Blepharoplasty

Blepharoplasty, from Ancient Greek βλέφαρον (blépharon), meaning “eyelid”, and πλαστός (plastós), meaning “moulded”, is the plastic surgery operation for correcting defects, deformities, and disfigurations of the eyelids; and for aesthetically modifying the eye region of the face. With the excision and the removal, or the repositioning (or both) of excess tissues, such as skin and fat, and the reinforcement of the corresponding muscle and tendon tissues, the blepharoplasty procedure resolves functional and cosmetic problems of the periorbita, which is the area from the eyebrow to the upper portion of the cheek. The procedure is more common among women, who accounted for approximately 85% of blepharoplasty procedures in 2014 in the US and 88% of such procedures in the UK.[1][2]

The operative goals of a blepharoplasty procedure are the restoration of the correct functioning to the affected eyelid(s) and the restoration of the aesthetics of the eye-region of the face, which are achieved by eliminating excess skin from the eyelid(s), smoothing the underlying eye muscles, tightening the supporting structures, and resecting and re-draping the excess fat of the retroseptal area of the eye, in order to produce a smooth anatomic transition from the lower eyelid to the cheek.

In an eye surgery procedure, the usual correction or modification (or both) is of the upper and the lower eyelids, and of the surrounding tissues of the eyebrows, the upper nasal-bridge area, and the upper portions of the cheeks, which are achieved by modifying the periosteal coverings of the facial bones that form the orbit (eye socket). The periosteum comprises two-layer connective tissues that cover the bones of the human body:

the external layer of networks of dense, connective tissues with blood vessels, and
the internal, deep layer of collagenous bundles composed of spindle-shaped cells of connective tissue, and a network of thin, elastic fibres.

Illustration for upper blepharoplasty

Illustration for lower blepharoplasty

The East Asian blepharoplasty procedure differs from the classic blepharoplasty. In younger patients, the goal of the surgery is to create a supratarsal fold (“double eyelid surgery”) whereas in older patients the goals are to create or elevate the supratarsal fold and to resect surplus eyelid skin (“Asian blepharoplasty”).[3][4]

Medical uses

The thorough pre-operative medical and surgical histories, and the physical examination of the patient’s periorbital area (eyebrow-to-cheek-to-nose), determine if the patient can safely undergo a blepharoplasty procedure to feasibly resolve (correct or modify, or both) the functional and aesthetic indications presented by the patient. Sequentially, lower eyelid blepharoplasty can successfully address the anatomic matters of excess eyelid skin, slackness of the eye-muscles and of the orbital septum (palpebral ligament), excess orbital fat, malposition of the lower eyelid, and prominence of the nasojugal groove, where the orbit (eye socket) meets the slope of the nose.[5]

Concerning the upper eyelid, a blepharoplasty procedure can resolve the loss of peripheral vision, caused by the slackness of the upper-eyelid skin draping over the eyelashes; the outer and the upper portions of the field of vision of the patient are affected and cause him or her difficulty in performing mundane activities such as driving an automobile and reading a book.[6]

Illustration for upper and lower blepharoplasty

Procedures

A blepharoplasty procedure usually is performed through external surgical incisions made along the natural skin lines (creases) of the upper and the lower eyelids, which then hide the surgical scars from view, especially when affected by the skin creases below the eyelashes of the lower eyelid. The incisions can also be made from the conjunctiva, the interior surface of the lower eyelid, as in the case of a transconjunctival blepharoplasty, the removal of orbital fat for the cosmetic modification of the lower eyelid.[7,8]

Illustration for transconjuntival lower blepharoplasty

Transconjunctival lower blepharoplasty technique was pioneered by Clinical Professor of Surgery at the University of Chicago Medicine,[9] Dr. Anthony J. Geroulis[10] and introduced to medical trial in 1998. This technique is particularly useful for patients with darker skin tones where standard external incision often leaves a visible white scar. In my daily practise, especially in young patiens with eyebag, transconjunctival lower blepharoplasty is one of my favorites.

Illustration for transconjuntival lower blepharoplasty

Transconjunctival blepharoplasty technique permits the excision (cutting and removal) of the lower-eyelid adipose tissue without leaving a visible scar, but the technique does not allow the removal of excess eyelid-skin.[6]

A blepharoplasty operation typically takes 1 hour to complete, and in most cases, it is completed in under an hour. Post-operatively, swelling and bruising are expected and will usually resolve without further intervention. Applying cold compresses can help reduce the duration and discomfort.[11] There are no standardized outcome measures for upper or lower blepharoplasty.[11] Blepharoplasty is generally a relatively safe surgery, but possible complications include hematoma/ecchymosis, lagophthalmos (incomplete or abnormal closure of the eyelids), ptosis (drooping of the upper eyelid), scarring, dry eyes, orbital hematoma/compartment syndrome, lymphedema, and ocular motility disorders.[12]

After the procedure, a type of stitch known as a canthopexy is placed near the outer corner of the lower eyelid, which is inside the tissue. This allows the eyelid’s position to remain fixed during the healing process. The canthopexy is dissolved after four to six weeks of use. However, canthopexy is optional and I use this technique for some of my patients. For particular patients, a mid-face elevation may be required to rejuvenate the lower eyelid-cheek complex.

