Blepharoplasty: Anatomy, Planning, Techniques, and Safety

Blepharoplasty: Anatomy, Planning, Techniques, and Safety Abstract Blepharoplasty is one of the most commonly performed cosmetic surgical procedures. To date it remains the most powerful method of periorbital rejuvenation when compared to other nonsurgical modalities, especially in the aging face. Despite that, the procedure has its shortcomings that include a steep learning curve, prolonged recovery, and potential for appearance and life-changing complications. Attaining successful outcomes relies on a solid understanding of facial topography, patient and technique selection, and, when appropriate, following a conservative approach. Modern blepharoplasty relies on tissue conservation and volume enhancement rather than aggressive removal. This concept was conceived after the realization that older techniques resulted in a hollowed appearance, which accentuated the aging process. It was further reinforced by advances in knowledge of periorbital anatomy and aging changes. This Continuing Medical Education (CME) article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient’s anatomy. Learning Objectives The reader is presumed to have a basic understanding of aesthetic eyelid surgical procedures. After studying this article, the participant should be able to: (1) Describe the periorbital anatomy and surface topography of the youthful and aging eyes. (2) Identify ideal candidates for aesthetic eyelid surgery and patients at risks for postoperative complications. (3) Recognize the various surgical techniques of upper and lower blepharoplasty. The American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this CME examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. Blepharoplasty is the surgical rejuvenation of the upper and lower eyelids. It is the fourth most common cosmetic procedure performed in the United States according to the 2016 American Society for Aesthetic Plastic Surgery statistics.1 Both upper and lower blepharoplasties are technically demanding operations that require careful planning and meticulous execution to achieve optimal outcomes and avoid complications. Numerous techniques have been described for both upper and lower blepharoplasties, with no comparative data supporting the superiority of one technique over the other.2-16 Regardless of the approach used, the goal of the operation should remain the same; restoring a youthful and natural look to the eye and periorbital area. For upper blepharoplasty, the goal is to restore the visibility of the pretarsal space with a well-defined upper lid crease while restoring an attractive upper lid fold volume, in proper proportion with the pretarsal space. Lower blepharoplasty aims to create a smooth lower lid surface with seamless transition into the cheek. As these objectives are accomplished, the shape and dimensions of the palpebral fissure should be maintained or improved. Like other procedures in plastic surgery, the concept of blepharoplasty has evolved over the years secondary to increasing knowledge of periorbital anatomy, facial topography, and the aging process. As a result, several surgical techniques have been described in an effort to maximize safety and improve the aesthetic results. The choice of particular blepharoplasty technique has been heavily debated with several different schools of thought.3,6,8,11,12,14 The fear of postoperative complications, especially with lower blepharoplasty, has driven many surgeons towards more conservative approaches sometimes at the expense of optimizing aesthetics.14 This CME article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient’s anatomy to attain the desired outcome. UPPER AND LOWER EYELID ANATOMY Knowledge of periorbital anatomy, topography, proportions, and volume distribution are critical in surgical planning. Both upper and lower eyelids should be assessed in the context of the surrounding periorbital area. Changes in the brow and cheek strongly influence the upper and lower eyelids, respectively. It has become common practice to address both the lateral brow and cheek as part of comprehensive periorbital rejuvenation.3,5,8,11,13,14,17-22 SURFACE TOPOGRAPHY Ideally, the periorbital area should project anteriorly in relationship to the globe. The reverse ratio results in aesthetically less attractive eyes as evidenced in patients with prominent eyes, negative vector, and cheek and brow deflation (Figure 1). A negative vector indicates that the globe projects further than the malar eminence23 and is often associated with lack of anterior cheek projection and decreased soft tissue volume of the cheek. The upper eyelid is divided into two distinct spaces, the upper eyelid fold, which is the space between the brow and upper lid crease, and the pretarsal space, defined as the space between the crease and the lash line.23 The ratio between both spaces (fold:pretarsal ratio) and the difference in volume is what determines upper eyelid aesthetics. This ratio differs from medial to lateral and between males and females. We have studied the upper eyelid topographical proportions in attractive Caucasian female models and found that an ideal fold:pretarsal ratio averages 1.87 medially and widens laterally to an average of 2.98, peaking at the lateral limbus.24 These findings reflect the importance of lateral brow vertical height and fullness, and the presence of some degree of pretarsal show in females (Figure 1). In males, on the other hand, pretarsal show is not as critical and upper lid fold height is more even across the width of the palpebral fissure. The upper eyelid sulcus is the space between the upper lid crease and the superior orbital rim. Uniform fullness of the sulcus is created by the orbital fat and directly contributes to the upper lid fold’s overall volume. With aging, the fat content in the upper lid can increase or decrease.25 Herniation of orbital fat can create localized bulges that obliterate the sulcus. Loss of orbital fat volume, on the other hand, deepens the sulcus and creates a sunken, shadow-filled area under the brow and a round hollowed upper lid (Figure 1).25,26 As a result of this volume depletion, the supraorbital rim becomes visible and the supratarsal crease may appear elevated. Figure 1. View largeDownload slide Comparison of surface topography of the periorbital area between a youthful face (left) and an aging face (right). Figure 1. View largeDownload slide Comparison of surface topography of the periorbital area between a youthful face (left) and an aging face (right). The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. An aesthetically pleasing eye has an almond shape with superior arc that peaks medially27 and a slight upward inclination of the lateral canthal angle (positive canthal tilt).3 The lateral canthal angle is sharp and crisp, with the lateral commissure closely opposed to the globe, while the medial canthal angle is slightly blunted and the commissure separated from the globe, by the caruncle and plica semilunaris. Assessment of the size and shape of the lateral scleral triangle preoperatively and postoperatively is a useful tool to assess the palpebral fissure shape and lower lid malposition.23 The lower eyelid crease is less defined than the upper eyelid crease, but similarly is considered a sign of youth and reflects normal lower eyelid animation. Topographically, the lower eyelid is divided into a pretarsal area, preseptal area, and the eyelid cheek junction. The pretarsal segment has a slight natural bulge that occurs with smiling and animation reflecting normal function of the pretarsal orbicularis. Orbicularis hypertrophy in some patients may cause a noticeable bulge in that segment of the eyelid especially with squinting and smiling. The preseptal segment of the lower eyelid is where the orbital septum and orbital fat are located. Anterior protrusion of the fat compartments in this segment results in distinct and well-localized bulges (Figure 2). The eyelid cheek junction is the area defined by a groove or a dark soft tissue depression known as the tear trough. This trough accentuates the orbital fat protrusion above and the upper cheek volume depletion below, resulting in a peak and valley visual effect and a dark shadow in the lower eyelid. Volume deflation in the upper cheek results in a central inverted triangular area of volume loss.28 An additional bulge may occur in the lateral cheek known as the malar mound. This mound results from descent of the prezygomatic space and is bordered superiorly by the lateral orbicularis retaining ligament and inferiorly by the zygomatic cutaneous ligaments that form the midface groove.29 Figure 2. View largeDownload slide Illustration of layered anatomy of the upper and lower eyelids and periorbital area. Figure 2. View largeDownload slide Illustration of layered anatomy of the upper and lower eyelids and periorbital area. Finally, the lateral orbital area is a very important aesthetic component that is frequently overlooked. It is formed by the merger of the lateral brow and upper lateral cheek as they meet just lateral to the lateral canthus. Graduated fullness from the lateral brow to the upper lateral cheek complements the results of blepharoplasty and closes the circle in periorbital rejuvenation. PERTINENT SURGICAL ANATOMY The eyelid is a complex structure that varies in its layered composition depending on the anatomic segment. The pretarsal segment extends from the lash line to the margin of the tarsal plate and is bilamellar. The anterior lamella is composed of skin and pretarsal orbicularis while the tarsus and conjunctiva make the posterior lamella. The importance of the pretarsal segment is that it harbors the pretarsal orbicularis (blink muscle) and the tarsoligamentous sling that are critical for lid function and support. The pretarsal orbicularis must be preserved in both upper and lower blepharoplasties by making the access incisions through the muscle (when indicated) at the junction of the pretarsal and preseptal orbicularis. The preseptal segment constitutes the remaining lid proper where the bulk of blepharoplasty surgery takes place, and is composed of the above bilamellar structure separated by the orbital septum and orbital fat. The preseptal orbicularis is loosely adherent to the underlying orbital septum through the suborbicularis oculi fascia creating the preseptal space,29,30 a commonly used dissection plane in blepharoplasty. The preseptal orbicularis can be trimmed, when indicated in both upper and lower blepharoplasty. The orbital orbicularis defines the area of the eyelid-brow and eyelid-cheek junctions, in the upper and lower eyelids, respectively. It is separated from the preseptal orbicularis by the orbicularis retaining ligament (Figure 2).31 In lower blepharoplasty, release of the orbicularis retaining ligament allows mobilization, suspension, and tightening of the preseptal and orbital orbicularis.12 The orbital orbicularis extends over the brow, lateral orbit, and cheek and overlies deep fat compartments. The orbicularis oculi muscle is responsible for eyelid tone and closure and is innervated by zygomatic and buccal branches of the facial nerve.32 It is believed that the inner canthal orbicularis, the main blinking muscle, is innervated by the buccal branch of the facial nerve that passes lateral to medial in a plane deep to the muscles of facial expression. Injury to this branch during aggressive dissection to release the medial tear trough can result in blink impairment.32 Both the pretarsal and preseptal orbicularis are almost devoid of superficial fat while the orbital orbicularis is covered with the superficial infraorbital fat compartment (Figure 3).33,34 Figure 3. View largeDownload slide Cadaver dissection of an injected head (a 62-year-old male) showing the superficial fat compartments of the periorbital area. The arrow marks the junction of the preseptal and orbital orbicularis in the lower eyelid, which corresponds to the eyelid-cheek junction. Notice how the bulk of the infraorbital superficial fat compartment is overlying the orbital portion of the orbicularis. Figure 3. View largeDownload slide Cadaver dissection of an injected head (a 62-year-old male) showing the superficial fat compartments of the periorbital area. The arrow marks the junction of the preseptal and orbital orbicularis in the lower eyelid, which corresponds to the eyelid-cheek junction. Notice how the bulk of the infraorbital superficial fat compartment is overlying the orbital portion of the orbicularis. The orbital septum is a fibrous structure that originates from the arcus marginalis and inserts on the inferior edge of the tarsal plate in the lower eyelid.30 In occidental upper eyelid, it inserts on the levator aponeurosis at the level of the upper tarsal edge. The orbital septum is located deep to the orbicularis oculi muscle, is thicker laterally, and acts as an anterior barrier to orbital fat herniation.30 The lateral extension of the orbital septum forms the superficial lateral canthal tendon that can be used as an anchor structure in lateral canthopexy.35 The capsulopalpebral fascia (CPF) and the accompanying smooth muscle fibers comprise the lower lid retractors. The CPF originates from the inferior rectus muscle and its head wraps around the inferior oblique muscle to ultimately insert on the inferior edge of the tarsal plate. The orbital septum in the lower eyelid is adherent to the CPF for 3 to 5 mm inferior to the lower tarsal edge. Therefore, a transconjuctival preseptal approach should be performed through this area of fusion, while a postseptal approach that preserves the orbital septum should be performed inferiorly, approximately 6 mm or more below the edge of the tarsus.8,30 The orbital fat is located deep to the septum and is partially separated into compartments, nasal and central in the upper eyelid and nasal, central, and lateral in the lower eyelid.23 The central upper eyelid fat is also known as the preaponeurotic fat and is located anterior to the levator aponeurosis, medial to the trochlea and lateral to the lacrimal gland.3,4,23 The nasal fat compartment is located deeper and is superficial to the trochlea. It has a characteristic whitish color and is separated from the central fat compartment by an extension of Whitnall’s ligament called the interpad septum (Figure 4C).23 There are two vascular structures that can be injured during manipulation of the nasal fat pad, one is the medial palpebral artery located medially and a branch of the superior ophthalmic vein located deep to the pad. Eisler’s fat pad is a small fat pad that can be used as a landmark for its proximity to Whitnall’s tubercle (Figure 5E).23 In the lower eyelid, the medial and central fat compartments are separated by the inferior oblique muscle while the central and lateral compartments are separated by the arcuate expansion of Lockwood’s ligament (Figure 6C). Release of this latter structure results in the ability to mobilize both the central and lateral compartments as one unit. The deep fat compartments are located deep to the orbital orbicularis and are divided into the retro-orbicuaris oculi fat (ROOF) compartment in the upper lid-brow junction and the medial and lateral suborbicularis fat compartments (SOOF) in the lower lid-cheek junction. These compartments are targets for augmentation through fat blending and fat grafting (Figure 2). Figure 4. View largeDownload slide (A) Skin markings of upper blepharoplasty in a 73-year-old woman, showing the crease and the lateral extent of the ellipse, which is marked parallel to the lower blepharoplasty lateral canthal incision. Ideally the distance between the two should be 10 mm although many time this distance ends up being shorter. (B) Open-sky technique showing the upper incision, dissection through the orbicularis oculi muscle (OO) and septum (S) exposing the preaponeurotic fat pad (PF). (C) Upper lid orbital fat showing the preaponeurotic (central) fat pad (PF) and the paler nasal fat pad (NF). (D) The preaponeurotic fat after it was mobilized and draped across the upper lid fold for volume augmentation. Figure 4. View largeDownload slide (A) Skin markings of upper blepharoplasty in a 73-year-old woman, showing the crease and the lateral extent of the ellipse, which is marked parallel to the lower blepharoplasty lateral canthal incision. Ideally the distance between the two should be 10 mm although many time this distance ends up being shorter. (B) Open-sky technique showing the upper incision, dissection through the orbicularis oculi muscle (OO) and septum (S) exposing the preaponeurotic fat pad (PF). (C) Upper lid orbital fat showing the preaponeurotic (central) fat pad (PF) and the paler nasal fat pad (NF). (D) The preaponeurotic fat after it was mobilized and draped across the upper lid fold for volume augmentation. Figure 5. View largeDownload slide Lateral canthoplasty in steps in a 73-year-old woman. (A) Lateral canthotomy. (B) Inferior cantholysis. (C) Estimating the degree of shortening and tightening. (D) Vertical bites through the cut end of the tarsal plate with double-armed suture. (E) Deep periosteal bite in the lateral orbital rim close to the location of Whitnall’s tubercle, the white arrow is pointing to Eisler’s fat pad, and (F) recreating the lateral canthal angle with a gray-line stitch. Figure 5. View largeDownload slide Lateral canthoplasty in steps in a 73-year-old woman. (A) Lateral canthotomy. (B) Inferior cantholysis. (C) Estimating the degree of shortening and tightening. (D) Vertical bites through the cut end of the tarsal