Blepharoplasty

The History of Blepharoplasty

 In the 20th century these techniques have been refined. Miller’s incision (1907) follows the curve of the eyelid. Kolle (1911) considers the aesthetic side of the operation. Noel (1926) writes about the senilos ectropion. Bourguet (1928) defined the position of the fat between the muscle and the fascia more exact and suggests different incision techniques. Sayoc (1954) writes about the correction of the lack of the upper lid furrow. Roger (1959) writes about the use of the electrocauter in connection with the correction of the upper lid furrow. Millard (1964) and Khoo-Boo-Chai (1976) write about Asian-type eye surgery, which was necessary because of the high number of mixed marriages. Rees (1980) describes the treatment of ectropion in great detail. In the past few years chemical peel, lasers and Botulin toxin have been used for the treatment of the wrinkles around the eye.

 

Relaxation of the Eyelid, or Blephachalasis (Fuchs)

It occurs rarely and is typical for young women mainly. Its features are: the skin is thin and creasy, the furrow on the upper lid disappears and the adipose tissue around the eye slips forward because of the weakness of the orbital septum. The reasons of this illness sre not known. Both sides are affected, the upper lid even a bit more. Cases of familiar inclination have been reported.

Baggy lids, or Dermatocholasis

It is frequently detectable on old people. The main reasons are loosened skin, the rupture of the orbital fat caused by the weakness of the connective tissue and sagging eyebrows. Both the the upper and the lower lids are affected, and it can occur in both sexes. The insufficiency of the middle septum is most frequent and it causes swellings in the middle of both the upper and lower lids.

Hypertrophy of the m. orbicularis oculi

The festoons muscle (Furnas, 1978) lies as a stiff cross-bar on the upper lid below the eyelashes.

Herniated orbicular fat

This is a misleading name, as it is not the real herniaton of the orbital fat, but a pseudohernia. It is the orbital septum that is lengthened and so pseudohernia comes about. It is typical on young patients, in the case of old patients it is just one component of all the symptoms.

Hanging eyebrow

If the eyebrow reaches lower than the upper curve of the orbita, often it induces extra skin for the upper lid. The field of sight can be narrowed in extreme cases.

Old-age eyelids

It may be the joint occurrence of the upper cases or another degenerative deformity of the eyelids, like the loss of elastic fibers, atrophy, which can result in ptosis or ectropion.

 

Patient Checkup, Consultation

The most important task is to clarify the expectations of the patient and what the doctor can and cannot do as the treatment. A good method is hending a mirror to the patient so that he can show us what he finds disturbing and what results he expects. The classification of surgical possibilities can save the patient and the doctor much trouble. Fine wrinkles, crow’s feet or pigment spots cannot always be removed during the eye syrgery. The nasolabial furrow and the upper lids do not change with lower lid surgery.

We can draw many conclusions with simple obsevations:

• • Lagophtalmus may be the sign of hyperthyreoidism, its examination is advisable therefore. Even if it is acquired, after the operation it can become more prominent.
• • Acquired ptosis develops especially on middle-aged and old people, the most common reason for it is the lengthening of the levator palpabrae aponeurosis for unknown reasons. Therefore the patient should be examined for neuromuscular illnesses, as ptosis can be the sign of myasthenia gravis.
• • The sclera above the pupil is visible often because of the spasm of the Müller muscle, which can mean hyperthyreoidism. Thyroid illnesses may cause other striking deformities around the eye, eg. the edema of the eyelid.
• • In the case of exophtalmus, if the sclera is visible below, the upper excision has to be minimalised in order to avoid ectropion. Even a small-size exophtalmus can lead to many post-operative difficulties, so some warning signs should be detected on such patients: the hypoplasia maxilla, the blur curve of the orbita, the shallow orbita can be diagnosed at the physical checkup, and an x-ray will make it unambiguous.
• • myxedema is hypothyreoidic illness of the kidney, a general edema caused by a circulation deficiency that results in baggy eyes.
• • The number of blinks is important. Patients, who blink rarely, often have post-operative cornea problems, especially if tear production is reduced as well.
• • The different degrees of asymmetry are important to document, because some patients notice it only after the operation, the differences between the two eyes have to be clarified before the operation, therefore. The difference of the size and shape of the eyeballs can be seen easier post-operatively because the eyeball becomes bigger and the sclera gets visible.