The anatomic condition of the eyelids, the “wear-and-tear” quality of the patient’s skin, age, and the general condition of the adjacent tissues affect the functional and aesthetic results achieved.

History

As techniques began developing the ancient Greeks and Romans began writing down and collecting everything they knew involving these procedures. Aulus Cornelius Celsus, a first-century Roman, described making an excision in the skin to relax the eyelids in his book De Medicina.[13]

Karl Ferdinand von Gräfe coined the phrase blepharoplasty in 1818 when the technique was used for repairing deformities caused by cancer in the eyelids.[12]

Laser

Laser blepharoplasty is the performance of eyelid surgery using a laser instead of a scalpel. Laser blepharoplasty is often combined with laser eyelid rejuvenation, as the two procedures can be performed in conjunction. In my clinic, I use CO2 laser to enhance our patients’ results.

CO₂ laser blepharoplasty offers many benefits over a blepharoplasty performed using a scalpel. Some of these benefits include less bleeding, shortened surgical time, better intraoperative visibility, less bruising and swelling, less pain or discomfort, and smoother healing.[14]

References

^“2014 Plastic Surgery Statistics Report” (PDF). American Society of Plastic Surgeons. p. 12. Archived from the original (PDF) on 16 June 2015. Retrieved 31 March 2016.
^Sedghi A (3 February 2014). “UK cosmetic surgery statistics 2013: which are the most popular?”. The Guardian. Retrieved 31 March 2016.
^Weng CJ (February 2009). “Oriental upper blepharoplasty”. Seminars in Plastic Surgery. 23 (1): 5– doi:10.1055/s-0028-1110096. PMC 2884894. PMID 20567720.
^McCurdy JA (February 2005). “Upper blepharoplasty in the Asian patient: the “double eyelid” operation”. Facial Plastic Surgery Clinics of North America. 13 (1): 47– doi:10.1016/j.fsc.2004.07.001. PMID 15519927.
^Rostami, Soheila; de la Torre, Jorge I.; Czyz, Craig N. (2022), “Lower Eyelid Blepharoplasty”, StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 28846282, retrieved 12 August 2022
^ Jump up to:^a ^b Rapp SJ, Pan BS, Kitzmiller WJ (2006). “Lower Lid Subciliary Blepharoplasty”. Medscape.
^“Los Angeles Eye Surgery 90210”. Oculoplastic Surgery. 3 February 2023. Retrieved 28 March 2023.
^“Eyelid Surgery NYC | Westchester NY Eyelid Surgery”. drberan.com. 11 March 2013. Retrieved 6 September 2018.
^“Anthony J. Geroulis”. University of Chicago Medicine Physician Bios. University of Chicago Medicine. 1998.
^Geroulis AJ (1998). “Eyelid Surgery Chicago Transconjunctival Techniques”. Archived from the original on 28 May 2015. Retrieved 28 May 2015.
^ Jump up to:^a ^b Alghoul, Mohammed (1 January 2019). “Blepharoplasty: Anatomy, Planning, Techniques, and Safety”. Aesthetic Surgery Journal. 39 (1): 10– doi:10.1093/asj/sjy034. ISSN 1527-330X. PMID 29474509.
^ Jump up to:^a ^b Bhattacharjee, Kasturi; Misra, Diva Kant; Deori, Nilutparna (July 2017). “Updates on upper eyelid blepharoplasty”. Indian Journal of Ophthalmology. 65 (7): 551– doi:10.4103/ijo.IJO_540_17. ISSN 1998-3689. PMC 5549405. PMID 28724810.
^Lazzeri D, Agostini T, Figus M, Nardi M, Spinelli G, Pantaloni M, Lazzeri S (June 2012). “The contribution of Aulus Cornelius Celsus (25 B.C.-50 A.D.) to eyelid surgery”. Orbit (Amsterdam, Netherlands). 31 (3): 162– doi:10.3109/01676830.2011.648816. PMID 22551367. S2CID 20670884.
^Morrow, D. M.; Morrow, L. B. (April 1992). “CO2 laser blepharoplasty. A comparison with cold-steel surgery”. The Journal of Dermatologic Surgery and Oncology. 18 (4): 307– doi:10.1111/j.1524-4725.1992.tb03676.x. ISSN 0148-0812. PMID 1560155.