plate with double-armed suture. (E) Deep periosteal bite in the lateral orbital rim close to the location of Whitnall’s tubercle, the white arrow is pointing to Eisler’s fat pad, and (F) recreating the lateral canthal angle with a gray-line stitch. Figure 6. View largeDownload slide View largeDownload slide Skin muscle flap lower blepharoplasty in a 73-year-old woman. (A) A stair-step incision starting as a subciliary skin incision 1 to 2 mm below the lash line followed by a muscle incision preserving 4 mm strip of PTOO. (B) Dissection in the preseptal plane or space showing the LFP and CFP separated by the arcuate expansion of Lockwood ligament, the black arrow is pointing to the orbicularis retaining ligament and the white arrow is pointing to the lateral orbital adhesion. (C) White arrow pointing at arcuate expansion of Lockwood ligament. (D) Mobilization of the orbital fat as pedicled flaps that can be advance over the orbital rim. (E) Redraping of the orbital fat in the preperiosteal plane. (F) Marking the lateral wedge of skin and muscle that are trimmed in the skin-muscle flap technique. (G) The excess skin is estimated only after excision of the tissue laterally and orbicularis suspension. (H) Skin is conservatively trimmed, notice the elevation of the marked line that was originally placed at the tear trough. CFP, central fat pad; LFP, lateral fat pad; PSOO, preseptal orbicularis oculi muscle; PTOO, pretarsal orbicularis oculi muscle; OF, orbital fat; S, septum; SOOF, suborbicularis oculi fat. Figure 6. View largeDownload slide View largeDownload slide Skin muscle flap lower blepharoplasty in a 73-year-old woman. (A) A stair-step incision starting as a subciliary skin incision 1 to 2 mm below the lash line followed by a muscle incision preserving 4 mm strip of PTOO. (B) Dissection in the preseptal plane or space showing the LFP and CFP separated by the arcuate expansion of Lockwood ligament, the black arrow is pointing to the orbicularis retaining ligament and the white arrow is pointing to the lateral orbital adhesion. (C) White arrow pointing at arcuate expansion of Lockwood ligament. (D) Mobilization of the orbital fat as pedicled flaps that can be advance over the orbital rim. (E) Redraping of the orbital fat in the preperiosteal plane. (F) Marking the lateral wedge of skin and muscle that are trimmed in the skin-muscle flap technique. (G) The excess skin is estimated only after excision of the tissue laterally and orbicularis suspension. (H) Skin is conservatively trimmed, notice the elevation of the marked line that was originally placed at the tear trough. CFP, central fat pad; LFP, lateral fat pad; PSOO, preseptal orbicularis oculi muscle; PTOO, pretarsal orbicularis oculi muscle; OF, orbital fat; S, septum; SOOF, suborbicularis oculi fat. The orbicularis retaining ligament is an osseocutaneous septum that separates the eyelids from the cheek and brow and is responsible for nasojugual and palpebromalar grooves (Figure 6B).28,29,31 The medial aspect of this ligament is sandwiched between the maxillary origin of the preseptal and orbital orbicularis and it ends at the medial scleral limbus. This segment of the ligament is known as the tear trough ligament (Figure 2).28 As it travels laterally it turns into a pure bilamellar septum that increases progressively in length and fuses with the lateral orbital thickening. This segment of the ligament is known as the orbicularis retaining ligament.28 It is critical to differentiate the orbicularis retaining ligament from the arcus marginalis. The latter is a distinct fibrous thickening seen at the orbital rim from the confluence of the orbital septum with the periorbita and periosteum.30 The arcus marginalis is encountered and released through a transconjunctival postseptal approach, and the result of this release is connecting the orbital fat with a preperiosteal or subperiosteal plane on the anterior rim while leaving the septum undisturbed.8,11,36 On the other hand, a transconjunctival preseptal approach and the transcutaneous approach usually open the septum and encounter and release the orbicularis retaining ligament while leaving the arcus undisturbed,13 except in cases where they transition into a subperiosteal plane, necessitating the release of arcus marginalis (Figure 7).36 Figure 7. View largeDownload slide (A) An illustration of a sagittal view of the lower lid showing the two main approaches to lower blepharoplasty; the dashed line is the plane of dissection for the skin-muscle flap preseptal approach transitioning into a supraperiosteal plane, and the dotted line is the plane of dissection for the transconjunctival post septal approach transitioning into a subperiosteal plane. (B) The skin-muscle flap approach releasing the orbicularis retaining ligament and advancing the orbital fat over the orbital rim in a supraperiosteal plane leaving arcus marginalis intact. (C) The transconjunctival approach releasing arcus marginalis and advancing the orbital fat over the orbital rim in a subperiosteal plane, and therefore indirectly releasing the orbicularis retaining ligament by releasing its periosteal origin. Figure 7. View largeDownload slide (A) An illustration of a sagittal view of the lower lid showing the two main approaches to lower blepharoplasty; the dashed line is the plane of dissection for the skin-muscle flap preseptal approach transitioning into a supraperiosteal plane, and the dotted line is the plane of dissection for the transconjunctival post septal approach transitioning into a subperiosteal plane. (B) The skin-muscle flap approach releasing the orbicularis retaining ligament and advancing the orbital fat over the orbital rim in a supraperiosteal plane leaving arcus marginalis intact. (C) The transconjunctival approach releasing arcus marginalis and advancing the orbital fat over the orbital rim in a subperiosteal plane, and therefore indirectly releasing the orbicularis retaining ligament by releasing its periosteal origin. The lateral canthal fixation is anatomically accomplished through three structures that attach to the lateral orbital rim at different levels. The lateral palpebral raphe is formed by the pretarsal and preseptal orbicularis and is located immediately under the lateral canthal skin.37 The superficial lateral canthal tendon is a continuation of the orbital septum sandwiched between the muscle and the lateral canthal tendon and inserts anteriorly on the periosteum of the lateral orbital rim.35,37 The lateral canthal tendon (lateral retinaculum), is the deepest attachment that originates from the upper and lower tarsal plates and inserts on Whitnall’s tubercle which is positioned 2 to 4 mm inside the lateral orbital rim.23,37,38 It receives contributions from the lateral horn of the levator aponeurosis and Whitnall’s ligament superiorly, Lockwood’s ligament inferiorly, and the check ligament of the lateral rectus muscle on its deep surface.23,37-39 PREOPERATIVE EVALUATION The goal of preoperative evaluation is to identify medical history and anatomical features that increase the risk of postoperative complications. History of poorly controlled hypertension, bleeding disorder, and certain medications and herbal supplements can increase the risk of bruising and bleeding.40 History of prior cosmetic and reconstructive periorbital procedures should be obtained. The presence of dry eye symptoms and predisposing risk factors for dry eye syndrome must be carefully evaluated, as upper and lower blepharoplasties cause transient impairment in eyelid closure mechanics, and can result in worsening of symptoms postoperatively.41-43 Patients with history of dry eyes or inability to tolerate contact lenses should undergo a Schirmer test, which relies on the degree of wetting of a filter paper strip placed at the lateral commissure. Wetting of less than 5 mm distance over a period of 5 minutes is considered diagnostic of dry-eye syndrome.40,42 The presence of a normal Bell’s phenomenon, manifested as upward rolling of the globe when attempting to open a closed eye should be documented.40 Absence of Bell’s phenomenon, although is not a contraindication for blepharoplasty, should steer the surgeon towards a more conservative approach. History of recent ocular or corneal surgery should be elucidated. It is advisable to wait for 6 months after laser-assisted in situ keratomileusis (LASIK) to allow for restoration of normal corneal sensitivity prior to eyelid surgery, as LASIK causes blunting of the normal blink reflex temporarily.44 The patient’s specific cosmetic complaints should be verified while looking in the mirror. Evaluation then proceeds with careful analysis of periorbital topography and signs of aging. Standardized preoperative photographs are taken in 6 views that include a front, lateral, three quarters, and a close-up view of the eyes. In addition, photographs of the eyes closed in repose and of the eyes open with the globe in upward gaze, help in evaluation of the amount of excess skin in the upper lid and excess orbital fat in the lower lid, respectively. Finally, a photograph of the eyes in animation (squinting) helps verify the size and function of the pretarsal orbicularis and accentuates the tear trough deformity.28 Pictures will often reveal asymmetries that are not clear on examination, especially with ptosis that is more apparent when the patient relaxes in front of a camera. Three-dimensional photographs allow more accurate measurements of periorbital volumization procedures.45 The surgical plan should be determined after discussing the patient’s goals and desired outcome and it should be customized depending on the presenting features. Upper Eyelids There are three important features that need to be evaluated in the upper eyelid: (1) the presence of a well defined and visible crease; (2) the degree of pretarsal show; and (3) the height, volume, and contour of the upper eyelid fold. The marginal reflex distance-1 (MRD-1), defined as the distance between the corneal light reflex and the upper eyelid margin, should be determined first to rule out a concomitant blepharoptosis, which should be addressed at the time of blepharoplasty. In Caucasian females, the crease has a gentle arch, averages 8 to 10 mm in height from the lash line at the midpupil, and should be visible through its full length from medial to lateral canthi. The degree of desired pretarsal show varies among patients and can be determined by examining old photographs. Caution should be practiced with patients who present for upper blepharoplasty who have full visibility of their crease and pretarsal space. A traditional upper blepharoplasty in this patient population can result in increased pretarsal show, which can be unattractive. The youthful upper eyelid fold has a smooth surface with a progressive gradual increase in height and volume from medial to lateral where it blends with the lateral orbital area (Figure 1).2 This progressive increase in height and volume in females is determined by the position of the temporal brow and retro-orbicularis oculi fat. It is for this reason that a temporal brow lift can be complementary to upper blepharoplasty (Figure 8). In non-Asian males, the crease (averaging 7-8 mm in height)46 is straighter and the upper lid fold is more uniform in height and volume with less emphasis on the visibility of the pretarsal space. Contour irregularity of the upper eyelid fold can result from excess skin, localized bulge created by herniating orbital fat, or a prolapsed lacrimal gland. Finally, the need for fat grafting to create a smooth, full, and convex upper eyelid fold should also be determined. Lower Eyelids The lower eyelid position is evaluated including the presence of scleral show or bowing of the lateral lower lid resulting in rounding of the lateral canthal angle.3,40 These features along with the presence of a negative vector place the patient at a high risk for post lower blepharoplasty retraction.40,47,48 The presence of a negative vector causes the lower lid to travel at an upslope to cover the globe, which creates a mechanical disadvantage that can be further deteriorated by surgical disruption of ligamentous and volume support of the lower eyelid.48 If the patient is suspected of having a prominent globe, a Hertel exophthalmometer can be used to measure the corneal projection relative to the lateral orbital rim. Normal range is defined to be between 15 and 17 mm and patients with prominent eyes (>18 mm) are at higher risk for postoperative lower lid malposition.3,40 Lower eyelid laxity and tone are examined through “distraction” and “snap back” tests.3,40,48 A lower eyelid that can be distracted >8 to 10 mm away from the globe constitutes an abnormal distraction test and indicates increased lower lid laxity.47,48 An abnormal snap back test on the other hand, defined as a slow return of a pulled down lower eyelid to a normal position that may require a blink, indicates both increased laxity and decreased muscle tone.40,47,48 Finally, the presence of lower eyelid malposition should be evaluated, investigated, and documented prior to surgery. Unacceptable cosmetic appearance of the lower eyelids can be due to one or more of the following: (1) dark shadows due to skin pigmentation and contour irregularity resulting from the tear trough depression and overlying bulging orbital fat; (2) orbicularis oculi muscle laxity or hypertrophy; (3) skin excess; and (4) volume loss at the eyelid cheek interface. These components are not present in all patients and they vary in severity, therefore the surgical plan should be tailored to each patient based on their presenting anatomy and risk for developing postoperative complications. The location and extent of each abnormality should be examined in the upright sitting position and the extent and severity of anterior lamellar changes should be evaluated to determine the best approach to address the anterior lamella. SURGICAL TECHNIQUES Upper Blepharoplasty Upper blepharoplasty has evolved over the years from a debulking procedure to a more balanced, volume-preserving approach.2-4,26,46,49,50 Regardless of the technique used, the following points have to be addressed: 1. Does the patient have a visible and nondisplaced crease? If so, then the incision should be marked and made in that crease instead of creating a crease that purely relies on measurements. However, making the incision slightly lower than the existing crease,49 and elevating the crease in patients who desire more pretarsal show have been described.2 On the other hand, if an upper lid crease is abnormally high as in tarsolavator dehiscence, or ill defined, then marking the crease should rely on measurements or the height of the tarsal plate, which can be determined by everting the lid. 2. Does the fat need to be removed, redistributed, or enhanced with grafting? If fat grafting is needed then a decision is made whether it’s done concomitantly or at a different stage depending on the extent of intraoperative dissection. 