 

Eyebrow Surgery

The reason for hanging eyelids are often sagging eyebrows. The patient is seated while drawing the incision lines. The relaxed eyebrow is set to the upper part of the orbita.

 

The Operation

We anaesthetise the area with 1% Lidocaine solution with Epinephrine. After a soft massage we wait 3-5 minutes.

 The lower incision follows the upper curve of the eyebrow hairs and runs parallel to the direction of hair growth.

We should start incising 2-3 mm from the medial end, so that the scar will not be disturbing. The incision runs centrally, laterally, at an angle of 30° upwards and is ended 2-3 mm from the end of the eyebrow. The upper incision is determined by the difference that is needed for the correct position of the eyebrow. We incise the skin with a blade of size 15 and cross cut the forehead muscles with scissors. 

If the sagging eyebrow is not symmetric, then we apply the above technique on the sagging side after the laurel-leaf shape incision.

 The skin is closed with knotted stitches using 6/0 silk or Prolen applying the continuous technique and considering the exact conciliation of the wound edges. After the operation we may apply some antibiotic creme on the area, and a bandage and a flexible head band is advisable as well. The sutures can be removed after 4-5 days. In order to relieve the scar, we can apply Steri strip for one week.

 

 General Aspects

Upper lid surgery has to follow eyebrow surgery, if both operations are advised. If any other facial surgery is performed (minilift, forehead surgery), it should precede eyelid surgery. However, often it is unnecessary to perform an early facial surgery, because of an eyebrow or eyelid surgery – especially in the case of young patients. We draw the incision lines in a lying position, we ask the patient to look up and down, so the physiological bending furrow becomes visible. On women this is usually in line with the midpupil, 10 mm from the eyelashes in the middle, on men the distance is 8 mm.

 

The medial edge should be 4 mm above the end of the lachrymal duct and 4 mm high at the edge of the lateral orbita. The curved linkage of these points results in the lower incision line, which bends upwards on both ends at an angle of 30°. It ends in a crow’s foot at the lateral side and does not reach beyond the lateral edge of the eyebrow. In order to draw th upper incision line, we gather enough skin with tweezers for the eye to open exactly 1 mm. The curved connection of the marks in the middle and at the two ends gives the upper incision line.

 

We should check the following before anaesthesia:

• • The two lower curves are symmetric and the lateral side continues in a crow’s foot.
• • The two upper curves are symmetric, the two ends are at equal heights at the edges of the orbita.

  

We inject 1% Lidocaine solution with Epinephrine in the subcutaneous tissue for sedation. After the massage we wait 2-3 minutes. We incise the skin with a blade size 15 and cross cut the superfluous with sharp dissection scissors starting from the lateral side. After this we divide the orbicular muscle from the skin with blunt scissors. It is recommended to keep the excised skin, so that we can compare its size to that of the other eyelid.

 The bleedings should be arrested. We softly feel the orbicular fat betwen the connective tissue. If there is no need for removal, we close the wound with 6/0 silk applying knotted stitches starting in the middle, and then at the central and lateral canthus. The advantage of knotted stitches is the better division of the different length wound edges. Further, we can apply continuous sutures with 6/0 Prolen, which makes suture removal easier.

 

The Removal of Superfluous Fat and Skin

If the orbicular muscle is loose and atrophic, we excise a parallel strip. If we assume superfluous orbital fat on the basis of the report, the fat pads hve to be examined beyond the muscles. Therefore we have to cross cut the muscle layer, even if there is no muscle atomy. We softly press the eyeballs, which makes the orbital fat protrude below the septum and can thus be removed.

