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Markus J. Pfeiffer
Fig. 11.3. In the primary position of gaze the lid Fig. 11.4. The lid crease normally tends to form in
crease covers the basic aperture angle formed by the the level of the aperture plane (1). If there is little tis-
aperture plane and the ocular surface (1). During lid sue volume within the aperture plane, the skin crease
closure the crease is unfolded anteriorly in front of will form at a higher level (2). Excessive tissue volume
the aperture plane (2). In the up gaze position, the lid like orbital fat in the aperture plane will lower the lid
crease is retracted behind the aperture plane (3) crease (3)
11.2.3 11.2.4
The Upper Lid Crease The Skin Fold
The upper lid crease cannot be seen directly, be- For the information of the patient and the plan-
cause it is located behind the normal skin fold. ning of blepharoplasty it is important to under-
After having created a surgical access through stand the mechanism of the skin fold formation
the skin, the lid crease can be viewed directly. in the upper lid. We find it useful to describe the
The lid crease is formed in a dynamic angle in vertical section of the fold in the center of the lid
the junction between the preseptal and the pre- like an “N” that is composed of an inward fold
tarsal surface. The angle becomes smaller when and an outward fold. For lid closure the fold has
the patient looks upward and wider in down- to be able to unfold freely to a straight layer
ward gaze (Fig. 11.3). The individual angle is without traction. The inward fold is cosmetical-
more dependent on the alterations of the septal ly more desirable, because it allows the skin to
surface than the tarsal surface. During surgery be stored away posteriorly while the lid is
we can easily observe the preseptal surface in opened. The aim of blepharoplasty can either be
various gaze positions. The upper lid crease for- the reduction of the outward fold or the en-
mation is the most important aspect in ble- hancement of the inward fold. In most cases
pharoplasty, because the position of the skin both folds have to be corrected, the outward fold
crease and its symmetry is evaluated more crit- by excision of redundant skin and the inward
ically by the patient than the brow position or fold by deepening the lid crease. The deepening
the upper lid level [25]. The position of the lid of the inward fold is achieved by the removal
crease depends on many factors: (1) the position of the lid crease inhibiting tissues like excessive
of the aperture plane, (2) the preseptal orbicu- preseptal orbicularis muscle, prolapsed pre-
laris muscle, (3) the anatomy of the orbital sep- aponeurotic fat or ptotic SOOF (Fig. 11.5).
tum, (4) the brow position, (5) the sub-brow fat-
pad (SOOF), (6) the preaponeurotic fat and (7)
the levator and its function (Fig. 11.4).
126 Chapter 11 Update on Upper Lid Blepharoplasty
The best approach to the medial SOOF is sub- direction of the medial and lateral canthal ten-
periosteal through a frontal or temporal inci- don. The unrestricted motility of the septum
sion behind the hairline. From an esthetic point has to be preserved. It seems unnecessary or
of view the SOOF has the benefit of smoothen- even counterproductive for the motility to try to
ing the contour of the orbital skull. Any proce- repair a transected septum [38]. In reoperations
dure on the SOOF should be planned carefully we observe that the membrane tends to reform
to avoid a sulcus formation in the superolateral in a natural way. It is also not recommended to
orbital area. Any brow elevation technique will try to deepen the skin crease by picking up deep
also lift the sub-brow fat pad. tissue since this can result in a shortening of the
septum and eyelid retraction.
11.2.11
The Orbital Septum 11.2.12
The Orbital Fat
The orbital septum is formed by a membrane
that separates the anterior eyelid lamella from The orbital fat fills the spaces between the
the orbital space. The septum can also be con- globe, the extraocular muscles, the neurovascu-
sidered as the entrance into the orbit [26].A ble- lar pathways and the orbital wall. The septum
pharoplasty can be performed with or without forms the anterior limitation of the orbital fat.
opening the septum. It can be opened through a We can differentiate central, medial and lateral
buttonhole incision, or through a wide ap- compartments of orbital fat. The fatpads are
proach. It plays an important role in the lid deformable and change their shape in different
crease formation. The upper insertions of the gaze positions. There is an age related tendency
septum are parallel to the orbital rim, where to protrusion of fat lobules caused by laxity of
they merge with the fascia of the SOOF and the the septum. Also an age related increase of the
periosteum. The upper insertion of the septum fat volume has been observed.
also depends on the volume and the motility of The orbital fat of the upper lid is composed
the sub-brow fat pad. The lower part of the sep- of two different fat pads: the preaponeurotic fat
tum fuses with the posterior lid lamella. There- and the medial orbital fat (Fig. 11.6).
fore the septum can also be defined as a bridge
between the container (orbit) and the content 11.2.12.1
(globe). The lower insertion of the septum on The Preaponeurotic Orbital Fat
the posterior lid lamella is extremely variable.
