Keywords

Fortunately, when performed carefully and on patients with realistic expectations, blepharoplasty surgery is very rewarding for the patient and the surgeon. Over the last 16 years of performing blepharoplasty surgeries, I have been very grateful to my surgical mentors for teaching the fundamentals but also the multitude of very understanding patients that have taught me through their outcomes how to continually improve. The following tips have been acquired either personally or adopted by listening to and observing “master” eyelid surgeons.

  1. 1.

    Lateral upper “eyelid fat” is really the lacrimal gland. Fixate it with Prolene or polyglactin suture intraoperatively if it is noticeably prolapsed inferiorly. If the lacrimal gland is causing prominent lateral upper eyelid bulges preoperatively, then often tightening the overlying septum with cautery will help improve the postoperative appearance.

  2. 2.

    Post-op patients that are suffering from excessive dry eyes despite compliance with recommended ocular lubricant therapy may benefit from forehead botulinum toxin to relax the frontalis and help with eyelid closure. Furthermore, neuromodulatory relearning with botulinum toxin can be performed early for patients that cannot seem to break years of overusing their frontalis muscle action to see better (Ben Simon et al. 2005).

  3. 3.

    Do not fix brow ptosis with an upper blepharoplasty. I often perform these surgeries simultaneously when indicated, but often take care of patients that had other surgeons erroneously perform an upper blepharoplasty when the patient actually needed brow ptosis repair. This will often leave insufficient upper eyelid skin when a fully corrected brow ptosis is what was and is still needed.

  4. 4.

    General suturing tips. I have gravitated toward closing blepharoplasty incisions with running 7-0 Prolene, which is sufficiently strong but easier and more comfortable to remove than 6-0, as it pulls through the tissue easier. Clinically, I have noted fewer suture milia at the incision lines when utilizing 7-0 Prolene especially compared to absorbable running sutures. The 7-0 Prolene works well for levator advancement and resection ptosis repair cases as well, and if a slight overcorrection occurs, it is easier to massage the overcorrected eyelid downward postoperatively having used this thinner suture for the levator passes. The suture passes between the medial and lateral canthal angles are under less tension and only need to include the skin; whereas the lateral most portion is generally under more tension and closes with better strength by incorporating orbicularis into the suture passes. Only incorporating the highly vascular orbicularis laterally minimizes rebleeding risk during suturing and postoperative bruising risk. If bleeding does occur with a suture pass, pressure with a cotton-tip applicator to the site will often stop the bleeding or, more rarely, the wound sutures can be loosened and cautery applied. On upper blepharoplasty incisions, a single interrupted suture at the outer 1/3 and the inner 2/3 junction, the area of greatest wound tension, is helpful and reduces wound dehiscence risk. When performing running suture closure, I find tying the medial knot with or without a loop a few millimeters above the skin allows for easier suture removal, as one does not have to “dig” into the skin during removal to get at the knot (Fig. 27.1). A suture loop further facilitates grasping of the suture and is more comfortable to the patient than tying the knot tightly and directly onto the skin surface. Furthermore, starting the incision a few (~4) millimeters within the medial and lateral ends allows for wound fluid egress in the first 24–48 hours postoperatively reducing bruising and swelling. Additionally, starting the running suture a few millimeters laterally reduces the risk of nasal area skin tension lines. Too often, in my experience, running absorbable sutures either dissolve too quickly or alternatively persist too long leading to patient frustration. In young to middle-aged patients, they can also result in more wound itching and erythema. Therefore, when utilizing absorbable sutures, I think simple interrupted passes result in better wound cosmesis and less frustration from overly persistent suture material or suture tract formation.

    Fig. 27.1
    figure 1

    Tying of the first suture knot at a loop above the skin a few millimeters and lateral to the medial end helps with postoperative suture removal

    Full size image
  5. 5.

    When performing upper blepharoplasty, I strongly encourage patients with any lower eyelid laxity or dry eyes to undergo simultaneous lateral canthal resuspension. This can be very easily performed from an internal approach without having to perform a lateral canthotomy (Taban et al. 2010; Georgescu et al. 2011). My preferred suture material is 5-0 antibiotic-coated polyglactin (VicrylTM Plus) as I have seen fewer suture abscesses since switching to this variation. Utilization of a P-3 needle allows for easy passage and suture incorporation of the inferior crus of the lateral canthal tendon. Lateral canthal resuspension and midface elevation can also reduce lateral blepharoplasty scarring by reducing wound tension and eliminating dead space by the placement of these deep sutures. It also helps reduce blepharoplasty-induced lateral brow ptosis by reducing downward tension.

