Upper Eyelid

Upper Eyelid

The procedure of upper eyelid blepharoplasty has changed dramatically in both understanding and performance over the last 20 years. Upper eyelid overhang and the resultant tired facies have led patients to seek correction for the last century. Understanding the dynamic anatomy of the upper eyelid and the palpebral crease allows tailoring the fold and eradicating the tired look in most patients.

History of the Procedure

Upper eyelid skin resection and fat resection from the upper eyelid fat pockets have been performed for more than a century. In the last 20 years, skin and fat resection has decreased to avoid causing incomplete eyelid closure and dry eye symptomatology. A deeper understanding of the dynamic nature of the upper eyelid has led to invagination techniques, largely borrowed from the Asian double-eyelid procedure, to deliver a crisp upper eyelid fold at a height that is optimum for the patient.

Problem

Upper eyelid blepharoplasty is the surgical approach to addressing dermachalasis (also known as dermatochalasis) of the upper eyelid. Dermachalasis represents redundant, loose skin of the upper eyelid that occurs with aging.

 Clearly differentiate upper eyelid dermachalasis from the myriad other problems of the upper eyelid that often are a component of upper eyelid aging. True dermachalasis is common, but often, all upper eyelid problems are treated with upper eyelid skin blepharoplasty, which is useful only for treating dermachalasis. Even with this problem properly diagnosed and differentiated from other periorbital problems, a better treatment is often found with an anchor blepharoplasty compared to simple skin resection or skin and partial muscle and fat resection.

Brow ptosis is the most common cause of upper eyelid fullness. Carefully assess brow position prior to planned rejuvenation of the periorbita. Please see the Medscape Reference text on brow lift (Periorbital Rejuvenation Brow Lift) for a more detailed discussion of this topic. Aggressive treatment of the upper eyelid for the treatment of brow ptosis is inadequate and counterproductive and rarely leads to any marked improvement in the condition.

Upper eyelid ptosis also commonly is mistaken for upper eyelid dermachalasis and cannot be treated with simple upper eyelid blepharoplasty or anchor blepharoplasty. Repair the dehiscence or shortened levator muscle in individuals with good levator function but acquired or congenital ptosis. If ptosis requires correction, perform an anterior or posterior procedure (Fasanella-Servat or partial Mullerectomy to preserve conjunctival mucus-secreting glands).

Pathophysiology

In an Asian patient with an upper eyelid lacking a fold (congenital), often some degree of medial epicanthus also is present. The degree to which the medial epicanthus is hidden by the epicanthal fold determines whether correction is necessary. Medial epicanthoplasty is discussed in Treatment, but a small median epicanthus is also an ethnic trait, and complete removal in all instances can markedly change the appearance of the individual. Clearly discuss this preoperatively and plan the degree of correction if necessary.

Upper Eyelid

Indications

The primary indication for upper eyelid blepharoplasty is the patient’s desire to improve his or her appearance. In rare instances, upper eyelid skin occludes peripheral vision, and some insurance carriers are willing to contribute to operative costs to improve the condition after visual field examination and mapping are performed. Rarely, a component of brow ptosis is absent in these patients.

The indications for upper eyelid procedures in the Asian patient merit further discussion. The intent of the procedure is to create a more beautiful Asian eye, not to create a Caucasian-appearing eye. The author has had parents bring in 5-year-old children for the procedure, and, although he declined to perform the procedure, the author believes individual practitioners should decide whether they consider this a congenital defect or a cosmetic variance.

Contraindications

No contraindications exist to a properly conceived and performed upper eyelid blepharoplasty in the typical patient. Approach lagophthalmos with caution, since no skin should be resected, but other corrections can be performed with the procedure. Multiply operated upper lids can present a formidable challenge to those inexperienced with the changing anatomy from previous surgery. The patient’s attitude and expectations must be appropriate and reasonable. The patient’s general health is always a consideration, but the procedure is minimally invasive, and, when performed alone, it can be performed readily with local anesthetic unaugmented by sedatives.