We can find very high insertions into the high The preaponeurotic fat can often be seen
aponeurosis where the septum correlates with through the septum. If it is not visible, an injec-
the aperture plane. Those patients will show a tion of clear solution under the septum will
maximal high lid crease. Asian eyelids show a make it shine through. Sometimes the pre-
very low insertion of the septum with a very low aponeurotic fat can be hardly detected and only
or non-existent lid crease. The septum can con- forms a thin layer above the levator muscle. In
tain various layers of a fibroelastic tissue. It can other cases it presents as an unsightly bulge.
be tight and straight or dilated and bulged. In After the septum is dissected and retracted, the
most cases the septum is formed like a bag fat will prolapse in a semiliquid manner. The
where the anterior layer continues into the pos- preaponeurotic fat is the most flexible and
terior layer on the aponeurosis. The fundus of liquid fat of the orbit. A resected lump of
the bag is not always filled with orbital fat. The preaponeurotic fat will form like a drop of oil on
identification of variations of the septal layers is a plane surface due to its homogeneous
very important for the safe access to the orbit. monolobular structure. The preaponeurotic fat
On downgaze the septum is stretched and forms is covered by a few thin transparent mem-
a more or less straightened layer. The medial branes. If these membranes are opened, the fat
and lateral insertions of the septum follow the transforms to a flat layer. The lateral part of the
11.2 Surgical Anatomy of the Upper Lid and Upper Orbit 129
taneous activity. The antagonists (orbicularis We all know the kind of patient who wishes to
muscle and procerus muscle) can be activated have the same operation that has been per-
unilaterally. This explains why we often find a formed successfully on another patient. The pa-
marked brow asymmetry in cases with symmet- tient’s expectation is based on the presumed
ric frontalis innervation. As any brow asymme- similarity of any orbital region, any aging
try will disturb our intentions to achieve a sym- process and any recommended eyelid surgery. If
metric blepharoplasty result, we need to find an esthetic improvement of the eyelid region is
out whether we can eliminate the cause before noticed, it is often difficult to explain what ex-
we have to intervene on the brow. Often we ob- actly has changed. Most patients are therefore
serve a unilateral compensatory brow elevation unable to describe in detail what they wish to
due to unilateral ptosis or pseudoptosis. The have corrected. Even if we show all our photo-
correction of ptosis would secondarily reduce graphs of pre- and postoperative examples,
the brow elevation [12] (Fig. 11.7). there will be no case that can be used as a reli-
able reference for an individual situation.A nor-
mal patient will usually not be able to recognize
11.2.15 the relevant details that are responsible for the
The Posterior Lid Lamella improvement of his or her lids. On the other
hand the patient is able to differentiate thou-
The tarsoconjunctiva is the essential structure sands of individual faces. This paradox explains
that enables the lid to function as a protective the main difficulty in blepharoplasty: (1) the pa-
“lid” on the cornea. The inner surface of the tient expects an improvement without being
tarsal plate corresponds to the corneal surface. conscious of the changed anatomical details
Any eyelid surgery should primarily respect and (2) the patient and their social environment
and never disturb this relationship of the lid will be very critical about any change in individ-
and the ocular surface. ual facial expression. The preoperative evalua-
11.3 Preoperative Evaluation and Surgical Planning 131
tion has to consider this paradox when the op- have to evaluate the position of each point in re-
eration is planned. The convergence of the pa- lation to the other two points: (1) the lid level
tient’s “what do I want?” and the surgeon’s “what (MRD) affects the skin crease level and the brow
can I do?” can never be aimed at an ideal. The level in an inverse manner. A drop of lid level
ideal can, however, be reduced to some basic makes the skin crease rise. A drop of the lid
guidelines that are commonly accepted in the level also makes the brow rise by compensatory
occidental population: (1) the upper lid surface innervation of the frontalis muscle. (2) The
is divided into two surfaces, the pretarsal and brow level only affects the lid crease level and
preseptal surface, (2) both surfaces should be has no effect on the lid level. (3) The lid crease
visible in the primary position and separated by level has no effect on the other two landmarks.
the skin crease, (3) the visible size of the two As the lid crease is hidden before and revealed
surfaces in the primary position is dependent after surgery, any preexistent asymmetry will be
on individual anatomical factors, and (4) both hidden before and revealed after surgery. I have
surfaces should be regular and uninterrupted the experience that patients usually tolerate a
[10]. 1-mm asymmetry, but are quite concerned
about a 2-mm asymmetry. Patients seem to be
much more concerned about lid crease asym-
11.3.2 metry than asymmetry of the lid level or the
Evaluation of the Lid Crease Symmetry brow level (Fig. 11.7).