  6. 6.

    For Asian patients, be sure you figure out what they want and you do not “westernize” them if they do not wish this. I have generally found suture passes to the levator aponeurosis as unnecessary increase formation, if meticulous incisions are made. When removing orbicularis, it is essential at the inferior portion of the incision that orbicularis be completely removed all the way down and across the entire length of tarsus. This fosters formation of the eyelid crease at this incision placement location.

  7. 7.

    Address facial asymmetry preoperatively and educate patients on what can and cannot be achieved through soft tissue surgical manipulation alone. Subtle brow asymmetry can often be greatly improved by removing more eyelid skin from the side that is higher, which will pull it more inferiorly postoperatively. Furthermore, internal brow elevation techniques performed unilaterally can be helpful with or without internal fixation for the lower side (Burroughs et al. 2006). Figure 27.2 shows a female optometrist that had marked preoperative brow asymmetry. During her upper blepharoplasty, greater skin was removed from the right side to pull the right brow downward, and internal brow elevation was performed on the left side to lift this side and improve her postoperative symmetry. Botulinum toxin is also a useful option to further improve brow asymmetry postoperatively.

    Fig. 27.2
    figure 2

    A 35-year-old female optometrist that underwent combined upper and lower fat transposition blepharoplasty. Note the preoperative brow asymmetry that was remarkably improved by removing greater skin on the right side and only performing internal brow elevation on the left side

    Full size image
  8. 8.

    Do not over sculpt upper eyelid fat to avoid feminization of male patients, and especially in the central eyelid to avoid an A-frame deformity. Oftentimes, for patients with only minimal fat prolapse, I will “thermo-liposculpt” by just tightening the septum with cautery and not remove fat if the tightening effect alone appears to reduce the fat “bulges” sufficiently. In most patients, only the medial fat pads need sculpting. Therefore, I advocate only opening the septum nasally. Alternatively, some patients with age-related superior sulcus deformities can be improved by releasing the septum across the full upper eyelid to allow the orbital fat to prolapse forward and help create a more youthful, fuller upper eyelid. I have also found some patients benefit by transferring some fat from areas of over prominence to areas of hollowness in the upper eyelids to be helpful analogous to lower eyelid fat transposition. It is critical in these patients to mark these areas prior to injection and making of the incisions and/or to have preoperative photographs available to refer to intraoperatively.

  9. 9.

    Lateral wound healing in my experience is better when orbicularis is removed fully from the lateral most portion contained within the upper blepharoplasty incisions. This allows the incision to close more flush with the surrounding periocular tissue and may help reduce lateral brow ptosis and the crow’s feet. To avoid a lateral dog-ear deformity, an assistant can use a skin hook to straighten the wound incisions aiding suture placement, and with more experience, this can be avoided by making the superior incision widths wider than the inferior suture bites, which need to be more closely placed.

  10. 10.

    Fix simultaneous dermatochalasis and blepharoptosis whenever possible. Patients need to be shown with a mirror and picture examples of the differences between ptosis of the eyelid margin and overhanging skin. This way, if they decline to have both addressed, it can be documented that this was explained helping to minimize postoperative dissatisfaction. Alternatively, a quick levator advancement for a subtle blepharoptosis in a patient with dermatochalasis goes a long way toward patient satisfaction and positive feedback.

  11. 11.

    For beginning cosmetic blepharoplasty surgeons, it is prudent to remind yourself that “less is more,” to avoid removing too much skin. It is easy after doing a high volume of functional cases to potentially be concerned that you are not doing enough for the patient if only a few millimeters of skin is removed; yet, that may be all that is necessary. It is always easier to go back to remove a little more, but never optimal to have to add skin back.

  12. 12.

    Lastly, a useful guiding principle to ask before every blepharoplasty case is what needs to be done, if anything, to improve the symmetry and/or appearance of the upper eyelid creases, steatoblepharon, hollowness, lacrimal gland positions, eyebrow positions, skin quality, and eyelid contour and positions. This has to of course coincide with careful discussion preoperatively with the patient’s concerns and goals. Simply doing the same exact procedure every time and bilaterally will not lead to optimal success. These assessments and management become more intuitive with experience, but I still find it very helpful to draw preoperative arrows and circles on the skin as guides and reminders intraoperatively to ensure the various issues are effectively addressed.