3. Does the patient require a temporal brow lift, or just brow volume enhancement? “Open Sky” Technique The “open sky” technique described by McCord,23 relies on the excision of a myocutaneous segment of skin, orbicularis oculi, and orbital septum to expose the preaponeurotic and nasal fat pads. Intraoperative skin markings are detailed in Video 1. The lateral extent of the marked skin excision is determined in an upright position while the patient’s tail of the brow is manually elevated and depressed assessing where the skin redundancy can be trimmed without creating a dog ear. The lateral point should preferably stay medial to the tail of the brow,46 and if it were to be extended laterally as in cases with extensive dermatochalasis, then it should be marked in a natural upper crow’s feet line (Figure 4A). The upper limit of excision is marked on the upper lid fold at least 10 mm from the junction of the brow-upper lid skin.3,23 This distance can be increased, and therefore shortening the vertical length of the excised skin, according to the desirable degree of pretarsal show. The lines are connected with a gentle curve that tapers nasally to avoid excessive skin excision in that area. The incisions should not extend nasal to the medial canthus.46 Skin infiltration with a local anesthetic is performed after marking the crease and it can facilitate drawing on an otherwise redundant skin. Pinching the area of marked skin with forceps allows for making adjustments before committing to the marked pattern.51 Incisions are made precisely, beginning with the crease. The upper fold incision is deepened through the orbicularis oculi muscle exposing the orbital septum while maintaining meticulous hemostasis. Gentle pressure applied on the globe (retropulsion) allows preaponeurotic fat to bulge forward and the orbital septum is incised. The preaponeurotic fat is trimmed or redistributed along the length of the sulcus (Figure 4D). The nasal fat pad is located next, freed from the surrounding connective tissue, and excised or blended with central fat pad as necessary.4 Following management of the orbital fat, the skin-muscle flap is excised at the level of the crease, beveling the scissors away from the crease to prevent disruption of the levator aponeurosis attachment to the tarsal plate. Transpalpebral browpexy or repositioning of the lacrimal gland can be performed as needed. Closure involves approximation of the skin and muscle in one or two layers. The addition of a supratarsal fixation as suggested by McCord can theoretically help stabilize the crease by reattaching the pretarsal orbicularis to the levator aponeurosis with a 6-0 absorbable suture.3,23 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Close Other Techniques A variety of other techniques have been previously reported in the literature to preserve the upper eyelid volume by conserving the orbicularis oculi and orbital fat.2,4,46,49,52 Skin markings are performed in a similar fashion and rely more on skin pinch while the brow is stabilized in position. After the skin is excised, the preseptal orbicularis can be incised or a window can be made in the muscle and septum as needed to address the preaponeurotic central fat and nasal fat pads.4 The temporal septum is also opened as needed to address a prolapsed orbital lobe of the lacrimal gland.53 After the fat pads are mobilized, they can be redraped across the sulcus or blended together to augment the upper lid fold and sulcus volume.54 The nasal fat pad can also be adequately mobilized and redraped while taking care not to injure any vascular structures or the tendon of the superior oblique muscle.4 Mobilizing the central or preaponeurotic fat pad has also been described to augment the lateral upper lid fold.50 The retro-orbicularis oculi fat can be sculpted as needed,23 however, it is better to preserve the brow volume and reposition it instead. Repositioning the ROOF has been advocated through surgical techniques that secure the cut edge of the preseptal orbicularis to the arcus marginalis.21 When the orbicualris oculi muscle is left untouched, plicating the muscle by incorporating it in skin closure helps define the upper lid crease and enhance the upper lid fold convexity.26,49 Adjunct procedures for upper blepharoplasty include lacrimal gland suspension, transpalpebral browpexy, fat grafting, and transpalpebral corrugator resection. The incidence of lacrimal gland prolapse has been reported to be 15% in the general population55 and higher in the aging population.53 In order to expose the gland, the temporal orbital septum is opened and the central fat pad is mobilized. Several techniques have been described for repositioning of the orbital portion of the lacrimal gland including suturing the capsule of the gland to superior orbital rim periosteum,56 suturing Whitnall’s ligament57 or the anterior surface of the lateral horn of the levator over the gland to the superior orbital rim periosteum,23 or the use scarring induced by cautery to reposition mild gland prolapse.53 If the lateral horn of the levator is placated to arcus, it is critical to place the upper lid on downward traction prior to suture placement to prevent postoperative lagophthalmos. Transpalpebral internal browpexy is mainly a brow-stabilizing procedure that fixes the lateral brow to the deep temporal fascia lateral to the temporal fusion line. Modifications were described of the internal browpexy using Endotine device (Coapt Systems, Inc., Palo Alto, CA) over the bony portion of the superior orbital rim, medial to the temporal fusion line for more lifting.19 Lower Blepharoplasty There are two popular approaches to surgical rejuvenation of the lower eyelid: the transconjunctival and skin-muscle flap blepharoplasties. The main distinguishing feature between the two is that the transconjunctival approach does not violate the orbicularis oculi muscle and the orbital septum can also be left intact. Therefore, it relies mainly on skin-only excision to address the anterior lamella, when indicated. The skin muscle flap technique on the other hand relies on mobilization and tightening of the orbicularis oculi muscle through suspension,58 which resembles a SMAS facelift. The term transcutaneous can indicate a variety of modifications of the skin-muscle technique but does not always involve orbicularis suspension. Skin-Muscle Flap Lower Blepharoplasty As the name indicates, this technique provides access to the orbital fat through an anterior approach.6 A stair-step incision is made in the skin immediately inferior to the lash line and is extended a few millimeters laterally beyond the lateral canthus (Figure 6A). The lateral extension is marked in an upright sitting position in a natural crow’s feet line if possible (Figure 4A). One must err on marking the lateral extension pointing slightly superiorly as it tends to drift inferiorly postoperatively, which results in an inferior aesthetic result. After the skin incision is made starting laterally, dissection is deepened through the orbicularis oculi muscle until the lateral orbital rim periosteum is identified. A small double prong skin hook is then used to pull on the incision edge laterally keeping the lower lid under tension and the skin incision is placed precisely 0.5 to 1.0 mm under the lash line. After the skin is separated from the orbicularis oculi, the muscle incision is extended preserving 4 millimeters of pretarsal orbicularis (Figure 6A). Dissection proceeds in a preseptal plane until the inferior orbital rim is reached. In this plane, the tear trough ligament and the orbicularis retaining ligaments are identified and are released in continuity with the lateral orbital adhesion (Figure 6B). It is this complete release of the retaining ligament and lateral adhesion that frees the muscle and allows mobilization of the orbital portion of the orbicularis6,12,59 along with its overlying subcutaneous fat compartment (infraorbital fat) superiorly.33 This maneuver is what defines the skin-muscle flap technique, as it redrapes and lifts the orbicularis taking the soft tissue redundancy laterally where the majority of trimming occurs (Figure 6F).6,58 After releasing the tear trough and the orbicularis retaining ligaments, the area of the SOOF is exposed and dissection proceeds in a supraperiosteal plane for 5 to 10 millimeters. If a midface lift is intended at the same time, dissection can be extended further either in a supraperiosteal plane spreading through the prezygomatic and premaxillary spaces12,29 or in a subperiosteal plane. If a midface lift is not planned, then the extent of dissection is judged by adequate release of the depression created by the retaining ligaments and the size of the pocket created for fat redraping. Fat excision or redraping (see below) is performed through a septal incision or partial excision (Figures 6D and E). After the orbicularis is redraped, a triangular skin and muscle excision is performed laterally and inset is performed after lateral canthal tightening. Conservative subciliary skin and muscle excision is performed after lateral inset of the orbicularis flap (Figure 6G). Proper inset of the skin-muscle flap is probably one of the most challenging steps of this technique for several reasons; there is a substantial dog ear that has to be chased while maintaining a relatively short incision, sewing the orbicularis back together can create a step off that has to be leveled, and finally imprecise inset of the skin near the lateral canthus can result in postoperative webbing. Given the nature of the stair-step incision, careful trimming of the preseptal orbicularis is necessary to avoid overlap and unintentional augmentation of the pretarsal orbicularis.6,12,16 There are several advantages of the skin-muscle flap blepharoplasty; it provides unparalleled exposure for fat redraping, it is a powerful technique for tightening of the anterior lamella (Figures 8-10) especially in patients with orbicularis oculi laxity, and it elevates the infraorbital superficial fat compartment, which helps with blending of the eyelid-cheek junction (Figure 6H). On the other hand, the skin-muscle flap technique is considered by some an aggressive approach with higher incidence of postblepharoplasty lower eyelid retraction.48 There is more scarring involved in the anterior and middle lamella by violating the muscle and septum in addition to partial denervation of the muscle which weakens the anterior support of the lower lid.48 Although EMG studies have refuted this hypothesis by showing normal innervation of the pretarsal orbicularis through preservation of the medial buccal branch of the facial nerve,32 there is possibly some loss of tone that occurs postoperatively that takes some time to recover. This loss of tone in addition to increased postoperative swelling can prolong the recovery of the procedure. Although the skin muscle-flap technique achieves excellent results, it can be unforgiving in inexperienced hands and if lateral canthal anchoring is not mastered.39,60,61 This is especially true in patients at high risk of postoperative retraction like those with negative vector (Figure 11).47,48 Figure 8. View largeDownload slide (A) Preoperative photograph of a 54-year-old woman with bilateral brow ptosis, lateral hooding, lower lid anterior lamellar changes with minimal orbital fat herniation. (B) Postoperative result 8 months after bilateral upper blepharoplasty and lower skin-muscle flap blepharoplasty with canthopexy. (C) Postoperative result at 18 months and after additional cheek fat grafting. In addition to that, she also underwent bilateral endoscopic temporal brow lift and transpalpebral corrugator resection in addition to fat grafting to the medial and lateral SOOF. Notice the improvement in her upper lid aesthetic proportions enhanced by the brow lift, and the smooth lower lid surface as a result of anterior lamellar tightening. Figure 8. View largeDownload slide (A) Preoperative photograph of a 54-year-old woman with bilateral brow ptosis, lateral hooding, lower lid anterior lamellar changes with minimal orbital fat herniation. (B) Postoperative result 8 months after bilateral upper blepharoplasty and lower skin-muscle flap blepharoplasty with canthopexy. (C) Postoperative result at 18 months and after additional cheek fat grafting. In addition to that, she also underwent bilateral endoscopic temporal brow lift and transpalpebral corrugator resection in addition to fat grafting to the medial and lateral SOOF. Notice the improvement in her upper lid aesthetic proportions enhanced by the brow lift, and the smooth lower lid surface as a result of anterior lamellar tightening. Figure 9. View largeDownload slide (A) Preoperative photograph of a 70-year-old woman with bilateral lower lid anterior lamellar changes, surface irregularities, asymmetry, minimal fat herniation on the right, and volume loss at the eyelid-cheek junction. (B) Postoperative results 18 months after bilateral lower blepharoplasty using the skin-muscle flap approach, lateral canthopexy, and fat grafting the deep medial cheek and SOOF compartments. Notice the improved symmetry and smooth eyelid-cheek transition. The patient declined upper blepharoplasty. Figure 9. View largeDownload slide (A) Preoperative photograph of a 70-year-old woman with bilateral lower lid anterior lamellar changes, surface irregularities, asymmetry, minimal fat herniation on the right, and volume loss at the eyelid-cheek junction. (B) Postoperative results 18 months after bilateral lower blepharoplasty using the skin-muscle flap approach, lateral canthopexy, and fat grafting the deep medial cheek and SOOF compartments. Notice the improved symmetry and smooth eyelid-cheek transition. The patient declined upper blepharoplasty. Figure 10. View largeDownload slide (A) Preoperative photograph of a 43-year-old woman with bilateral upper lid dermatochalasis and “tired look” as a result of bilateral lower lid tear trough deformity and medial orbital fat herniation. (B) Postoperative photograph 16 months after bilateral upper blepharoplasty and bilateral skin-muscle flap lower blepharoplasty, fat transposition, fat grafting to the cheek, and canthopexy. Notice the postoperative increase in pretarsal show and worsening hollowing despite that this was a skin only removal indicating the need for volume enhancement with fat grafting. The lower lids are smooth with elimination of the tear trough deformity and the “tired look.” Figure 10. View largeDownload slide (A) Preoperative photograph of a 43-year-old woman with bilateral upper lid dermatochalasis and “tired look” as a result of bilateral lower lid tear trough deformity and medial orbital fat herniation. (B) Postoperative photograph 16 months after bilateral upper blepharoplasty and bilateral skin-muscle flap lower blepharoplasty, fat transposition, fat grafting to the cheek, and canthopexy. Notice the postoperative increase in pretarsal show and worsening hollowing despite that this was a skin only removal indicating the need for volume enhancement with fat grafting. The lower lids are smooth with elimination of the tear trough deformity and the “tired look.” Figure 11. View largeDownload slide (A) Preoperative oblique view of a 41-year-old woman with a prominent tear-trough deformity and medial orbital fat herniation. The patient has negative vector and scleral show at baseline. (B) Postoperative photograph 3 years after bilateral lower blepharoplasty, skin-muscle flap approach, with release of the tear trough ligament and medial and central orbital fat transposition, and lateral canthopexy with over correction. Notice the improvement in her tear trough and lower lid contour with preservation of the lower lid position. Figure 11. View largeDownload slide (A) Preoperative oblique view of a 41-year-old woman with a prominent tear-trough deformity and medial orbital fat herniation. The patient has negative vector and scleral show at baseline. (B) Postoperative photograph 3 years after bilateral lower blepharoplasty, skin-muscle flap approach, with release of the tear trough ligament and medial and central orbital fat transposition, and lateral canthopexy with over correction. Notice the improvement in her tear trough and lower lid contour with preservation of the lower lid position. Transconjunctival Lower Blepharoplasty A transconjuctival incision provides access to the orbital fat through a posterior approach and leaves the orbicularis muscle and septum undisturbed, although there are reported transconjuctival techniques that involved some form of orbicularis tightening.8,17 An incision is made in the conjunctiva 5 to 6 mm inferior to the tarsus to avoid the zone of fusion between the capsulopalpebral fascia and the orbital septum. This allows direct posterior access to the orbital fat while staying in a postseptal plane. A preseptal dissection can also be performed if the transconjunctival incision were to be made within 5 mm of the tarsus (Video 2). The incision in the capsulopalpebral fascia can be made horizontally along the same line with conjunctiva, or separately as a vertical split to preserve the retracting function of the muscle. There have been no reported complications, however, from dividing the CPF horizontally. Staying in the postseptal plane until the inferior orbital rim is reached leads to the posterior aspect of the arcus marginalis, so this plane continues naturally into a subperiosteal plane unless an incision is made at the inferior border of the septum above the arcus marginalis to continue in a supraperiosteal plane. A subperiosteal dissection is performed with a periosteal elevator taking care not to injure the infraorbital neurovascular bundle, which is clearly visualized.8,11,36 The tear trough and orbicularis retaining ligaments are not directly severed as their periosteal origin is elevated, therefore there is more emphasis on “arcus marginalis release” in this type of procedure than on orbicularis retaining ligament release. The end effect should be similar as the tear trough area of depression is elevated and separated from bone. A preseptal dissection is preferred by others13 as it provides better access to release the palpebral part of the orbicularis oculi, tear trough ligament, orbital part of the orbicularis oculi, and the orbicularis retaining ligament. After the fat is redraped, lateral canthal tightening can be performed when indicated and the conjunctival incision is closed or left to heal by secondary intention. The skin is addressed through a separate incision when indicated. Different techniques were described for skin excision including a “pinch”7 and a skin only flap.8,17 In a “pinch” blepharoplasty, the skin is pinched with forceps creating a vertical skin pillar that is excised and closed while avoiding any everting tension on the lid margin. A skin only flap on the other hand separates the skin from the orbicularis oculi down to the inferior orbital rim and redrapes the skin (Supplemental Figure 1). Video 2 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Video 2 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Close Fat Transposition and Fat Grafting First described by Loeb62 in 1981, using the orbital fat as pedicled grafts to augment the eyelid-cheek junction has become a popular and reliable technique. The orbital fat can be accessed through a preseptal or a postseptal approach and is redraped in a subperiosteal or supraperiosteal plane.6,8,9,11,13,14,16,17,36,63 In a preseptal approach, the orbital septum is opened or partially excised and the fat is mobilized by lysis of the fibrous connective tissue that restricts it (Figure 6D). The use of a needle-tip electrocautery on a low current facilitates this dissection, which is continued until the fat pedicles are completely freed and redraped over the inferior orbital rim without creating any tension on the lower lid (Figure 6E). The septal reset technique, described by Hamra,64 involves incising the inferior border of the septum and advancing the septum along with the orbital fat over the orbital rim where it is secured.16,64,65 The most common orbital fat redistribution is the use of the nasal and central fat compartments to augment the