Keys to Success When Marking the Skin in Upper Blepharoplasty

Abstract

It is critical to maintain symmetry in the height, depth, and fold of the eyelid crease, which is paramount in the success of the upper blepharoplasty. We avoid medial webbing by drawing a gentle upturn to the medial incision markings. Laterally we extend the markings to approximately 5 mm above the lateral canthus, then upturn to hide the lateral incision and to avoid elevation of the temporal eyelid crease.

• There are few procedures in oculofacial plastic surgery more gratifying for both functional and cosmesis improvements to the surgeon and patient than upper blepharoplasty. Keys to success are a strong patient-physician relationship and making certain goals that are also realistic expectations.

• One should avoid removing upper eyelid skin that would leave less than 20–22 mm between the eyelid margin and the brow cilia to avoid lagophthalmos and lowering of the brow tissues. Older patients with dry eyes may need 25 mm of upper eyelid skin maintained. Many patients require internal brow elevation through the blepharoplasty incision to obtain optimal results. In fact, when adequate skin cannot be left after marking the eyelids, then the brows should instead be raised. For patients with thin or plucked eyebrow cilia, the transition zone between thin more wrinkled eyelid skin and the thicker brow skin should be used for measuring to ensure adequate skin is left behind.

• Patients should be marked in an upright position as the brows elevate in a supine position.

• We advise patients to wear no makeup or moisturizer on the day of surgery, and wipe the skin with alcohol and dry gauze to remove oils prior to marking to ensure that the surgical markings will remain after patient prepping.

• We use the extra fine point skin marker by Scanlan® (1-800-328-9458), which allows very precise marking (Fig. 23.1). The white bottom cap of the marker is approximately 10 mm in length and readily serves as a quick way to estimate the placement of the incision markings (Fig. 23.2). For patients with poor or multiple eyelid creases, the bottom cap measurement technique is a quick way to ensure symmetry for incision placement.

  Fig. 23.1

  

  Scanlan^® marking pen with a white bottom end-cap that is approximately 10 mm in length

  Fig. 23.2

  

  Blepharoplasty skin marking showing gentle medial and lateral upturn and white end-cap being used to measure at least 10 mm of skin between the upper marking and the brow cilia. Note that the thinner eyelid skin transition to the thicker brow skin also quickly demarcates the upper extent of the incision

• We advise against placing the lower skin incision lower than 9–10 mm unless the natural crease is lower. Simply marking the patient’s natural eyelid creases can be quite variable, and in acquired ptosis patients may be higher than normal. Symmetry in the lid crease markings is paramount in upper blepharoplasty.

• We mark the upper incision in the sitting position by having the patient gaze straight ahead to help determine the upper extent of the upper blepharoplasty incision. Upon up gaze the upper skin will fold upon itself, which is a also quick visual marker for where to place the upper marking. The bottom white cap of the Scanlan™ marker is then used to quickly check that at least 10 mm of eyelid skin remains above and below the marked areas (Fig. 23.2).

• It is critical to maintain symmetry in the depth and fold of the eyelid crease. We avoid medial webbing by drawing a gentle upturn at the most medial incision marking (Fig. 23.3). Laterally we extend the markings to approximately 5 mm above the lateral canthus then upturn to hide the lateral incision and to avoid elevation of the temporal eyelid crease. Incisions should not extend beyond the lateral orbital rim to lessen scarring. If aggressive midface elevation through the upper eyelid incision is to be done, then the lateral skin marking may proceed slightly more inferiorly as the midface elevation will recruit skin into this area and could cause a lateral prominence of excess skin, which can otherwise take several weeks or longer to smooth out. Adequate lateral canthal resuspension helps avoid this situation as well.

  Fig. 23.3

  

  Blepharoplasty skin marking showing gentle medial upturn to avoid medial webbing and lateral portion extending within 5 mm of lateral canthus. The lateral upturn and keeping within the outside of the orbital rim helps hide the incision temporally