11.3.5
Planning Blepharoplasty According
to the Typology of Cases
Fig. 11.9. If a brow lift is not planned, narrow and Fig. 11.11. Narrow and thin eyelids are common in
thick eyelids present the greatest difficulty in achiev- males. As the aperture plane is frequently inclined
ing a sufficient lid crease. The thickness of the eyelids posteriorly, there is enough distance left to elevate the
is reduced by resection of orbicularis muscle, sub- skin crease sufficiently without the need to lift the
brow fat and preaponeurotic fat brow. In this case the 1-mm ptosis on the right was
corrected to prevent a lid crease asymmetry
Fig. 11.10. In wide and thick eyelids the lid crease Fig. 11.12. Blepharoplasty in wide and thin eyelids
can be formed easily by reduction of sub-brow fat, tends to result in an undesired high lid crease and a
orbicularis muscle and preaponeurotic fat. Excessive demarcation of the orbital rim. To avoid this problem
resection must be avoided resection has to be limited
11.4.5
Orbicularis Separation
Fig. 11.14. After having resected a portion of the Fig. 11.15. After a wide “open sky” section of the
orbicularis muscle, the septum is exposed and an orbital septum, the preaponeurotic fat can be visual-
anesthetic solution is injected below to visualize the ized and reduced laterally, centrally or intermedially
underlying orbital anatomy
be more difficult to identify. In these cases we Care must be taken in the neighborhood of the
recommend choosing a higher level of septum intermedial area, where we get very close to the
penetration and first injecting liquid under the supraorbital neurovascular bundle, and in the
membrane to improve the visibility below lateral area, where we need to preserve the
(Fig. 11.14). lacrimal gland [34]. The fat lobuli can be lifted
gently with a forceps and cut with scissors, a ra-
diofrequency needle or laser [27, 31, 36]. To avoid
11.4.8 any traction, we prefer not to clamp the fat with
Dissection of the Septum a forceps (Fig. 11.15).
11.4.9
Management of the Preaponeurotic Fat 11.4.11
Exposure of the Medial Orbital Fat
The preaponeurotic fat pad is the most easily
approached compartment in the orbit. As it is The medial orbital fat is covered by two fibrous
semiliquid it can dislocate medially or laterally. membranes, the medial extensions of the sep-
The best area to begin the resection is the cen- tum and the medial extensions of the aponeuro-
tral part of the fat pat, where vessels are rare. sis. The two layers can be encountered separate-
11.4 Surgical Technique of the Most Frequent Types of Upper Lid Blepharoplasty 137
Fig. 11.16. The intermedial part of the preaponeu- Fig. 11.17. Medial orbital fat protrudes after the
rotic fat is exposed, while the medial orbital fat is still careful section of the anterior fibrous membranes
covered by a fibrous membrane
ly or found to be fused into one layer. The ap- modules. They form a sausage-like structure
proach is much easier in cases with thin eyelids, that continues backwards into the orbit. They
where the medial fat pad tends to herniate. The can also be resected more extensively with the
dilated and thinned anterior fibrous mem- intention of decompressing the orbit (Fig. 11.17).
branes are transparent and let the fat shine
through. After the incision of the membranes
the fat protrudes and can be resected. When the 11.4.13
fibrous membranes show a greater density, the Resection of the Medial Subcutaneous Fat
approach to the medial fat can be achieved by
retracting the septum medially upwards and Medially above the lacrimal punctum we fre-
medially downwards with two small Desmarres quently find a fatty infiltration in the layer of the
retractors. Thus the small anterior membrane of medial preseptal orbicularis muscle, which is re-
the medial fat pad can be exposed. With the in- sponsible for a postoperative prolonged swelling
jection of an anesthetic solution beyond the fi- and protrusion of the tissue. The medial subcu-
brous membrane, the medial fat compartment taneous fat can be resected while the overlying
is visualized before the membrane is incised in skin has to be preserved carefully. This is
a semicircular manner. The apex of the semicir- achieved by stretching the skin like a tent to car-
cular incision is placed laterally in order to pre- ry out the subcutaneous debulking. Any skin re-
serve the medial wall of the compartment, section in this area should be avoided (Fig. 11.18).
where vessels are running from the supraorbital
vascular supply downwards to the medial can-
thal tendon to connect with the tarsal arcade. 11.4.14
SOOF Resection
11.5.7 11.5.8.2
Excessive Resection of Medial Orbital Fat Unilateral Low Lid Crease
Excessive medial fat resection has a decompres- A low lid crease can be caused by upper lid re-
sive effect on the orbit and can be used for this traction or by brow ptosis. If the problem has
purpose. We have rarely found any excavation not been detected and corrected during ble-
problems of the medial area, presumably be- pharoplasty, the patients will need a second pro-
cause the anterior membranes of the septum cedure to lift the brow or to lower the lid. The
and the extensions of the aponeurosis reform direct brow lift by a supra-brow excision is often
sufficiently to build a firm barrier. impossible because the scar cannot be hidden
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