area of the tear trough with its accompanying central triangular depression at the eyelid cheek junction, while excising the lateral fat compartment.3,6,8,9,11,13 Fat transposition has been reported with and without anchoring to periosteum or to skin.6,8,11-13,36 The use of excised orbital fat as free grafts has been also reported with good outcomes.13,15 Fat grafting has become an important adjunct procedure that is being performed more frequently with both upper and lower blepharoplasties. This is attributed to several recent topographical and anatomical studies that advanced our understanding of periorbital aging and its relationship to soft tissue deflation, and facial fat compartments of the face.22,33,34,66 The purpose of fat grafting is to blend the eyelid-cheek junction and to improve both the anterior and lateral brow and cheek projection, enhancing periorbital aesthetics. In the upper lid, fat grafting improves the volume of the upper eyelid sulcus, the upper lid fold, and the brow.18,26 This has a favorable effect on the position of the brow and the upper eyelid fold to pretarsal space ratio. The main target areas in the upper lid are sulcus both medially and laterally and the lateral brow fat compartment (retroorbicularis oculi fat, ROOF). In lower blepharoplasty, fat grafting the deep medial fat compartment improves the anterior cheek projection and the inverted V defromity, while fat grafting the lateral and medial SOOF helps improve the lateral cheek projection and blend the eyelid cheek junction, respectively.22,33,34 The main challenge with concomitant fat grafting and blepharoplasty is trying to perform grafting in a plane that has not been violated, in order to comply with Coleman’s fat grafting principles.67 This becomes more challenging when the tear trough and the orbicularis retaining ligaments are released, opening up both the medial and lateral SOOF compartments. One possible advantage of subperiosteal dissection is the preservation of the preperiosteal plane, where fat grafting can be performed concomitantly. The use of both micro and fractionated (fracto) fat grafting have been reported for blending the eyelid junction.18,22 Lateral Canthal Tightening The need for lateral canthal tightening after lower blepharoplasty remains a controversial topic between proponents of routine6,11,12,14,47,48,59 and selective8,36,68,69 application. The term canthopexy indicates lateral tightening of the lower lid without a canthotomy or cantholysis, while canthoplasty is lid tightening in the presence of canthotomy and/or cantholysis (Figure 5). Lateral canthoplasty allows for lid shortening in cases of severe lower lid laxity, in addition to reshaping and repositioning of the lateral canthal angle, while canthopexy is merely a splinting procedure that maintains the posture of the lid and relaxes with time.60 Canthopexy is more frequently applied in the setting of aesthetic blepharoplasty and canthoplasty is reserved to cases where lower lid horizontal shortening is indicated. Several canthopexy techniques have been described, each differ in the lower lid tissue being captured with suture including tarsus,6 inferior or lateral retinaculum,38,39 or superficial lateral canthal tendon (Video 2).35 They all, however, anchor to the periosteal lining of the lateral orbital rim.6,8,11,35,38,39 Although the term “canthopexy” has also been used to describe anchoring the orbicularis to periosteum,8 this maneuver is more in line with orbicularis suspension. To date there is no consensus on the routine use of lateral canthal tightening with lower blepharoplasty, perhaps due to the fact that blepharoplasty techniques vary in approach, dissection, and amount of tissue removal. This is further confounded by publications showing low rate of lower lid malposition with selective68,69 or no canthopexy70 even with skin-muscle flap blepharoplasty. It should be noted however, that a lateral canthal tightening procedure is required in the following situations: (1) a skin-muscle flap blepharoplasty; (2) patients with negative vector; and (3) patients with moderate to severe lower lid laxity. OUTCOMES AND COMPLICATIONS To date, there are no standardized outcome measures for either upper or lower blepharoplasty. The majority of studies and case series reported in the literature mainly focus on reporting complications and need for revision. Only a few studies utilized some form of objective evaluation or aesthetic score calculation.14,68,69,71 The FACE-Q eye module has been developed as a patient reported outcome measure but hasn’t been widely adopted yet due to its recent introduction.72 Postoperative complications after blepharoplasty include hematoma, asymmetry, lagophthalmos, lower lid malposition, scleral show, dry eyes, frank lower lid ectropion, lateral canthal webbing, and chemosis. The most devastating complication after blepharoplasty is blindness that can occur as a result of globe injury, retrobulbar hematoma, and/or fat grafting.46,73 Reported complications and reoperation in the literature are generally low6,8,9,11-13,59,68,69 but probably do not reflect common practice as they are often published in series of experienced surgeons. The duration of postoperative recovery after blepharoplasty is underreported and perhaps underestimated. Postoperative bruising and ecchymosis is expected in the early postoperative period and is minimized by application of cold compresses for 48 hours.42 Peribulbar hematoma usually occurs due to bleeding from the orbicularis oculi muscle, and although it is not vision threatening, it can result in increased inflammation, scarring, and lower lid malposition. Retrobulbar hematoma is the most serious complication after blepharoplasty and should be treated emergently, as it can lead to vision loss due to compression of the neurovascular structures.46 Postblepharoplasty lower eyelid retraction (PBLER) is one of the most feared complications after lower blepharoplasty. Risk factors that predispose to PBLER include excessive skin or muscle resection, scarring of the middle lamella, and failure to recognize and address lower eyelid laxity.40,47,48,61 Other patient-related risk factors include the presence of negative vector that is usually associated with lack of adequate volume support in the cheek and reduced orbicularis function.48 Management of PBLER is mainly through prevention by applying proper lateral canthal tightening techniques, which include canthopexy with overcorrection in patients with prominent eyes and negative vector, and canthoplasty with lid shortening in patients with severe lower eyelid laxity.6,38,39,47,61 Customizing procedure selection to the patient’s anatomy is also critical to avoid PBLER, as in avoiding skin-muscle transcutaneous approaches in patients with negative vector who predominantly require treatment of orbital fat herniation and a tear trough deformity in the absence of anterior lamellar laxity. Another critical consideration is in avoiding over resection of skin, muscle, or fat as this will result in scarring and vertical shortening of the lid and reduction in soft tissue support. Chemosis is a bulbar conjunctival swelling that can occur with varying severity, mainly in the setting of lower blepharoplasty.74 Multiple etiologies have been associated with the development of chemosis including inflammation, exposure, and lymphatic disruption.42,43,74 A recent anatomical study of the periorbital lymphatic drainage by Shoukath et al described the presence of a deep lymphatic drainage system that drains the conjunctiva and passes deep to the preseptal orbicularis piercing the orbicularis retaining ligament laterally at its junction with lateral orbital thickening.75 These findings are suggestive that any procedures involving deep lateral dissection can theoretically increase the incidence of chemosis. The incidence of reported postoperative chemosis ranges between 0% to 12.1%, with one series reporting an incidence of 34.5%.43 The data from previously published case series suggest higher incidence of chemosis with the skin muscle flap compared with transconjunctival approach especially with the routine use of lateral canthal tightening.75 There is no evidence supporting that lateral canthoplasty is associated with higher incidence chemosis when compared to lateral canthopexy.6 A cyclic relationship can develop between exposure and chemosis leading to the propagation of the latter. As the formation of conunctivocalasis and blister formation impairs eyelid closure, this leads to further conjunctival exposure, desiccation, and inflammation.42,74 Treatment strategies include frequent lubrication of the conjunctiva with wetting drops, topical antibiotic ointments with steroids, and vasoconstrictive agents such as 2.5% ophthalmic phenylephrine. These measures are usually effective in treating mild chemosis. If chemosis develops intraoperatively, a lateral tarsorrhaphy suture and/or plication of the redundant conjunctiva at the fornix can be helpful in preventing further propagation. In more severe cases, firm patching of the eye for 24 to 48 hours can be effective. The patient should be instructed to keep the eye closed under the patch. In cases of severe refractory chemosis, a snip conjunctivotomy to release the fluid is recommended, combined with firm patching and systemic anti-inflammatories.41,42,74 Dry eyes syndrome after blepharoplasty occurs in patients with predisposing risk factors and is reported to persist longer than 2 weeks in 11% of patients.41 The presenting symptoms include dry eyes, irritation, and foreign body sensation, which develop as a result of decreased tear film production or increased evaporation.41,42 After blepharoplasty, the precision of the blink mechanism is affected due to swelling, lagophthalmos, and sometimes transient muscle denervation. In addition, there is a decreased production of the lipid component of the tear film by the Meibomian glands, which leads to increased evaporation.41-43 Management of dry eye syndrome is mainly through prevention by avoiding or staging the procedure in patients with history of dry eyes, and using conservative surgical approach in high-risk patients. Postoperative management include continued lubrication with wetting eye drops until the symptoms resolve, treatment of inflammation with topical antibiotics and steroid ointment, and minimizing exposure.40-43 Support of the lower lid with taping during the healing phase and early treatment of chemosis are critical especially if symptoms persist longer than two weeks. Surgical correction of lagophthalmos due to skin or muscle over resection, and lower lid malposition should be undertaken when it becomes clear that those changes are irreversible. The use of punctal plugs and an ophthalmology referral can be considered in patients with prolonged or refractory symptoms. CONCLUSION Upper and lower blepharoplasties are effective and safe cosmetic surgical procedures that require knowledge of periorbital anatomy and carful preoperative planning. The choice of approach should be tailored to the patient’s needs and preoperative risk factors. Volume preservation and enhancement rather than excessive tissue removal define modern blepharoplasty. Mastering certain techniques such as canthal anchoring and fat grafting help prevent postoperative complications and refine outcomes. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic surgery national data bank statistics. Aesthet Surg J . 2017; 37( suppl 2): 1- 29. 2. Fagien S. The role of the orbicularis oculi muscle and the eyelid crease in optimizing results in aesthetic upper blepharoplasty: a new look at the surgical treatment of mild upper eyelid fissure and fold asymmetries. Plast Reconstr Surg . 2010; 125( 2): 653- 666. 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Tonnard PL, Verpaele AM, Zeltzer AA. Augmentation blepharoplasty: a review of 500 consecutive patients. Aesthet Surg J . 2013; 33( 3): 341- 352. Google Scholar CrossRef Search ADS PubMed  19. Cohen BD, Reiffel AJ, Spinelli HM. Browpexy through the upper lid (BUL): a new technique of lifting the brow with a standard blepharoplasty incision. Aesthet Surg J . 2011; 31( 2): 163- 169. Google Scholar CrossRef Search ADS PubMed  20. Zarem HA. Browpexy. Aesthet Surg J . 2004; 24( 4): 368- 372. Google Scholar CrossRef Search ADS PubMed  21. Zarem HA, Resnick JI, Carr RM, Wootton DG. Browpexy: lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr Surg . 1997; 100( 5): 1258- 1261. Google Scholar CrossRef Search ADS PubMed  22. Pezeshk RA, Sieber DA, Rohrich RJ. The six-step lower blepharoplasty: using fractionated fat to enhance blending of the lid-cheek junction. Plast Reconstr Surg . 2017; 139( 6): 1381- 1383. Google Scholar CrossRef Search ADS PubMed  23. Codner MA, McCord CDJr, eds. Eyelid & Periorbital Surgery . Boca Raton, FL: CRC Press; 2016. 24. Vaca EE, Alghoul M. Identifying aesthetically appealing upper eyelid topographic proportions. Presented at the American Society for Aesthetic Plastic Surgery Annual Meeting in New York, NY; April 2018. 25. Lambros V. Volumizing the brow with hyaluronic acid fillers. Aesthet Surg J . 2009; 29( 3): 174- 179. Google Scholar CrossRef Search ADS PubMed  26. Ramil ME. Fat grafting in the hollow upper eyelids and volumetric upper blepharoplasty. Plast Reconstr Surg . 2017; 140( 5): 889- 897. Google Scholar CrossRef Search ADS   27. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg . 2007; 120( 5): 1367- 1376; discussion 1377. Google Scholar CrossRef Search ADS PubMed  28. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg . 2012; 129( 6): 1392- 1402. Google Scholar CrossRef Search ADS PubMed  29. Wong CH, Mendelson B. Facial soft-tissue spaces and retaining ligaments of the midcheek: defining the premaxillary space. Plast Reconstr Surg . 2013; 132( 1): 49- 56. Google Scholar CrossRef Search ADS PubMed  30. Kakizaki H, Malhotra R, Madge SN, Selva D. Lower eyelid anatomy: an update. Ann Plast Surg . 2009; 63( 3): 344- 351. Google Scholar CrossRef Search ADS PubMed  31. Ghavami A, Pessa JE, Janis J, Khosla R, Reece EM, Rohrich RJ. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg . 2008; 121( 3): 994- 1001. Google Scholar CrossRef Search ADS PubMed  32. DiFrancesco LM, Anjema CM, Codner MA, McCord CD, English J. Evaluation of conventional subciliary incision used in blepharoplasty: preoperative and postoperative videography and electromyography findings. Plast Reconstr Surg . 2005; 116( 2): 632- 639. Google Scholar CrossRef Search ADS PubMed  33. Pessa JE, Rohrich RJ. Facial Topography: Clinical Anatomy of the Face . Boca Raton, FL: CRC Press; 2012. 34. Rohrich RJ, Arbique GM, Wong C, Brown S, Pessa JE. The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg . 2009; 124( 3): 946- 951. Google Scholar CrossRef Search ADS PubMed  35. Knize DM. The superficial lateral canthal tendon: anatomic study and clinical application to lateral canthopexy. Plast Reconstr Surg . 2002; 109( 3): 1149- 1157; discussion 1158. Google Scholar CrossRef Search ADS PubMed  36. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg . 2011; 127( 1): 386- 395. Google Scholar CrossRef Search ADS PubMed  37. Hwang K, Nam YS, Kim DJ, Han SH, Hwang SH. Anatomic study of the lateral palpebral raphe and lateral palpebral ligament. Ann Plast Surg . 2009; 62( 3): 232- 236. Google Scholar CrossRef Search ADS PubMed  38. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg . 1997; 100( 5): 1262- 1270; discussion 1271. Google Scholar CrossRef Search ADS PubMed  39. Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: a simplified suture canthopexy. Plast Reconstr Surg . 1999; 103( 7): 2042- 2053; discussion 2054. Google Scholar CrossRef Search ADS PubMed  40. Jindal K, Sarcia M, Codner MA. Functional considerations in aesthetic eyelid surgery. Plast Reconstr Surg . 2014; 134( 6): 1154- 1170. Google Scholar CrossRef Search ADS PubMed  41. Hamawy AH, Farkas JP, Fagien S, Rohrich RJ. Preventing and managing dry eyes after periorbital surgery: a retrospective review. Plast Reconstr Surg . 2009; 123( 1): 353- 359. Google Scholar CrossRef Search ADS PubMed  42. Pacella SJ, Codner MA. Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show. Plast Reconstr Surg . 2010; 125( 2): 709- 718. Google Scholar CrossRef Search ADS PubMed  43. Prischmann J, Sufyan A, Ting JY, Ruffin C, Perkins SW. Dry eye symptoms and chemosis following blepharoplasty: a 10-year retrospective review of 892 cases in a single-surgeon series. JAMA Facial Plast Surg . 2013; 15( 1): 39- 46. Google Scholar CrossRef Search ADS PubMed  44. Korn BS, Kikkawa DO, Schanzlin DJ. Blepharoplasty in the post-laser in situ keratomileusis patient: preoperative considerations to avoid dry eye syndrome. Plast Reconstr Surg . 2007; 119( 7): 2232- 2239. Google Scholar CrossRef Search ADS PubMed  45. Stern CS, Schreiber JE, Surek CC, et al.   Three-dimensional topographic surface changes in response to compartmental volumization of the medial cheek: defining a malar augmentation zone. Plast Reconstr Surg . 2016; 137( 5): 1401- 1408. Google Scholar CrossRef Search ADS PubMed  46. Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg . 2004; 113( 3): 32e- 42e. Google Scholar CrossRef Search ADS PubMed  47. Tepper OM, Steinbrech D, Howell MH, Jelks EB, Jelks GW. A retrospective review of patients undergoing lateral canthoplasty techniques to manage existing or potential lower eyelid malposition: identification of seven key preoperative findings. Plast Reconstr Surg . 2015; 136( 1): 40- 49. Google Scholar CrossRef Search ADS PubMed  48. Griffin G, Azizzadeh B, Massry GG. New insights into physical findings associated with postblepharoplasty lower eyelid retraction. Aesthet Surg J . 