Advanced upper lid blepharoplasty.

Advanced blepharoplasty invaginates the upper lid tissues. It requires an intimate familiarity with the anatomy of the upper lid. The two keys to success are (1) approaching the deep fascia network via strip resection of the pretarsal fascia and (2) forming a free edge of the levator aponeurosis. The result is an attractive and permanent upper lid fold.     

Complications in blepharoplasty

I believe that if one follows the precautions outlined, including a time-tested surgical technique and thorough clinical history and physical examination, the operation of blepharoplasty should prove to be one of the most gratifying aesthetic operations.     

Asian blepharoplasty

The author describes blepharoplasty and related techniques to achieve fresh, youthful, and attractive eyes in the Asian patient. Emphasis is on maintaining ethnic integrity and recognizing the need for appropriate adjunctive procedures. (Aesthetic Surg J 2002;22:558-568.)     

Augmentation blepharoplasty

Conventional lower lid blepharoplasty techniques emphasize the removal of excess skin and fatty bulges of the lower eyelid. The appearance is improved at the expense of lateral pretarsal flatness associated with the senile eyelid. Augmentation blepharoplasty is a modified technique for a lower lid blepharoplasty using an overlapping orbicularis oculi muscle repair to increase pretarsal fullness, which is associated with the youthful lower eyelid. The technique was used successfully in 30 consecutive, unselected patients, and this experience is reviewed in detail. The technique, surgical anatomy, and complications are outlined. The results prove this technique to be a safe method of lower lid blepharoplasty that does not interfere with the additional goals of periorbital fat and excess skin removal.     

Aesthetic blepharoplasty

Suzanne No?l, a pioneer of aesthetic surgery in Europe, first published her results with cosmetic blepharoplasty in 1926, in a book entitled: "The social role of aesthetic surgery". Paul Tessier further expanded the range and surgical possibilities of blepharoplasty by incorporating lateral canthopexies and underlying the importance of the craniofacial skeleton. Other authors in the 20th century brought their own technical refinements to this operation, such as the transconjunctival route, and various fat preserving modifications as well as lipostructure. The aim of this paper was to review the surgical approach to blepharoplasty, according to both historical and currently used protocols (including data gathered by questionnaires sent to eight French and foreign plastic surgical teams). A new perspective is proposed regarding the analysis of different morphological and ageing subtypes. The indication for individual surgical techniques stems from an accurate analysis of each patient according to anatomical categories. Pre-operative records before any orbito-palpebral surgery should include a full orthoptic and ophthalmological assessment, as well as high-quality medical photographs. An increasing emphasis has developed recently upon the use of autologous fat harvested locally (septofat advancement), or from a distant site (lipostructure).     

Laser blepharoplasty in Asians

Traditional blepharoplasty removes periorbital wrinkles by cutting and stretching the skin. However, this method has a substantial risk of producing ectropion or scleral show. In addition, fine periocular wrinkles may persist because this method does not change skin texture. The pulsed CO2 laser has recently become a primary surgical tool in treating aging eyelids. Periorbital wrinkles vary in depth not only from person to person, but also among different races. Compared with whites, most Asians have a thicker dermis, so more laser passes and a higher power may be required to remove periorbital wrinkles, but concerns about hyperpigmentation and prolonged erythema have limited its use on Asian skin. In this study, 346 patients underwent laser blepharoplasty at the Korea University Medical Center and at Dr Choi's Aesthetic Clinic. They were followed for 12 months on average from September 1995 to September 1999. The CO2 laser was used in resurfacing periorbital wrinkles, transcutaneous skin excision, and transconjunctival blepharoplasty, including fat removal. The authors assessed the benefit of using the UltraPulse CO2 laser in Asian blepharoplasty. They found that 291 patients (84%) had good to excellent results. The incidence of side effects was very low. Prolonged erythema occurred in 19 patients (5%) and hyperpigmentation occurred in 35 patients (10%), but the erythema disappeared spontaneously within 2 months and the hyperpigmentation could be managed readily by the topical use of retinoids and hydroquinone cream. Therefore, the authors conclude that postoperative hyperpigmentation is no longer a problem limiting laser resurfacing in Asian blepharoplasty. The UltraPulse CO2 laser is a safe and effective rejuvenation method for treating aging eyelids in Asians.     

Operative technique for transconjunctival lower blepharoplasty.

In the past 3 years, more than 125 patients have undergone primary and secondary lower blepharoplasty by the transconjunctival method. The ability to adequately remove fat with this approach has been impressive. Exposure of the central and medial fat compartments is excellent. The lateral fat pad area is not as easy to visualize, and care must be taken to assure that adequate fat removal is achieved. Although one might suspect that postoperative conjunctival irritation could be a problem with this procedure, this has been notably absent in our patient population. In addition, there have been remarkably few patients with dry eye complaints following transconjunctival lower blepharoplasty. The question of skin resection must also be addressed. Currently, we believe that the majority of patients seeking improvement of the lower eyelids benefit most by a transconjunctival blepharoplasty without skin resection (Figs. 3 and 4). When there is obvious skin excess, we believe that it is best approached by removing the fat through the transconjunctival incision and then removing skin with a simple skin flap or skin pinch technique. This must be done considerably more conservatively than has been recommended in the past, to retain a natural palpebral fissure. Secondary skin removal, if necessary, is a straightforward procedure that can be readily done under local anesthesia at a later date. Transconjunctival lower blepharoplasty has not been associated with prolonged (exceeding 1 month) lower lid retraction problems in any of our patients. The technique is easy to learn but does require some experience with the anatomy. The technique should become the basic procedure for correction of excess fat in the lower eyelids.     