 

We grab the septum with tweezers and incise with scissors. (This technique results in better visibility.) The superfluous fat is removed with tweezers, then undermining with the mosquito we grab the fat in the capsule and coagulate.

 

After the removal with the scalpel, we arrest the bleeding before slipping back the rest of the adipose tissue to its place. The fat is removed first in the middle, where the orbital fat is yellow-white and then centrally, where it is butter-white.

 

We have to watch the lachrymal gland and the lachrymal duct .

 We do not have to have a deep suture, although some people use 7/0 silk. The skin is closed like in the above technique. Antibiotic creme and antiseptic gauze with physiological saline can be put on the eye. Icing should be started as soon as possible and continued 24-48 hours. Suture removal is advised after 4-5 days and also for the sake of relief the application of Steri strip at the lateral canthus for a week. 

 Variations of the Operative Technique

The basic technique may vary individually:

• • After the correction of the ptosis, the development of the bending furrow may be necessary. At the skin sutures we make 1-1 stitches from the aponeurosis at the upper edge of the tarsus.
• • After the removal of the superfluous skin from the upper eyelid often a thick tissue remains below the eyebrow, which needs correction. This does not indicate a new incision, but the excision of the rest of the lengthened orbicular muscle after the undermining along the upper incision line. Usually we carry out this correction on both sides, and it is followed by the same procedure as already mentioned.
• • If the levator of the aponeurosis becomes visible, we can develop the bending furrow by excising a strip from the lengthened praetarsal orbicular muscle. We apply cross stitches afterwards.
• • The fat removed from the medial canthus can lengthen the curve of the incision, in which cases we excise a small triangle medially upwards, so that the original incision does not get closer to the lachrymal opening than 4 mm.

 

The post-operative swelling, discolouration can increase on the second day after the operation, which is usually not a consequence of new bleeding, but of the tissue edema that developed during the operation. The patient is advised to keep the wound clean and wipe the eyelid with a cotton bud with warm water and use no make-up for 2 weeks.

 

After the suture removal (4-6th day) a Steri strip is applied at the lateral ends for another week. The patient should come for control in the 1st, 3rd and 6th months of the post-operative period, when we can also take pictures of him.

 Lower Eyelid Surgery 

Similarly to upper eyelid surgery, the superfluous fat and skin are removed here as well. The incision line runs directly under the eyelashes in the full lengthe of the upper lid till the edge of the orbita, and ends 2 mm from the lateral canthus in an angle of 30° downwards in a crow’s foot. If we perform an upper lid surgery simultaneously, we should take care that there are 6-8 mm between the two incision ends. If we have to remove the orbital fat only, the lateral edge of the incision should reach no further than 2 mm beyond the lateral canthus.

 

We anaesthetise with the 1 % solution of Lidocaine with Epinephrine. With this we infiltrate the subcutaneous area and the deeper layer as well during the removal of the orbital fat.

 

The operation

We incise the skin with a scalpel blade size 15, in order not to shorten the lashes. We cross cut the skin with sharp dissection scissors starting from the outer edge. We make a stitch centrally on the upper edge with 6/0 silk, which helps the preparation as it is hanged on a mosquito.

 

After arresting the bleeding, we examine the orbital fat. We press the eyeball very softly, thus the fat appears betwen the orbicular septum and the muscle. We cross cut the orbital septum in full length, thus the fat appears. The removal is made in the same way as in the case of the upper lid surgery (cf. figure).

 

The superfluous fat is never removed from the direction of the orbita, and we should always check the rest of the extension after arresting the bleeding. The quantity of the removed fat from both eyes is compared. If the baggyness of both eyes was symmetric, we have to remove the same quantity of fat.

 

 The Correction of Special Deformities

If the tone of the eyelid was reduced in previous check-ups, first we have to shorten the eyelid before excising the superfluous skin. The length of the excised part is rarely more than 3-4 mm, but we should excise at least as much as the eyelid is tight enough. Of course the excision should have the shape of a pentagon.