2014; 34( 7): 995- 1004. Google Scholar CrossRef Search ADS PubMed  49. Fagien S. Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper periorbita. Plast Reconstr Surg . 2002; 110( 1): 278- 291; discussion 292. Google Scholar CrossRef Search ADS PubMed  50. Sozer SO, Agullo FJ, Palladino H, Payne PE, Banerji S. Pedicled fat flap to increase lateral fullness in upper blepharoplasty. Aesthet Surg J . 2010; 30( 2): 161- 165. Google Scholar CrossRef Search ADS PubMed  51. Hartstein ME, Massry GG, Holds JB, eds. Pearls and Pitfalls in Cosmetic Oculoplastic Surgery . 2nd ed. New York, NY: Springer; 2015. 52. Yoo DB, Peng GL, Massry GG. Effacing the orbitoglabellar groove with transposed upper eyelid fat. Ophthal Plast Reconstr Surg . 2013; 29( 3): 220- 224. Google Scholar CrossRef Search ADS PubMed  53. Massry GG. Prevalence of lacrimal gland prolapse in the functional blepharoplasty population. Ophthal Plast Reconstr Surg . 2011; 27( 6): 410- 413. Google Scholar CrossRef Search ADS PubMed  54. Jeon MS, Jung GY, Lee DL, Shin HK. Correction of sunken upper eyelids by anchoring the central fat pad to the medial fat pad during upper blepharoplasty. Arch Plast Surg . 2015; 42( 4): 469- 474. Google Scholar CrossRef Search ADS PubMed  55. Smith B, Lisman RD. Dacryoadenopexy as a recognized factor in upper lid blepharoplasty. Plast Reconstr Surg . 1983; 71( 5): 629- 632. Google Scholar CrossRef Search ADS PubMed  56. Smith B, Petrelli R. Surgical repair of prolapsed lacrimal glands. Arch Ophthalmol . 1978; 96( 1): 113- 114. Google Scholar CrossRef Search ADS PubMed  57. Beer GM, Kompatscher P. A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthetic Plast Surg . 1994; 18( 1): 65- 69. Google Scholar CrossRef Search ADS PubMed  58. McCord CDJr, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconstr Surg . 1998; 102( 7): 2471- 2479. Google Scholar CrossRef Search ADS PubMed  59. Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: retrospective review of 212 consecutive cases. Plast Reconstr Surg . 2010; 125( 1): 315- 323. Google Scholar CrossRef Search ADS PubMed  60. Fagien S. Discussion: Traditional lower blepharoplasty: is additional support necessary? A 30-year review. Plast Reconstr Surg . 2011; 128( 1): 274- 277. Google Scholar CrossRef Search ADS PubMed  61. Patipa M. Transblepharoplasty lower eyelid and midface rejuvenation: part I. Avoiding complications by utilizing lessons learned from the treatment of complications. Plast Reconstr Surg . 2004; 113( 5): 1459- 1468; discussion 1475-1477. Google Scholar CrossRef Search ADS PubMed  62. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg . 1981; 8( 4): 757- 776. Google Scholar PubMed  63. Yoo DB, Peng GL, Massry GG. Transconjunctival lower blepharoplasty with fat repositioning: a retrospective comparison of transposing fat to the subperiosteal vs supraperiosteal planes. JAMA Facial Plast Surg . 2013; 15( 3): 176- 181. Google Scholar CrossRef Search ADS PubMed  64. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg . 1998; 102( 5): 1646- 1657. Google Scholar CrossRef Search ADS PubMed  65. Hamra ST. Repositioning the orbicularis oculi muscle in the composite rhytidectomy. Plast Reconstr Surg . 1992; 90( 1): 14- 22. Google Scholar CrossRef Search ADS PubMed  66. Ramanadham SR, Rohrich RJ. Newer understanding of specific anatomic targets in the aging face as applied to injectables: superficial and deep facial fat compartments-an evolving target for site-specific facial augmentation. Plast Reconstr Surg . 2015; 136( 5 Suppl): 49S- 55S. Google Scholar CrossRef Search ADS PubMed  67. Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg . 2006; 33( 4): 567- 577. Google Scholar CrossRef Search ADS PubMed  68. Sultan B, Genther DJ, Perkins SW. Measurement of change in lower eyelid position in patients undergoing transcutaneous skin-muscle flap lower eyelid blepharoplasty. JAMA Facial Plast Surg . 2016; 18( 6): 429- 435. Google Scholar CrossRef Search ADS PubMed  69. Schiller JD. Lysis of the orbicularis retaining ligament and orbicularis oculi insertion: a powerful modality for lower eyelid and cheek rejuvenation. Plast Reconstr Surg . 2012; 129( 4): 692e- 700e. Google Scholar CrossRef Search ADS PubMed  70. Maffi TR, Chang S, Friedland JA. Traditional lower blepharoplasty: is additional support necessary? A 30-year review. Plast Reconstr Surg . 2011; 128( 1): 265- 273. Google Scholar PubMed  71. Rosenberg DB, Lattman J, Shah AR. Prevention of lower eyelid malposition after blepharoplasty: anatomic and technical considerations of the inside-out blepharoplasty. Arch Facial Plast Surg . 2007; 9( 6): 434- 438. Google Scholar CrossRef Search ADS PubMed  72. Klassen AF, Cano SJ, Grotting JC, et al.   FACE-Q eye module for measuring patient-reported outcomes following cosmetic eye treatments. JAMA Facial Plast Surg . 2017; 19( 1): 7- 14. Google Scholar CrossRef Search ADS PubMed  73. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S. Blindness following cosmetic injections of the face. Plast Reconstr Surg . 2012; 129( 4): 995- 1012. Google Scholar CrossRef Search ADS PubMed  74. McCord CD, Kreymerman P, Nahai F, Walrath JD. Management of postblepharoplasty chemosis. Aesthet Surg J . 2013; 33( 5): 654- 661. Google Scholar CrossRef Search ADS PubMed  75. Shoukath S, Taylor GI, Mendelson BC, et al.   The lymphatic anatomy of the lower eyelid and conjunctiva and correlation with postoperative chemosis and edema. Plast Reconstr Surg . 2017; 139( 3): 628e- 637e. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Blepharoplasty: Anatomy, Planning, Techniques, and Safety

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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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1090-820X
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Abstract

Abstract Blepharoplasty is one of the most commonly performed cosmetic surgical procedures. To date it remains the most powerful method of periorbital rejuvenation when compared to other nonsurgical modalities, especially in the aging face. Despite that, the procedure has its shortcomings that include a steep learning curve, prolonged recovery, and potential for appearance and life-changing complications. Attaining successful outcomes relies on a solid understanding of facial topography, patient and technique selection, and, when appropriate, following a conservative approach. Modern blepharoplasty relies on tissue conservation and volume enhancement rather than aggressive removal. This concept was conceived after the realization that older techniques resulted in a hollowed appearance, which accentuated the aging process. It was further reinforced by advances in knowledge of periorbital anatomy and aging changes. This Continuing Medical Education (CME) article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient’s anatomy. Learning Objectives The reader is presumed to have a basic understanding of aesthetic eyelid surgical procedures. After studying this article, the participant should be able to: (1) Describe the periorbital anatomy and surface topography of the youthful and aging eyes. (2) Identify ideal candidates for aesthetic eyelid surgery and patients at risks for postoperative complications. (3) Recognize the various surgical techniques of upper and lower blepharoplasty. The American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this CME examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. Blepharoplasty is the surgical rejuvenation of the upper and lower eyelids. It is the fourth most common cosmetic procedure performed in the United States according to the 2016 American Society for Aesthetic Plastic Surgery statistics.1 Both upper and lower blepharoplasties are technically demanding operations that require careful planning and meticulous execution to achieve optimal outcomes and avoid complications. Numerous techniques have been described for both upper and lower blepharoplasties, with no comparative data supporting the superiority of one technique over the other.2-16 Regardless of the approach used, the goal of the operation should remain the same; restoring a youthful and natural look to the eye and periorbital area. For upper blepharoplasty, the goal is to restore the visibility of the pretarsal space with a well-defined upper lid crease while restoring an attractive upper lid fold volume, in proper proportion with the pretarsal space. Lower blepharoplasty aims to create a smooth lower lid surface with seamless transition into the cheek. As these objectives are accomplished, the shape and dimensions of the palpebral fissure should be maintained or improved. Like other procedures in plastic surgery, the concept of blepharoplasty has evolved over the years secondary to increasing knowledge of periorbital anatomy, facial topography, and the aging process. As a result, several surgical techniques have been described in an effort to maximize safety and improve the aesthetic results. The choice of particular blepharoplasty technique has been heavily debated with several different schools of thought.3,6,8,11,12,14 The fear of postoperative complications, especially with lower blepharoplasty, has driven many surgeons towards more conservative approaches sometimes at the expense of optimizing aesthetics.14 This CME article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient’s anatomy to attain the desired outcome. UPPER AND LOWER EYELID ANATOMY Knowledge of periorbital anatomy, topography, proportions, and volume distribution are critical in surgical planning. Both upper and lower eyelids should be assessed in the context of the surrounding periorbital area. Changes in the brow and cheek strongly influence the upper and lower eyelids, respectively. It has become common practice to address both the lateral brow and cheek as part of comprehensive periorbital rejuvenation.3,5,8,11,13,14,17-22 SURFACE TOPOGRAPHY Ideally, the periorbital area should project anteriorly in relationship to the globe. The reverse ratio results in aesthetically less attractive eyes as evidenced in patients with prominent eyes, negative vector, and cheek and brow deflation (Figure 1). A negative vector indicates that the globe projects further than the malar eminence23 and is often associated with lack of anterior cheek projection and decreased soft tissue volume of the cheek. The upper eyelid is divided into two distinct spaces, the upper eyelid fold, which is the space between the brow and upper lid crease, and the pretarsal space, defined as the space between the crease and the lash line.23 The ratio between both spaces (fold:pretarsal ratio) and the difference in volume is what determines upper eyelid aesthetics. This ratio differs from medial to lateral and between males and females. We have studied the upper eyelid topographical proportions in attractive Caucasian female models and found that an ideal fold:pretarsal ratio averages 1.87 medially and widens laterally to an average of 2.98, peaking at the lateral limbus.24 These findings reflect the importance of lateral brow vertical height and fullness, and the presence of some degree of pretarsal show in females (Figure 1). In males, on the other hand, pretarsal show is not as critical and upper lid fold height is more even across the width of the palpebral fissure. The upper eyelid sulcus is the space between the upper lid crease and the superior orbital rim. Uniform fullness of the sulcus is created by the orbital fat and directly contributes to the upper lid fold’s overall volume. With aging, the fat content in the upper lid can increase or decrease.25 Herniation of orbital fat can create localized bulges that obliterate the sulcus. Loss of orbital fat volume, on the other hand, deepens the sulcus and creates a sunken, shadow-filled area under the brow and a round hollowed upper lid (Figure 1).25,26 As a result of this volume depletion, the supraorbital rim becomes visible and the supratarsal crease may appear elevated. Figure 1. View largeDownload slide Comparison of surface topography of the periorbital area between a youthful face (left) and an aging face (right). Figure 1. View largeDownload slide Comparison of surface topography of the periorbital area between a youthful face (left) and an aging face (right). The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. An aesthetically pleasing eye has an almond shape with superior arc that peaks medially27 and a slight upward inclination of the lateral canthal angle (positive canthal tilt).3 The lateral canthal angle is sharp and crisp, with the lateral commissure closely opposed to the globe, while the medial canthal angle is slightly blunted and the commissure separated from the globe, by the caruncle and plica semilunaris. Assessment of the size and shape of the lateral scleral triangle preoperatively and postoperatively is a useful tool to assess the palpebral fissure shape and lower lid malposition.23 The lower eyelid crease is less defined than the upper eyelid crease, but similarly is considered a sign of youth and reflects normal lower eyelid animation. Topographically, the lower eyelid is divided into a pretarsal area, preseptal area, and the eyelid cheek junction. The pretarsal segment has a slight natural bulge that occurs with smiling and animation reflecting normal function of the pretarsal orbicularis. Orbicularis hypertrophy in some patients may cause a noticeable bulge in that segment of the eyelid especially with squinting and smiling. The preseptal segment of the lower eyelid is where the orbital septum and orbital fat are located. Anterior protrusion of the fat compartments in this segment results in distinct and well-localized bulges (Figure 2). The eyelid cheek junction is the area defined by a groove or a dark soft tissue depression known as the tear trough. This trough accentuates the orbital fat protrusion above and the upper cheek volume depletion below, resulting in a peak and valley visual effect and a dark shadow in the lower eyelid. Volume deflation in the upper cheek results in a central inverted triangular area of volume loss.28 An additional bulge may occur in the lateral cheek known as the malar mound. This mound results from descent of the prezygomatic space and is bordered superiorly by the lateral orbicularis retaining ligament and inferiorly by the zygomatic cutaneous ligaments that form the midface groove.29 Figure 2. View largeDownload slide Illustration of layered anatomy of the upper and lower eyelids and periorbital area. Figure 2. View largeDownload slide Illustration of layered anatomy of the upper and lower eyelids and periorbital area. Finally, the lateral orbital area is a very important aesthetic component that is frequently overlooked. It is formed by the merger of the lateral brow and upper lateral cheek as they meet just lateral to the lateral canthus. Graduated fullness from the lateral brow to the upper lateral cheek complements the results of blepharoplasty and closes the circle in periorbital rejuvenation. PERTINENT SURGICAL ANATOMY The eyelid is a complex structure that varies in its layered composition depending on the anatomic segment. The pretarsal segment extends from the lash line to the margin of the tarsal plate and is bilamellar. The anterior lamella is composed of skin and pretarsal orbicularis while the tarsus and conjunctiva make the posterior lamella. The importance of the pretarsal segment is that it harbors the pretarsal orbicularis (blink muscle) and the tarsoligamentous sling that are critical for lid function and support. The pretarsal orbicularis must be preserved in both upper and lower blepharoplasties by making the access incisions through the muscle (when indicated) at the junction of the pretarsal and preseptal orbicularis. The preseptal segment constitutes the remaining lid proper where the bulk of blepharoplasty surgery takes place, and is composed of the above bilamellar structure separated by the orbital septum and orbital fat. The preseptal orbicularis is loosely adherent to the underlying orbital septum through the suborbicularis oculi fascia creating the preseptal space,29,30 a commonly used dissection plane in blepharoplasty. The preseptal orbicularis can be trimmed, when indicated in both upper and lower blepharoplasty. The orbital orbicularis defines the area of the eyelid-brow and eyelid-cheek junctions, in the upper and lower eyelids, respectively. It is separated from the preseptal orbicularis by the orbicularis retaining ligament (Figure 2).31 In lower blepharoplasty, release of the orbicularis retaining ligament allows mobilization, suspension, and tightening of the preseptal and orbital orbicularis.12 The orbital orbicularis extends over the brow, lateral orbit, and cheek and overlies deep fat compartments. The orbicularis oculi muscle is responsible for eyelid tone and closure and is innervated by zygomatic and buccal branches of the facial nerve.32 It is believed that the inner canthal orbicularis, the main blinking muscle, is innervated by the buccal branch of the facial nerve that passes lateral to medial in a plane deep to the muscles of facial expression. Injury to this branch during aggressive dissection to release the medial tear trough can result in blink impairment.32 Both the pretarsal and preseptal orbicularis are almost devoid of superficial fat while the orbital orbicularis is covered with the superficial infraorbital fat compartment (Figure 3).33,34 Figure 3. View largeDownload slide Cadaver dissection of an injected head (a 62-year-old male) showing the