短切口重睑成形术

目的：探讨短切口重睑成形术的适应证及特点。方法：于上睑拟定重睑线中部做长约1cm的短切口，通过该切口切除睑板前的全长眼轮匝肌和疝出的眶隔脂肪，将上睑切口皮肤和睑板上缘固定。结果：本组受术者共80例，经1～8个月随访，术后l～4周消肿，重睑形态自然，切口瘢痕轻微。结论：短切口重睑成形术，适合于上睑皮肤不松弛者，具有重睑形态自然，恢复快、瘢痕轻微的特点。     

Upper lid blepharoplasty

Upper lid blepharoplasty is the most commonly performed operation in patients seeking facial rejuvenation. When evaluating the patient, attention should be focused on the possibility of concomitant eyelid or eyebrow ptosis. Meticulous planning and technique are required to achieve high levels of patient satisfaction.     

The quick-stick blepharoplasty

A simple technique for temporary instant office blepharoplasty in selected patients is presented.     

Upper lid blepharoplasty

Upper lid blepharoplasty is the most common cosmetic procedure performed in men and women. The eyes are the most important aesthetic facial unit and also a sensitive projector of facial aging changes. Patients will complain about tired eyes, sad eyes, or extra tissue around the eyes. Dermatochalasis, fat herniation or protrusion, brow ptosis, and eyelid ptosis secondary to disinsertion or dehiscence of the levator aponeurosis all contribute to a patient's perceptions of the need for upper lid blepharoplasty. In this article we discuss aging changes in the periocular region in Asian and Caucasian type eyelids and in male and female patients. Traditional upper lid blepharoplasty techniques, indications for surgery, psychological considerations in candidates for cosmetic surgery, and frequently encountered complications are also covered.     

Complications of blepharoplasty

Various involutional eyelid changes, such as fine rhytids, dynamic laugh lines in the lateral canthal area, secondary malar bags, and dermal pigmentation are not effectively treated by a blepharoplasty. Preoperative discussions are important to ensure that adequate expectations are held. Too often, a patient is informed that fine rhytids and dermal pigmentation can be successfully treated with lid surgery alone. The importance of the preoperative interview in determining patient expectations cannot be minimized. Preoperative ophthalmic and periocular examination is essential to identify any pre-existing pathology. Even though the surgical approach is adapted to the individual needs of each patient, the most meticulous of surgeons is predetermined to encounter his or her share of complications. There is a fine line between a "complication" and a common, but unwanted, sequela of surgery. Patients, overwhelmingly, do have some widening of their palpebral fissures, even following conservative surgery. Unfortunately, this occasionally creates ocular irritation or gross discomfort in allergic or borderline dry eyed patients. Lower eyelid bowing is so common even in the face of minimal skin resection that we do not consider it a "complication" if it does not produce a functional problem. It is humbling for all surgeons to review their blepharoplasty problems and helpful to recognize that, statistically, we are all due to face these events eventually.     

A new concept in blepharoplasty

Apart from what may be considered complications, the intervention of any aesthetic surgery can have undesired effects (scar sequelae, normal regional dynamic disorders, edema, iatrogenic acceleration of the aging process in the area). The orbital region is particularly sensitive to these undesirable effects due to its situation and the importance of the eyelids in facial sign language. The sum of these undesirable effects and not infrequent complications often place the plastic surgeon in a compromising situation. It is for this reason that in recent years we have made a special effort to analyze causes, to design new techniques, and to evaluate the combination of different techniques in an attempt to minimize these undesirable effects, so as to be able to offer patients more natural and safer results. It is with this intention that this paper records some anatomical and functional details of the eyelids, analyzes the physiology of the aging process, and examines some classic and modern techniques.     

Cosmetic upper blepharoplasty

The anatomy of the upper eyelid is complex; however, those structures that make it complex are not involved in routine cosmetic blepharoplasty. The most common reason for patients seeking cosmetic surgery of the upper eyelids is excess skin and its associated heaviness. Appropriate removal of skin, preseptal orbicularis oculi muscle, submuscular fat, and orbital fat will achieve consistently good results.     

Complications of blepharoplasty

Blepharoplasty is one of the most commonly performed surgeries for rejuvenation of the periorbital region, yet its complexity is often underappreciated. The surgeon must have a precise understanding of the underlying anatomy from skin to orbital rim and must recognize which components require surgery to achieve a desired aesthetic result in each individual. Understanding the limitations imposed by a particular patient's anatomy and conveying realistic aesthetic expectations are essential to avoid complications. The underpinning of successful blepharoplasty is an awareness of potential complications (Table 1) and understanding how best to avoid them and how to manage them.     

Case studies in Asian blepharoplasty

Many techniques have been reported for rejuvenation of the upper eyelids. As the facial structure and skin of Asians differ from those of other races and nationalities (specifically, Caucasians), the operative strategy and technique for treating these patients should take into account their specific anatomy. In this article, the author illustrates his techniques for Asian blepharoplasty (including skin-muscle resection, subeybrow resection, filler or fat injections, double eyelid procedures, block fat grafting, and/or levator shortening), concluding that thorough preoperative evaluation and proper technique selection are key for successful results.