 After the shortening the quantity of the superfluous skin should be determined. For this we ask the patient to open his mouth and look upwards. This manoeuvre results in the maximal tightening of the upper lid. The superfluous skin will remain above the lashes and at the lateral side. We hold its edge with tweezers, two triangle-shaped areas will become superfluous.

 The tip of one trinagle points towards the nose, and the tip of the other one points downwards. After the skin excision we remove a 1mm piece from the subcutaneous tissue, if it is too thick. We close the operational wound with continuous sutures applying 6/0 silk or Prolen. We may use antibiotic creme on the wound, and the icing of this area is advised.

As it is the lateral canthus that takes the most tightening, we relieve the area with a Steri strip even a week after the suture removal, which is recommended 4-6 days after the operation. 

The basic technique can be varied in different cases:

• • In the case of young patients it is often only the fat that comes out without any extra skin. In these cases it is important for the incised wound edge to remain unhurt, because we do not remove skin. Thus, the application of transconjunctival lower lid surgery is preferable in such cases (see later).
• • If the flexibility of the upper lid is insufficient and the patient has dermatochalasis, we can place a deep tarsal stitch using 6/0 thread fixed to the lateral canthus besides the pentagonal excision for a better result.
• • We may apply canthoplasty, if the tarsus is too loose, here we fix the lateral edge of the tarsus to the periosteum of the orbita.
• • The baggy lids of some old patients are a result of both the protruding fat and the loose muscles. Sometimes the muscle hangs to the malar protrusion, as Furnas described it in 1978. This kind of muscle and loose skin requires a special surgery technique to excise the superfluous fat. Usually we proceed in two steps: the first is the preparation of the skin, and then we lift the muscle separately, hold it laterally to the front and excise a triangle-shaped piece. We sew the muscle and/or fix it to the orbital periosteum. Thus the muscle has a supportive function.

 Lagophthalmus

It develops if we excise too much skin and/or the orbital septum does not reach the appropriate height. If the post-operative conservative treatment of the eye (the use of artificial tears, the soft massage of the eyes, the temporary application of plasters) does not provide the expected result, surgical intervention is necessary in order to avoid dehydration of the cornea. We examine the position of the septums along the original incision line and develop a new bending furrow, which should be 10-12 mm from the eyelashes. We cross cut the orbicular muscle till the orbital septum and remove some of the orbital fat if necessary.The new bending furrow is developed with small stitches placed in the edge of the skin and the aponeurosis of the levator muscle, as it was mentioned above. If this does not help, we need to carry out a full thickness skin transplantation. The removal of too much orbital fat may result in hollows, the correction of which is difficult. If there is a great deficiency, we can try to correct it with the flap of the orbicuar muscle, but usually the results are poor.

 

The low bending furrow can be the result of low incision lines and of the fact that the aponeurosis of the levator is not stitched to the skin. The stitching of the aponeurosis of the levator to the edge of the skin can be corrected from a small incision, which lifts the furrow.

 

A thick, bundle-like scar resulting from the insufficient excision of the lengthened orbicular muscle. If it does not improve after massage, the excision is recommended.

 

Post-operative ptosis usually results from the injury of the aponeurosis of the levator during the operation. It may occur if we stitch the aponeurosis of the levator too high, in which case the removal of the subcutaneous stitch solves the problem. If the ptosis does not improve for 4-6 months, a new surgical procedure is advised. We excise from the traumatised or lengthened aponeurosis and fix it tothe upper edge of the tarsus with 5/0 Vicryl.

Conclusion

Blepharoplasty is one of the most spectacular operations, because it is usually the wrinkles around the eye that attract attention to the ageing process, thus this is the operation that is first recommended to patients who require anti-ageing treatment.

 The operative are can be easily sedated and the ambulant treatment is not very burdenful for patients. The sutures are removed 4-5 days after the operation, thus the patient can re-integrate into his everyday life relatively quickly. This procedure may postpone the date of face lifting, but can be combined with it. As the result of a good operation, the patient can forget the problems around his eye for 5-10 years, especially if other methods are used as supplementary procedures (eg. laser resurfacing).