superficial fat compartments of the periorbital area. The arrow marks the junction of the preseptal and orbital orbicularis in the lower eyelid, which corresponds to the eyelid-cheek junction. Notice how the bulk of the infraorbital superficial fat compartment is overlying the orbital portion of the orbicularis. Figure 3. View largeDownload slide Cadaver dissection of an injected head (a 62-year-old male) showing the superficial fat compartments of the periorbital area. The arrow marks the junction of the preseptal and orbital orbicularis in the lower eyelid, which corresponds to the eyelid-cheek junction. Notice how the bulk of the infraorbital superficial fat compartment is overlying the orbital portion of the orbicularis. The orbital septum is a fibrous structure that originates from the arcus marginalis and inserts on the inferior edge of the tarsal plate in the lower eyelid.30 In occidental upper eyelid, it inserts on the levator aponeurosis at the level of the upper tarsal edge. The orbital septum is located deep to the orbicularis oculi muscle, is thicker laterally, and acts as an anterior barrier to orbital fat herniation.30 The lateral extension of the orbital septum forms the superficial lateral canthal tendon that can be used as an anchor structure in lateral canthopexy.35 The capsulopalpebral fascia (CPF) and the accompanying smooth muscle fibers comprise the lower lid retractors. The CPF originates from the inferior rectus muscle and its head wraps around the inferior oblique muscle to ultimately insert on the inferior edge of the tarsal plate. The orbital septum in the lower eyelid is adherent to the CPF for 3 to 5 mm inferior to the lower tarsal edge. Therefore, a transconjuctival preseptal approach should be performed through this area of fusion, while a postseptal approach that preserves the orbital septum should be performed inferiorly, approximately 6 mm or more below the edge of the tarsus.8,30 The orbital fat is located deep to the septum and is partially separated into compartments, nasal and central in the upper eyelid and nasal, central, and lateral in the lower eyelid.23 The central upper eyelid fat is also known as the preaponeurotic fat and is located anterior to the levator aponeurosis, medial to the trochlea and lateral to the lacrimal gland.3,4,23 The nasal fat compartment is located deeper and is superficial to the trochlea. It has a characteristic whitish color and is separated from the central fat compartment by an extension of Whitnall’s ligament called the interpad septum (Figure 4C).23 There are two vascular structures that can be injured during manipulation of the nasal fat pad, one is the medial palpebral artery located medially and a branch of the superior ophthalmic vein located deep to the pad. Eisler’s fat pad is a small fat pad that can be used as a landmark for its proximity to Whitnall’s tubercle (Figure 5E).23 In the lower eyelid, the medial and central fat compartments are separated by the inferior oblique muscle while the central and lateral compartments are separated by the arcuate expansion of Lockwood’s ligament (Figure 6C). Release of this latter structure results in the ability to mobilize both the central and lateral compartments as one unit. The deep fat compartments are located deep to the orbital orbicularis and are divided into the retro-orbicuaris oculi fat (ROOF) compartment in the upper lid-brow junction and the medial and lateral suborbicularis fat compartments (SOOF) in the lower lid-cheek junction. These compartments are targets for augmentation through fat blending and fat grafting (Figure 2). Figure 4. View largeDownload slide (A) Skin markings of upper blepharoplasty in a 73-year-old woman, showing the crease and the lateral extent of the ellipse, which is marked parallel to the lower blepharoplasty lateral canthal incision. Ideally the distance between the two should be 10 mm although many time this distance ends up being shorter. (B) Open-sky technique showing the upper incision, dissection through the orbicularis oculi muscle (OO) and septum (S) exposing the preaponeurotic fat pad (PF). (C) Upper lid orbital fat showing the preaponeurotic (central) fat pad (PF) and the paler nasal fat pad (NF). (D) The preaponeurotic fat after it was mobilized and draped across the upper lid fold for volume augmentation. Figure 4. View largeDownload slide (A) Skin markings of upper blepharoplasty in a 73-year-old woman, showing the crease and the lateral extent of the ellipse, which is marked parallel to the lower blepharoplasty lateral canthal incision. Ideally the distance between the two should be 10 mm although many time this distance ends up being shorter. (B) Open-sky technique showing the upper incision, dissection through the orbicularis oculi muscle (OO) and septum (S) exposing the preaponeurotic fat pad (PF). (C) Upper lid orbital fat showing the preaponeurotic (central) fat pad (PF) and the paler nasal fat pad (NF). (D) The preaponeurotic fat after it was mobilized and draped across the upper lid fold for volume augmentation. Figure 5. View largeDownload slide Lateral canthoplasty in steps in a 73-year-old woman. (A) Lateral canthotomy. (B) Inferior cantholysis. (C) Estimating the degree of shortening and tightening. (D) Vertical bites through the cut end of the tarsal plate with double-armed suture. (E) Deep periosteal bite in the lateral orbital rim close to the location of Whitnall’s tubercle, the white arrow is pointing to Eisler’s fat pad, and (F) recreating the lateral canthal angle with a gray-line stitch. Figure 5. View largeDownload slide Lateral canthoplasty in steps in a 73-year-old woman. (A) Lateral canthotomy. (B) Inferior cantholysis. (C) Estimating the degree of shortening and tightening. (D) Vertical bites through the cut end of the tarsal plate with double-armed suture. (E) Deep periosteal bite in the lateral orbital rim close to the location of Whitnall’s tubercle, the white arrow is pointing to Eisler’s fat pad, and (F) recreating the lateral canthal angle with a gray-line stitch. Figure 6. View largeDownload slide View largeDownload slide Skin muscle flap lower blepharoplasty in a 73-year-old woman. (A) A stair-step incision starting as a subciliary skin incision 1 to 2 mm below the lash line followed by a muscle incision preserving 4 mm strip of PTOO. (B) Dissection in the preseptal plane or space showing the LFP and CFP separated by the arcuate expansion of Lockwood ligament, the black arrow is pointing to the orbicularis retaining ligament and the white arrow is pointing to the lateral orbital adhesion. (C) White arrow pointing at arcuate expansion of Lockwood ligament. (D) Mobilization of the orbital fat as pedicled flaps that can be advance over the orbital rim. (E) Redraping of the orbital fat in the preperiosteal plane. (F) Marking the lateral wedge of skin and muscle that are trimmed in the skin-muscle flap technique. (G) The excess skin is estimated only after excision of the tissue laterally and orbicularis suspension. (H) Skin is conservatively trimmed, notice the elevation of the marked line that was originally placed at the tear trough. CFP, central fat pad; LFP, lateral fat pad; PSOO, preseptal orbicularis oculi muscle; PTOO, pretarsal orbicularis oculi muscle; OF, orbital fat; S, septum; SOOF, suborbicularis oculi fat. Figure 6. View largeDownload slide View largeDownload slide Skin muscle flap lower blepharoplasty in a 73-year-old woman. (A) A stair-step incision starting as a subciliary skin incision 1 to 2 mm below the lash line followed by a muscle incision preserving 4 mm strip of PTOO. (B) Dissection in the preseptal plane or space showing the LFP and CFP separated by the arcuate expansion of Lockwood ligament, the black arrow is pointing to the orbicularis retaining ligament and the white arrow is pointing to the lateral orbital adhesion. (C) White arrow pointing at arcuate expansion of Lockwood ligament. (D) Mobilization of the orbital fat as pedicled flaps that can be advance over the orbital rim. (E) Redraping of the orbital fat in the preperiosteal plane. (F) Marking the lateral wedge of skin and muscle that are trimmed in the skin-muscle flap technique. (G) The excess skin is estimated only after excision of the tissue laterally and orbicularis suspension. (H) Skin is conservatively trimmed, notice the elevation of the marked line that was originally placed at the tear trough. CFP, central fat pad; LFP, lateral fat pad; PSOO, preseptal orbicularis oculi muscle; PTOO, pretarsal orbicularis oculi muscle; OF, orbital fat; S, septum; SOOF, suborbicularis oculi fat. The orbicularis retaining ligament is an osseocutaneous septum that separates the eyelids from the cheek and brow and is responsible for nasojugual and palpebromalar grooves (Figure 6B).28,29,31 The medial aspect of this ligament is sandwiched between the maxillary origin of the preseptal and orbital orbicularis and it ends at the medial scleral limbus. This segment of the ligament is known as the tear trough ligament (Figure 2).28 As it travels laterally it turns into a pure bilamellar septum that increases progressively in length and fuses with the lateral orbital thickening. This segment of the ligament is known as the orbicularis retaining ligament.28 It is critical to differentiate the orbicularis retaining ligament from the arcus marginalis. The latter is a distinct fibrous thickening seen at the orbital rim from the confluence of the orbital septum with the periorbita and periosteum.30 The arcus marginalis is encountered and released through a transconjunctival postseptal approach, and the result of this release is connecting the orbital fat with a preperiosteal or subperiosteal plane on the anterior rim while leaving the septum undisturbed.8,11,36 On the other hand, a transconjunctival preseptal approach and the transcutaneous approach usually open the septum and encounter and release the orbicularis retaining ligament while leaving the arcus undisturbed,13 except in cases where they transition into a subperiosteal plane, necessitating the release of arcus marginalis (Figure 7).36 Figure 7. View largeDownload slide (A) An illustration of a sagittal view of the lower lid showing the two main approaches to lower blepharoplasty; the dashed line is the plane of dissection for the skin-muscle flap preseptal approach transitioning into a supraperiosteal plane, and the dotted line is the plane of dissection for the transconjunctival post septal approach transitioning into a subperiosteal plane. (B) The skin-muscle flap approach releasing the orbicularis retaining ligament and advancing the orbital fat over the orbital rim in a supraperiosteal plane leaving arcus marginalis intact. (C) The transconjunctival approach releasing arcus marginalis and advancing the orbital fat over the orbital rim in a subperiosteal plane, and therefore indirectly releasing the orbicularis retaining ligament by releasing its periosteal origin. Figure 7. View largeDownload slide (A) An illustration of a sagittal view of the lower lid showing the two main approaches to lower blepharoplasty; the dashed line is the plane of dissection for the skin-muscle flap preseptal approach transitioning into a supraperiosteal plane, and the dotted line is the plane of dissection for the transconjunctival post septal approach transitioning into a subperiosteal plane. (B) The skin-muscle flap approach releasing the orbicularis retaining ligament and advancing the orbital fat over the orbital rim in a supraperiosteal plane leaving arcus marginalis intact. (C) The transconjunctival approach releasing arcus marginalis and advancing the orbital fat over the orbital rim in a subperiosteal plane, and therefore indirectly releasing the orbicularis retaining ligament by releasing its periosteal origin. The lateral canthal fixation is anatomically accomplished through three structures that attach to the lateral orbital rim at different levels. The lateral palpebral raphe is formed by the pretarsal and preseptal orbicularis and is located immediately under the lateral canthal skin.37 The superficial lateral canthal tendon is a continuation of the orbital septum sandwiched between the muscle and the lateral canthal tendon and inserts anteriorly on the periosteum of the lateral orbital rim.35,37 The lateral canthal tendon (lateral retinaculum), is the deepest attachment that originates from the upper and lower tarsal plates and inserts on Whitnall’s tubercle which is positioned 2 to 4 mm inside the lateral orbital rim.23,37,38 It receives contributions from the lateral horn of the levator aponeurosis and Whitnall’s ligament superiorly, Lockwood’s ligament inferiorly, and the check ligament of the lateral rectus muscle on its deep surface.23,37-39 PREOPERATIVE EVALUATION The goal of preoperative evaluation is to identify medical history and anatomical features that increase the risk of postoperative complications. History of poorly controlled hypertension, bleeding disorder, and certain medications and herbal supplements can increase the risk of bruising and bleeding.40 History of prior cosmetic and reconstructive periorbital procedures should be obtained. The presence of dry eye symptoms and predisposing risk factors for dry eye syndrome must be carefully evaluated, as upper and lower blepharoplasties cause transient impairment in eyelid closure mechanics, and can result in worsening of symptoms postoperatively.41-43 Patients with history of dry eyes or inability to tolerate contact lenses should undergo a Schirmer test, which relies on the degree of wetting of a filter paper strip placed at the lateral commissure. Wetting of less than 5 mm distance over a period of 5 minutes is considered diagnostic of dry-eye syndrome.40,42 The presence of a normal Bell’s phenomenon, manifested as upward rolling of the globe when attempting to open a closed eye should be documented.40 Absence of Bell’s phenomenon, although is not a contraindication for blepharoplasty, should steer the surgeon towards a more conservative approach. History of recent ocular or corneal surgery should be elucidated. It is advisable to wait for 6 months after laser-assisted in situ keratomileusis (LASIK) to allow for restoration of normal corneal sensitivity prior to eyelid surgery, as LASIK causes blunting of the normal blink reflex temporarily.44 The patient’s specific cosmetic complaints should be verified while looking in the mirror. Evaluation then proceeds with careful analysis of periorbital topography and signs of aging. Standardized preoperative photographs are taken in 6 views that include a front, lateral, three quarters, and a close-up view of the eyes. In addition, photographs of the eyes closed in repose and of the eyes open with the globe in upward gaze, help in evaluation of the amount of excess skin in the upper lid and excess orbital fat in the lower lid, respectively. Finally, a photograph of the eyes in animation (squinting) helps verify the size and function of the pretarsal orbicularis and accentuates the tear trough deformity.28 Pictures will often reveal asymmetries that are not clear on examination, especially with ptosis that is more apparent when the patient relaxes in front of a camera. Three-dimensional photographs allow more accurate measurements of periorbital volumization procedures.45 The surgical plan should be determined after discussing the patient’s goals and desired outcome and it should be customized depending on the presenting features. Upper Eyelids There are three important features that need to be evaluated in the upper eyelid: (1) the presence of a well defined and visible crease; (2) the degree of pretarsal show; and (3) the height, volume, and contour of the upper eyelid fold. The marginal reflex distance-1 (MRD-1), defined as the distance between the corneal light reflex and the upper eyelid margin, should be determined first to rule out a concomitant blepharoptosis, which should be addressed at the time of blepharoplasty. In Caucasian females, the crease has a gentle arch, averages 8 to 10 mm in height from the lash line at the midpupil, and should be visible through its full length from medial to lateral canthi. The degree of desired pretarsal show varies among patients and can be determined by examining old photographs. Caution should be practiced with patients who present for upper blepharoplasty who have full visibility of their crease and pretarsal space. A traditional upper blepharoplasty in this patient population can result in increased pretarsal show, which can be unattractive. The youthful upper eyelid fold has a smooth surface with a progressive gradual increase in height and volume from medial to lateral where it blends with the lateral orbital area (Figure 1).2 This progressive increase in height and volume in females is determined by the position of the temporal brow and retro-orbicularis oculi fat. It is for this reason that a temporal brow lift can be complementary to upper blepharoplasty (Figure 8). In non-Asian males, the crease (averaging 7-8 mm in height)46 is straighter and the upper lid fold is more uniform in height and volume with less emphasis on the visibility of the pretarsal space. Contour irregularity of the upper eyelid fold can result from excess skin, localized bulge created by herniating orbital fat, or a prolapsed lacrimal gland. Finally, the need for fat grafting to create a smooth, full, and convex upper eyelid fold should also be determined. Lower Eyelids The lower eyelid position is evaluated including the presence of scleral show or bowing of the lateral lower lid resulting in rounding of the lateral canthal angle.3,40 These features