the angular vein, and the lateral extent should end 12 mm lateral to the interpalpebral fissure and extend superiorly at a 45-degree angle. Others support an arcuate or lenticular skin excision design.53 For some, the most important aspect is a slight upward angle at both the medial and lateral ends of the wound to prevent webbing.15 Most advocate for leaving at least 1 cm of sub-brow skin or 20 mm of total remaining anterior lamella after skin excision according to Flowerโs rule.16,52 Regardless of which design is chosen, the โpinchโ technique can also help guide the maximal allowable skin excision without induction of lagophthalmos.6
There is debate in the literature as to whether it is better to excise skin alone or skin and orbicularis muscle. Much of this controversy stems from the common complication of postoperative lagophthalmos. There are also varied opinions about different aesthetic outcomes if skin versus skin and muscle are removed. There are several well-designed, prospective studies addressing this question. While most of these studies are small (22 patients at the most), they all were designed in a split face fashion, were randomized, and used blinded graders for outcome assessment.
Kiang et al. sought to examine the degree of lagophthalmos in eyes that had skin only compared to skin and muscle excision. Over a 6-month follow-up period, lagophthalmos only occurred in eyelids that had more than 8 mm of orbicularis oculi muscle excised, suggesting that lesser amounts of muscle excision may not affect eyelid function.54 Interestingly, the lagophthalmos resolved in most patients by 6 weeks postoperatively, suggesting that there may not be long-term sequelae even if larger amounts of muscle are removed. A similar conclusion was made in a small primate study where postoperative lagophthalmos was assessed based on the degree of orbicularis muscle excision. Lagophthalmos was only noted in monkeys that had all three segments of orbicularis removed (pretarsal, preseptal, and orbital), but not with smaller amounts excised.55 Damasceno et al. found that there were significantly slower healing times and worse aesthetic ratings in the skin and muscle group compared to the skin only group during the early postoperative period. However, by 2 weeks after surgery, both groups were graded to be the same.5 Conversely, others have found that there are no differences in aesthetic outcomes at any time point between eyelids with skin only versus skin and muscle excision.56
Traditional upper lid blepharoplasty has centered on reductive principles, with the goal to excise variable amounts of skin, muscle and fat. Unlike lower blepharoplasty, less attention has been given to conservation and repositioning of upper lid volume. However, superior sulcus hollowing is a common postoperative complication,57 prompting a recent shift toward volume preservation in upper lid blepharoplasty as well.50,58 There are many techniques described in the literature to address a sunken superior sulcus in upper lid blepharoplasty, including autologous fat grafting. The
science of surgical microfat grafting is still lacking in robust evidence-based support, though several general principles have been recommended: (1) the donor site is unimportant in graft survival rates, (2) aspirated fat with large bore needles is better than excised fat for long-term survival, and (3) fat injection is best performed with a fine cannula with multiple passes at varying depths.59 While supraperiosteal microautologous fat injection is well described for volume replacement in the upper lid, there are reports of success with fascia-fat composite grafting, dermis-fat grafting, and small aliquots of hyaluronic acid.37,60-63
Nasal fat pad repositioning by creating a fat pedicle with central or lateral repositioning is also effective at preserving upper lid volume, and may also be a useful adjunct to blepharoplasty.9,64 Transconjunctival upper eyelid blepharoplasty has been described as a favorable approach in select patients who have a prominent nasal fat pad, but minimal or absent upper lid dermatochalasis.65โ68 The main advantage of this technique is avoidance of an upper eyelid incision. It has also been effective in patients with isolated medial fat prolapse undergoing concurrent brow lift.69,70