The document discusses different surgical techniques for blepharoplasty, including upper and lower blepharoplasty, focusing on approaches for removing excess skin and fat to improve the appearance of the eyes while maintaining natural shape. Key steps for upper and lower blepharoplasty techniques are outlined, including incision placement and closure, as well as potential complications.

1. MANISH JAIN
BLEPHAROPLASTY

2. What is blepharoplasty?
 Surgical procedure aimed at improving the
appearance of eyes.
 Goals- to improve the appearance of eyes
while maintaining the natural shape of eyes.
 Upper and lower blepharoplasty removes:
fold of skin
fat pads

3. Function of eyelid
 Protect the globe
 Provide a sufficient and appropriately located
aperture for vision
 Also assume a role of facial expression
 Tear production and distribution

4. Surface anatomy
Appearance of eye largely determine by shape of
palpebral fissure and it position relative to globe
• Palpebral aperture
• Skin
• Lid margin
• Grey line
• Glands
• Skin crease

6. Orbicularis oculi
•Two part
oPars orbitalis
oPars palpebarum -
divided into preseptal
and pretarsal
Medially divided into
superficial head – form
medial canthal tendon
deep head – insert
into posterior lacrimal
crest and lacrimal sac
fascia

7. Eyelid support
 Primary by bony attachment of canthi
o Medial canthus - fixed to orbital wall
o Lateral canthus – mobile
Lateral canthus is approximately 2mm heigher then
medial
 Secondary from orbicularis muscle and its fascial
attachment

8. Medial canthus tendon
•Integration of pretarsal and
preseptal orbicularis oculi,
septum orbitale, medial end of
lockwood ligament, medial horn
of levator aponeurosis and
check ligament of medial rectus
muscle
•Insert into frontal process of
maxilla into tripartite manner
oAnterior – onto anterior lacrimal
crest
oPosterior – onto posterior
lacrimal crest
oVertical – on medial orbital rim
and contribute mainly to stability

9. Lateral canthus tendon
•Y shape fibrous
condensation
•Extend from upper and
lower tarsal plate and
reinforce by lateral horn
of levator aponeurosis,
lockwood ligament and
check ligament of lateral
rectus to form lateral
retinaculum
•Inset to lateral orbital
wall at whitnall tubercle

10. Tarsus
•Crescentric shape,
dense condensation of
connective tissue
•Maintain the integrity of
eyelid
•Upper tarsus – 29 mm
long and 10 mm wide in
central part
•Lower tarsus – 24 mm
long and 4-5 mm wide
•Contain meibomian
glands

11. Septal orbitale
• Represent the continuation of orbital periosteum
• Thin fibroelastic membrane
• Attach medially to spine at lower end of anterior
lacrimal crest
• Laterally attach to lateral canthal raphe
• Arcus marginalis – junction of fusion of periosteum
and septum
• In upper lid, septum attach to levator aponeurosis
about 25 mm above the superior edge of tarsal plate
to form the conjoined fascia
• In lower lid, septum attch to capsulopalpebral fascial
below the inferior edge of tarsus

12. Eyelid fat
•Preseptal fat – extra orbital(ROOF), 6mm thick
•Postseptal – intra orbital, are the fat extension from
adipose body of orbit except upper lid central fat pad
oUpper lid – two (medial and central)
oLower lid - three (medial, central and lateral)
•Eisler fat pad – between septum and lateral canthal
tendon, use as a landmark for whitnall tubercle

13. Eyelid retractor
•Levator plapebrae
superioris -
•Muller muscle
•Capsulopalpebral fascia –
peripheral extension of
inferior rectus muscle

14. Lacrimal system
•Basic secretor
•Reflex secretor

15. Blood supply
•Internal carotid
artery(predominant)
oOphthalmic artery
•Externl carotid artery
oAngular artery
oInfraorbital artery
oSuperficial temporal
artery

16. Indications
Blepherochalasis :
-Loss of tone & relaxation of lid skin
- Affect upper lid
-Redundant fold of skin & often
muscle
-Interfere with upward field of vision

17.  Dermochalasis :
-Excess fold of skin of upper lid
-Skin hangs over the ciliary margin .
-Usually occurs from middle age onwards-aging
process

18.  Hypertrophy of the
orbicularis oculi
muscles :
-Ridge of bulging
muscle running
horizontally along the
lower lid below the
ciliary margin

19. Goal
-Symmetry
-Aperture length &
height
-Limited scleral
exposure.
-Supratarsal fold.
-Eyebrows
-Scar

20. Examination And Planning
 Accurate pre-op planning is important.
 EVALUATION BASICS:
 PT. seated in front
 Gen. appearance
 Symmetry & posture
 Skin & fat quantification
 Brow examination
 Modified snap test