along with the presence of a negative vector place the patient at a high risk for post lower blepharoplasty retraction.40,47,48 The presence of a negative vector causes the lower lid to travel at an upslope to cover the globe, which creates a mechanical disadvantage that can be further deteriorated by surgical disruption of ligamentous and volume support of the lower eyelid.48 If the patient is suspected of having a prominent globe, a Hertel exophthalmometer can be used to measure the corneal projection relative to the lateral orbital rim. Normal range is defined to be between 15 and 17 mm and patients with prominent eyes (>18 mm) are at higher risk for postoperative lower lid malposition.3,40 Lower eyelid laxity and tone are examined through “distraction” and “snap back” tests.3,40,48 A lower eyelid that can be distracted >8 to 10 mm away from the globe constitutes an abnormal distraction test and indicates increased lower lid laxity.47,48 An abnormal snap back test on the other hand, defined as a slow return of a pulled down lower eyelid to a normal position that may require a blink, indicates both increased laxity and decreased muscle tone.40,47,48 Finally, the presence of lower eyelid malposition should be evaluated, investigated, and documented prior to surgery. Unacceptable cosmetic appearance of the lower eyelids can be due to one or more of the following: (1) dark shadows due to skin pigmentation and contour irregularity resulting from the tear trough depression and overlying bulging orbital fat; (2) orbicularis oculi muscle laxity or hypertrophy; (3) skin excess; and (4) volume loss at the eyelid cheek interface. These components are not present in all patients and they vary in severity, therefore the surgical plan should be tailored to each patient based on their presenting anatomy and risk for developing postoperative complications. The location and extent of each abnormality should be examined in the upright sitting position and the extent and severity of anterior lamellar changes should be evaluated to determine the best approach to address the anterior lamella. SURGICAL TECHNIQUES Upper Blepharoplasty Upper blepharoplasty has evolved over the years from a debulking procedure to a more balanced, volume-preserving approach.2-4,26,46,49,50 Regardless of the technique used, the following points have to be addressed: 1. Does the patient have a visible and nondisplaced crease? If so, then the incision should be marked and made in that crease instead of creating a crease that purely relies on measurements. However, making the incision slightly lower than the existing crease,49 and elevating the crease in patients who desire more pretarsal show have been described.2 On the other hand, if an upper lid crease is abnormally high as in tarsolavator dehiscence, or ill defined, then marking the crease should rely on measurements or the height of the tarsal plate, which can be determined by everting the lid. 2. Does the fat need to be removed, redistributed, or enhanced with grafting? If fat grafting is needed then a decision is made whether it’s done concomitantly or at a different stage depending on the extent of intraoperative dissection. 3. Does the patient require a temporal brow lift, or just brow volume enhancement? “Open Sky” Technique The “open sky” technique described by McCord,23 relies on the excision of a myocutaneous segment of skin, orbicularis oculi, and orbital septum to expose the preaponeurotic and nasal fat pads. Intraoperative skin markings are detailed in Video 1. The lateral extent of the marked skin excision is determined in an upright position while the patient’s tail of the brow is manually elevated and depressed assessing where the skin redundancy can be trimmed without creating a dog ear. The lateral point should preferably stay medial to the tail of the brow,46 and if it were to be extended laterally as in cases with extensive dermatochalasis, then it should be marked in a natural upper crow’s feet line (Figure 4A). The upper limit of excision is marked on the upper lid fold at least 10 mm from the junction of the brow-upper lid skin.3,23 This distance can be increased, and therefore shortening the vertical length of the excised skin, according to the desirable degree of pretarsal show. The lines are connected with a gentle curve that tapers nasally to avoid excessive skin excision in that area. The incisions should not extend nasal to the medial canthus.46 Skin infiltration with a local anesthetic is performed after marking the crease and it can facilitate drawing on an otherwise redundant skin. Pinching the area of marked skin with forceps allows for making adjustments before committing to the marked pattern.51 Incisions are made precisely, beginning with the crease. The upper fold incision is deepened through the orbicularis oculi muscle exposing the orbital septum while maintaining meticulous hemostasis. Gentle pressure applied on the globe (retropulsion) allows preaponeurotic fat to bulge forward and the orbital septum is incised. The preaponeurotic fat is trimmed or redistributed along the length of the sulcus (Figure 4D). The nasal fat pad is located next, freed from the surrounding connective tissue, and excised or blended with central fat pad as necessary.4 Following management of the orbital fat, the skin-muscle flap is excised at the level of the crease, beveling the scissors away from the crease to prevent disruption of the levator aponeurosis attachment to the tarsal plate. Transpalpebral browpexy or repositioning of the lacrimal gland can be performed as needed. Closure involves approximation of the skin and muscle in one or two layers. The addition of a supratarsal fixation as suggested by McCord can theoretically help stabilize the crease by reattaching the pretarsal orbicularis to the levator aponeurosis with a 6-0 absorbable suture.3,23 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Close Other Techniques A variety of other techniques have been previously reported in the literature to preserve the upper eyelid volume by conserving the orbicularis oculi and orbital fat.2,4,46,49,52 Skin markings are performed in a similar fashion and rely more on skin pinch while the brow is stabilized in position. After the skin is excised, the preseptal orbicularis can be incised or a window can be made in the muscle and septum as needed to address the preaponeurotic central fat and nasal fat pads.4 The temporal septum is also opened as needed to address a prolapsed orbital lobe of the lacrimal gland.53 After the fat pads are mobilized, they can be redraped across the sulcus or blended together to augment the upper lid fold and sulcus volume.54 The nasal fat pad can also be adequately mobilized and redraped while taking care not to injure any vascular structures or the tendon of the superior oblique muscle.4 Mobilizing the central or preaponeurotic fat pad has also been described to augment the lateral upper lid fold.50 The retro-orbicularis oculi fat can be sculpted as needed,23 however, it is better to preserve the brow volume and reposition it instead. Repositioning the ROOF has been advocated through surgical techniques that secure the cut edge of the preseptal orbicularis to the arcus marginalis.21 When the orbicualris oculi muscle is left untouched, plicating the muscle by incorporating it in skin closure helps define the upper lid crease and enhance the upper lid fold convexity.26,49 Adjunct procedures for upper blepharoplasty include lacrimal gland suspension, transpalpebral browpexy, fat grafting, and transpalpebral corrugator resection. The incidence of lacrimal gland prolapse has been reported to be 15% in the general population55 and higher in the aging population.53 In order to expose the gland, the temporal orbital septum is opened and the central fat pad is mobilized. Several techniques have been described for repositioning of the orbital portion of the lacrimal gland including suturing the capsule of the gland to superior orbital rim periosteum,56 suturing Whitnall’s ligament57 or the anterior surface of the lateral horn of the levator over the gland to the superior orbital rim periosteum,23 or the use scarring induced by cautery to reposition mild gland prolapse.53 If the lateral horn of the levator is placated to arcus, it is critical to place the upper lid on downward traction prior to suture placement to prevent postoperative lagophthalmos. Transpalpebral internal browpexy is mainly a brow-stabilizing procedure that fixes the lateral brow to the deep temporal fascia lateral to the temporal fusion line. Modifications were described of the internal browpexy using Endotine device (Coapt Systems, Inc., Palo Alto, CA) over the bony portion of the superior orbital rim, medial to the temporal fusion line for more lifting.19 Lower Blepharoplasty There are two popular approaches to surgical rejuvenation of the lower eyelid: the transconjunctival and skin-muscle flap blepharoplasties. The main distinguishing feature between the two is that the transconjunctival approach does not violate the orbicularis oculi muscle and the orbital septum can also be left intact. Therefore, it relies mainly on skin-only excision to address the anterior lamella, when indicated. The skin muscle flap technique on the other hand relies on mobilization and tightening of the orbicularis oculi muscle through suspension,58 which resembles a SMAS facelift. The term transcutaneous can indicate a variety of modifications of the skin-muscle technique but does not always involve orbicularis suspension. Skin-Muscle Flap Lower Blepharoplasty As the name indicates, this technique provides access to the orbital fat through an anterior approach.6 A stair-step incision is made in the skin immediately inferior to the lash line and is extended a few millimeters laterally beyond the lateral canthus (Figure 6A). The lateral extension is marked in an upright sitting position in a natural crow’s feet line if possible (Figure 4A). One must err on marking the lateral extension pointing slightly superiorly as it tends to drift inferiorly postoperatively, which results in an inferior aesthetic result. After the skin incision is made starting laterally, dissection is deepened through the orbicularis oculi muscle until the lateral orbital rim periosteum is identified. A small double prong skin hook is then used to pull on the incision edge laterally keeping the lower lid under tension and the skin incision is placed precisely 0.5 to 1.0 mm under the lash line. After the skin is separated from the orbicularis oculi, the muscle incision is extended preserving 4 millimeters of pretarsal orbicularis (Figure 6A). Dissection proceeds in a preseptal plane until the inferior orbital rim is reached. In this plane, the tear trough ligament and the orbicularis retaining ligaments are identified and are released in continuity with the lateral orbital adhesion (Figure 6B). It is this complete release of the retaining ligament and lateral adhesion that frees the muscle and allows mobilization of the orbital portion of the orbicularis6,12,59 along with its overlying subcutaneous fat compartment (infraorbital fat) superiorly.33 This maneuver is what defines the skin-muscle flap technique, as it redrapes and lifts the orbicularis taking the soft tissue redundancy laterally where the majority of trimming occurs (Figure 6F).6,58 After releasing the tear trough and the orbicularis retaining ligaments, the area of the SOOF is exposed and dissection proceeds in a supraperiosteal plane for 5 to 10 millimeters. If a midface lift is intended at the same time, dissection can be extended further either in a supraperiosteal plane spreading through the prezygomatic and premaxillary spaces12,29 or in a subperiosteal plane. If a midface lift is not planned, then the extent of dissection is judged by adequate release of the depression created by the retaining ligaments and the size of the pocket created for fat redraping. Fat excision or redraping (see below) is performed through a septal incision or partial excision (Figures 6D and E). After the orbicularis is redraped, a triangular skin and muscle excision is performed laterally and inset is performed after lateral canthal tightening. Conservative subciliary skin and muscle excision is performed after lateral inset of the orbicularis flap (Figure 6G). Proper inset of the skin-muscle flap is probably one of the most challenging steps of this technique for several reasons; there is a substantial dog ear that has to be chased while maintaining a relatively short incision, sewing the orbicularis back together can create a step off that has to be leveled, and finally imprecise inset of the skin near the lateral canthus can result in postoperative webbing. Given the nature of the stair-step incision, careful trimming of the preseptal orbicularis is necessary to avoid overlap and unintentional augmentation of the pretarsal orbicularis.6,12,16 There are several advantages of the skin-muscle flap blepharoplasty; it provides unparalleled exposure for fat redraping, it is a powerful technique for tightening of the anterior lamella (Figures 8-10) especially in patients with orbicularis oculi laxity, and it elevates the infraorbital superficial fat compartment, which helps with blending of the eyelid-cheek junction (Figure 6H). On the other hand, the skin-muscle flap technique is considered by some an aggressive approach with higher incidence of postblepharoplasty lower eyelid retraction.48 There is more scarring involved in the anterior and middle lamella by violating the muscle and septum in addition to partial denervation of the muscle which weakens the anterior support of the lower lid.48 Although EMG studies have refuted this hypothesis by showing normal innervation of the pretarsal orbicularis through preservation of the medial buccal branch of the facial nerve,32 there is possibly some loss of tone that occurs postoperatively that takes some time to recover. This loss of tone in addition to increased postoperative swelling can prolong the recovery of the procedure. Although the skin muscle-flap technique achieves excellent results, it can be unforgiving in inexperienced hands and if lateral canthal anchoring is not mastered.39,60,61 This is especially true in patients at high risk of postoperative retraction like those with negative vector (Figure 11).47,48 Figure 8. View largeDownload slide (A) Preoperative photograph of a 54-year-old woman with bilateral brow ptosis, lateral hooding, lower lid anterior lamellar changes with minimal orbital fat herniation. (B) Postoperative result 8 months after bilateral upper blepharoplasty and lower skin-muscle flap blepharoplasty with canthopexy. (C) Postoperative result at 18 months and after additional cheek fat grafting. In addition to that, she also underwent bilateral endoscopic temporal brow lift and transpalpebral corrugator resection in addition to fat grafting to the medial and lateral SOOF. Notice the improvement in her upper lid aesthetic proportions enhanced by the brow lift, and the smooth lower lid surface as a result of anterior lamellar tightening. Figure 8. View largeDownload slide (A) Preoperative photograph of a 54-year-old woman with bilateral brow ptosis, lateral hooding, lower lid anterior lamellar changes with minimal orbital fat herniation. (B) Postoperative result 8 months after bilateral upper blepharoplasty and lower skin-muscle flap blepharoplasty with canthopexy. (C) Postoperative result at 18 months and after additional cheek fat grafting. In addition to that, she also underwent bilateral endoscopic temporal brow lift and transpalpebral corrugator resection in addition to fat grafting to the medial and lateral SOOF. Notice the improvement in her upper lid aesthetic proportions enhanced by the brow lift, and the smooth lower lid surface as a result of anterior lamellar tightening. Figure 9. View largeDownload slide (A) Preoperative photograph of a 70-year-old woman with bilateral lower lid anterior lamellar changes, surface irregularities, asymmetry, minimal fat herniation on the right, and volume loss at the eyelid-cheek junction. (B) Postoperative results 18 months after bilateral lower blepharoplasty using the skin-muscle flap approach, lateral canthopexy, and fat grafting the deep medial cheek and SOOF compartments. Notice the improved symmetry and smooth eyelid-cheek transition. The patient declined upper blepharoplasty. Figure 9. View largeDownload slide (A) Preoperative photograph of a 70-year-old woman with bilateral lower lid anterior lamellar changes, surface irregularities, asymmetry, minimal fat herniation on the right, and volume loss at the eyelid-cheek junction. (B) Postoperative results 18 months after bilateral lower blepharoplasty using the skin-muscle flap approach, lateral canthopexy, and fat grafting the deep medial cheek and SOOF compartments. Notice the improved symmetry and smooth eyelid-cheek transition. The patient declined upper blepharoplasty. Figure 10. View largeDownload slide (A) Preoperative photograph of a 43-year-old woman with bilateral upper lid dermatochalasis and “tired look” as a result of bilateral lower lid tear trough deformity and medial orbital fat herniation. (B) Postoperative photograph 16 months after bilateral upper blepharoplasty and bilateral skin-muscle flap lower blepharoplasty, fat transposition, fat grafting to the cheek, and canthopexy. Notice the postoperative increase in pretarsal show and worsening hollowing despite that this was a skin only removal indicating the need for volume enhancement with fat grafting. The lower lids are smooth with elimination of the tear trough deformity and the “tired look.” Figure 10. View largeDownload slide (A) Preoperative photograph of a 43-year-old woman with bilateral upper lid dermatochalasis and “tired look” as a result of bilateral lower lid tear trough deformity and medial orbital fat herniation. (B) Postoperative photograph 16 months after bilateral upper blepharoplasty and bilateral skin-muscle flap lower blepharoplasty, fat transposition, fat grafting to the cheek, and canthopexy. Notice the postoperative increase in pretarsal show and worsening hollowing despite that this was a skin only removal indicating the need for volume enhancement with fat grafting. The lower lids are smooth with elimination of the tear trough deformity and the “tired look.” Figure 11. View largeDownload slide (A) Preoperative oblique view of a 41-year-old woman with a prominent tear-trough deformity and medial orbital fat herniation. The patient has negative vector and scleral show at baseline. (B) Postoperative photograph 3 years after bilateral lower blepharoplasty, skin-muscle flap approach, with release of the tear trough ligament and medial and central orbital fat transposition, and lateral canthopexy with over correction. Notice the improvement in her tear trough and lower lid contour with preservation of the lower lid position. Figure 11. View largeDownload slide (A) Preoperative oblique view of a 41-year-old woman with a prominent tear-trough deformity and medial orbital fat herniation. The patient has negative vector and scleral show at baseline. (B) Postoperative photograph 3 years after bilateral lower blepharoplasty, skin-muscle flap approach, with release of the tear trough ligament and medial and central orbital fat transposition, and lateral canthopexy with over correction. Notice the improvement in her tear trough and lower lid contour with preservation of the lower lid position. Transconjunctival Lower Blepharoplasty A transconjuctival incision provides access to the orbital fat through a posterior approach and leaves the orbicularis muscle and septum undisturbed, although there are reported transconjuctival techniques that involved some form of orbicularis tightening.8,17 An incision is made in the conjunctiva 5 to 6 mm inferior to the tarsus to avoid the zone of fusion between the capsulopalpebral fascia and the orbital septum. This allows direct posterior access to the orbital fat while staying in a postseptal plane. A preseptal dissection can also be performed if the transconjunctival incision were to be made within 5 mm of the tarsus (Video 2). The incision in the capsulopalpebral fascia can be made horizontally along the same line with conjunctiva, or separately as a vertical split to preserve the retracting function of the muscle. There have been no reported complications, however, from dividing the CPF horizontally. Staying in the postseptal plane until the inferior orbital rim is reached leads to the posterior aspect of the arcus marginalis, so this plane continues naturally into a subperiosteal plane unless an incision is made at the inferior border of the septum above the arcus marginalis to continue in a supraperiosteal plane. A subperiosteal dissection is performed with a periosteal elevator taking care not to injure the infraorbital neurovascular bundle, which is clearly visualized.8,11,36 The tear trough and orbicularis retaining ligaments are not directly severed as their periosteal origin is elevated, therefore there is more emphasis on “arcus marginalis release” in this type of procedure than on orbicularis retaining ligament release. The end effect should be similar as the tear trough area of depression is elevated and separated from bone. A preseptal dissection is preferred by others13 as it provides better access to release the palpebral part of the orbicularis oculi, tear trough ligament, orbital part of the orbicularis oculi, and the orbicularis retaining ligament. After the fat is redraped, lateral canthal tightening can be performed when indicated and the conjunctival incision is closed or left to heal by secondary intention. The skin is addressed through a separate incision when indicated. Different techniques were described for skin excision including a “pinch”7 and a skin only flap.8,17 In a “pinch” blepharoplasty, the skin is pinched with forceps creating a vertical skin pillar that is excised and closed while avoiding any everting tension on the lid margin. A skin only flap on the other hand separates the skin from the orbicularis oculi down to the inferior orbital rim and redrapes the skin (Supplemental Figure 1). Video 2 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Video 2 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy034 Close Fat Transposition and Fat Grafting First described by Loeb62 in 1981, using the orbital fat as pedicled grafts to augment the eyelid-cheek junction has become a popular and reliable technique. The orbital fat can be accessed through a preseptal or a postseptal approach and is redraped in a subperiosteal or supraperiosteal plane.6,8,9,11,13,14,16,17,36,63 In a preseptal approach, the orbital septum is opened or partially excised and the fat is mobilized by lysis of the fibrous connective tissue that restricts it (Figure 6D). The use of a needle-tip electrocautery on a low current facilitates this dissection, which is continued until the fat pedicles are completely freed and redraped over the inferior orbital rim without creating any tension on the lower lid (Figure 6E). The septal reset technique, described by Hamra,64 involves incising the inferior border of the septum and advancing the septum along with the orbital fat over the orbital rim where it is secured.16,64,65 The most common orbital fat redistribution is the use of the nasal and central fat compartments to augment the area of the tear trough with its accompanying central triangular depression at the eyelid cheek junction, while excising the lateral fat compartment.3,6,8,9,11,13 Fat transposition has been reported with and without anchoring to periosteum or to skin.6,8,11-13,36 The use of excised orbital fat as free grafts has been also reported with good outcomes.13,15 Fat grafting has become an important adjunct procedure that is being performed more frequently with both upper and lower blepharoplasties. This is attributed to several recent topographical and anatomical studies that advanced our understanding of periorbital aging and its relationship to soft tissue deflation, and facial fat compartments of the face.22,33,34,66 The purpose of fat grafting is to blend the eyelid-cheek junction and to improve both the anterior and lateral brow and cheek projection, enhancing periorbital aesthetics. In the upper lid, fat grafting improves the volume of the upper eyelid sulcus, the upper lid fold, and the brow.18,26 This has a favorable effect on the position of the brow and the upper eyelid fold to pretarsal space ratio. The main target areas in the upper lid are sulcus both medially and laterally and the lateral brow fat compartment (retroorbicularis oculi fat, ROOF). In lower blepharoplasty, fat grafting the deep medial fat compartment improves the anterior cheek projection and the inverted V defromity, while fat grafting the lateral and medial SOOF helps improve the lateral cheek projection and blend the eyelid cheek junction, respectively.22,33,34 The main challenge with concomitant fat grafting and blepharoplasty is trying to perform grafting in a plane that has not been violated, in order to comply with Coleman’s fat grafting principles.67 This becomes more challenging when the tear trough and the orbicularis retaining ligaments are released, opening up both the medial and lateral SOOF compartments. One possible advantage of subperiosteal dissection is the preservation of the preperiosteal plane, where fat grafting can be performed concomitantly. The use of both micro and fractionated (fracto) fat grafting have been reported for blending the eyelid junction.18,22 Lateral Canthal Tightening The need for lateral canthal tightening after lower blepharoplasty remains a controversial topic between proponents of routine6,11,12,14,47,48,59 and selective8,36,68,69 application. The term canthopexy indicates lateral tightening of the lower lid without a canthotomy or cantholysis, while canthoplasty is lid tightening in the presence of canthotomy and/or cantholysis (Figure 5). Lateral canthoplasty allows for lid shortening in cases of severe lower lid laxity, in addition to reshaping and repositioning of the lateral canthal angle, while canthopexy is merely a splinting procedure that maintains the posture of the lid and relaxes with time.60 Canthopexy is more frequently applied in the setting of aesthetic blepharoplasty and canthoplasty is reserved to cases where lower lid horizontal shortening is indicated. Several canthopexy techniques have been described, each differ in the lower lid tissue being captured with suture including tarsus,6 inferior or lateral retinaculum,38,39 or superficial lateral canthal tendon (Video 2).35 They all, however, anchor to the periosteal lining of the lateral orbital rim.6,8,11,35,38,39 Although the term “canthopexy” has also been used to describe anchoring the orbicularis to periosteum,8 this maneuver is more in line with orbicularis suspension. To date there is no consensus on the routine use of lateral canthal tightening with lower blepharoplasty, perhaps due to the fact that blepharoplasty techniques vary in approach, dissection, and amount of tissue removal. This is further confounded by publications showing low rate of lower lid malposition with selective68,69 or no canthopexy70 even with skin-muscle flap blepharoplasty. It should be noted however, that a lateral canthal tightening procedure is required in the following situations: (1) a skin-muscle flap blepharoplasty; (2) patients with negative vector; and (3) patients with moderate to severe lower lid laxity. OUTCOMES AND COMPLICATIONS To date, there are no standardized outcome measures for either upper or lower blepharoplasty. The majority of studies and case series reported in the literature mainly focus on reporting complications and need for revision. Only a few studies utilized some form of objective evaluation or aesthetic score calculation.14,68,69,71 The FACE-Q eye module has been developed as a patient reported outcome measure but hasn’t been widely adopted yet due to its recent introduction.72 Postoperative complications after blepharoplasty include hematoma, asymmetry, lagophthalmos, lower lid malposition, scleral show, dry eyes, frank lower lid ectropion, lateral canthal webbing, and chemosis. The most devastating complication after blepharoplasty is blindness that can occur as a result of globe injury, retrobulbar hematoma, and/or fat grafting.46,73 Reported complications and reoperation in the literature are generally low6,8,9,11-13,59,68,69 but probably do not reflect common practice as they are often published in series of experienced surgeons. The duration of postoperative recovery after blepharoplasty is underreported and perhaps underestimated. Postoperative bruising and ecchymosis is expected in the early postoperative period and is minimized by application of cold compresses for 48 hours.42 Peribulbar hematoma usually occurs due to bleeding from the orbicularis oculi muscle, and although it is not vision threatening, it can result in increased inflammation, scarring, and lower lid malposition. Retrobulbar hematoma is the most serious complication after blepharoplasty and should be treated emergently, as it can lead to vision loss due to compression of the neurovascular structures.46 Postblepharoplasty lower eyelid retraction (PBLER) is one of the most feared complications after lower blepharoplasty. Risk factors that predispose to PBLER include excessive skin or muscle resection, scarring of the middle lamella, and failure to recognize and address lower eyelid laxity.40,47,48,61 Other patient-related risk factors include the presence of negative vector that is usually associated with lack of adequate volume support in the cheek and reduced orbicularis function.48 Management of PBLER is mainly through prevention by applying proper lateral canthal tightening techniques, which include canthopexy with overcorrection in patients with prominent eyes and negative vector, and canthoplasty with lid shortening in patients with severe lower eyelid laxity.6,38,39,47,61 Customizing procedure selection to the patient’s anatomy is also critical to avoid PBLER, as in avoiding skin-muscle transcutaneous approaches in patients with negative vector who predominantly require treatment of orbital fat herniation and a tear trough deformity in the absence of anterior lamellar laxity. Another critical consideration is in avoiding over resection of skin, muscle, or fat as this will result in scarring and vertical shortening of the lid and reduction in soft tissue support. Chemosis is a bulbar conjunctival swelling that can occur with varying severity, mainly in the setting of lower blepharoplasty.74 Multiple etiologies have been associated with the development of chemosis including inflammation, exposure, and lymphatic disruption.42,43,74 A recent anatomical study of the periorbital lymphatic drainage by Shoukath et al described the presence of a deep lymphatic drainage system that drains the conjunctiva and passes deep to the preseptal orbicularis piercing the orbicularis retaining ligament laterally at its junction with lateral orbital thickening.75 These findings are suggestive that any procedures involving deep lateral dissection can theoretically increase the incidence of chemosis. The incidence of reported postoperative chemosis ranges between 0% to 12.1%, with one series reporting an incidence of 34.5%.43 The data from previously published case series suggest higher incidence of chemosis with the skin muscle flap compared with transconjunctival approach especially with the routine use of lateral canthal tightening.75 There is no evidence supporting that lateral canthoplasty is associated with higher incidence chemosis when compared to lateral canthopexy.6 A cyclic relationship can develop between exposure and chemosis leading to the propagation of the latter. As the formation of conunctivocalasis and blister formation impairs eyelid closure, this leads to further conjunctival exposure, desiccation, and inflammation.42,74 Treatment strategies include frequent lubrication of the conjunctiva with wetting drops, topical antibiotic ointments with steroids, and vasoconstrictive agents such as 2.5% ophthalmic phenylephrine. These measures are usually effective in treating mild chemosis. If chemosis develops intraoperatively, a lateral tarsorrhaphy suture and/or plication of the redundant conjunctiva at the fornix can be helpful in preventing further propagation. In more severe cases, firm patching of the eye for 24 to 48 hours can be effective. The patient should be instructed to keep the eye closed under the patch. In cases of severe refractory chemosis, a snip conjunctivotomy to release the fluid is recommended, combined with firm patching and systemic anti-inflammatories.41,42,74 Dry eyes syndrome after blepharoplasty occurs in patients with predisposing risk factors and is reported to persist longer than 2 weeks in 11% of patients.41 The presenting symptoms include dry eyes, irritation, and foreign body sensation, which develop as a result of decreased tear film production or increased evaporation.41,42 After blepharoplasty, the precision of the blink mechanism is affected due to swelling, lagophthalmos, and sometimes transient muscle denervation. In addition, there is a decreased production of the lipid component of the tear film by the Meibomian glands, which leads to increased evaporation.41-43 Management of dry eye syndrome is mainly through prevention by avoiding or staging the procedure in patients with history of dry eyes, and using conservative surgical approach in high-risk patients. Postoperative management include continued lubrication with wetting eye drops until the symptoms resolve, treatment of inflammation with topical antibiotics and steroid ointment, and minimizing exposure.40-43 Support of the lower lid with taping during the healing phase and early treatment of chemosis are critical especially if symptoms persist longer than two weeks. Surgical correction of lagophthalmos due to skin or muscle over resection, and lower lid malposition should be undertaken when it becomes clear that those changes are irreversible. The use of punctal plugs and an ophthalmology referral can be considered in patients with prolonged or refractory symptoms. CONCLUSION Upper and lower blepharoplasties are effective and safe cosmetic surgical procedures that require knowledge of periorbital anatomy and carful preoperative planning. The choice of approach should be tailored to the patient’s needs and preoperative risk factors. 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Blindness following cosmetic injections of the face. Plast Reconstr Surg . 2012; 129( 4): 995- 1012. Google Scholar CrossRef Search ADS PubMed  74. McCord CD, Kreymerman P, Nahai F, Walrath JD. Management of postblepharoplasty chemosis. Aesthet Surg J . 2013; 33( 5): 654- 661. Google Scholar CrossRef Search ADS PubMed  75. Shoukath S, Taylor GI, Mendelson BC, et al.   The lymphatic anatomy of the lower eyelid and conjunctiva and correlation with postoperative chemosis and edema. Plast Reconstr Surg . 2017; 139( 3): 628e- 637e. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: Feb 21, 2018

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