21. Cntd…..
 Medical and ophthalmologic history
 Ocular examination
 Visual acquity
 Pupils
 Extraocular muscles
 Globe
 Retina
 Tear film- Schirmer`s test.
 Photographs

22. Upper blepharoplasty – Skin
approach
•Appearance of aged upper eyelid is primarily due to
excessive skin, muscle, and fat often in conjunction with
brow descend
•Approach should be individualize
•Appreciation of volume shift which lead to fat
malposition
•Volume loss lead to deepening of upper sulcus
•Position of upper eyelid crease
•Brow position

23. Incision
•Patient with deep
upper eyelid sulcus
benefit from 10 mm or
higher incision
•In presence of brow
ptosis , lower the
crease incision
•Incision include only
skin
•Brow fold distance is
thereby maximized to
reduce ptotic brow
appearance

25. Pinch test
•Serve as a guide
to the maximum
allowable skin
resection
•End point is that
of skin tautness
without the
eversion of
eyelash margin

26. •Upper demarcation
usually follow the
contour of eyebrow
•Usually the amount of
skin excision should
ultimately be less than
this specified amount

27. •Infiltrate local
anaesthesia with
adrenaline
•Plane of
dissection –
subcutaneous
•Incision should be
through skin only
•Dissection begin
at lateral ellipse

28. •Hemostasis by
monopolar cautery
•Liberal application at
lower edge of wound
allow for creation of
adhesive interface
which facilitates
establishment of
crease, enhanced by
transorbicularis
fibrosis and maintain
tautness of the
pretarsal soft tissue.

29. •A small button hole
through orbicularis
muscle and orbital
septum as made at
medial extent of
wound to
accommodate medial
orbital fat excision
•Minimal or none of
preaponeurotic fat is
excised.

30. •Closed with multiple
interrupted 6-0 nylon
suture
•If lateral retinacular
suspension for
browpexy is to be
performed, the outer
one fourth of wound
remains open until
the lower
blepharoplasty and
canthopexy is
performed

31. Discussion
 Over dissection of anterior upper eyelid structure
can result in loss of tight adherence and
conjoined fascial relationships that are replaced
by cicatrix of soft tissue layer
 Excision of orbicularis muscle avoided as it can
lead to lagophthalmos and blepharoptosis
 This approach best consider the physiologic
change that occur in the aging of this region, and
delivers results that are most rejuvenative, with
less stigmata of surgery.

32. Upper blepharoplasty in asian patient
Approximately 50 % of asian population have upper eyelid
crease while remaining don’t have.

34. Surgical technique
 Conjuctival suturing
o Non invasive
o Have disadvantage that crease disappear with time
 External incision

35. External incision technique
•Vertical height of
central portion of
upper tarsus is
transcribed onto the
skin surface
centrally
•This serve as a
central point for
lower line of
incision, with the
overall line dictated
by shape of crease
desired
•Upper line of

36. •After the incision, a
wet field cautery is
applied for
hemostasis and a
surgical cautery is
use to incise
through orbicularis
oculi muscle along
the superior incision
line

37. •Orbital septum is
first opened with a
monopolar cautery
along the upper line
of incision and then
extend horizontally
with scissors

38. •A small amount of
preaponeurotic fat
pad is excised

39. •2- 3 mm of pretarsal
orbicularis muscle is
excised along the
inferior edge of skin
wound to facilitate the
infolding of surgically
created crease.

40. •Placement of
interrupted suture from
the skin to the levator
aponeurosis to the
skin for crease
formation

41. •Skin closure using
placement of five to six
interrupted 6-0 sutures to
form the crease and a
continuous suture to
approximate the edge of
wound

42. Complication
 Hemorrhage
 Grossly asymmetric crease
 Obliteration or fading of crease
 Prolong postoperative edema
 Hypertrophic scar formation
 Excessive fat removal with a hollowed eye
apperance
 Formation of multiple creases

43. Transconjuctival approach to
resection of lower eyelid herniated
orbital fat
 Useful for patient who have only herniated orbital fat
with minimal or no evidence of dermatochalasis and
no hypertrophic orbicularis oculi muscle
 Also advantageous for
o Younger patients with large amount of herniated
orbital fat
o Patient who have had previous blepharoplaties via
external approach
o Patient with wrinkled or minimally excessive lower
eyelid skin in whom plication of lateral canthi or laser
resurfacing of lower eyelid is useful
• Contraindicated to patient with minimal lower eyelid
fat, inferior orbital rim or nasojugal hollowing

44.  Advantage
o Eliminates external scarring
o Less ecchymosis
 Disadvantage
o Develop conjuctival chemosis
o Slight redundancy and wrinkling of skin

45. Surgical technique
•Performed under local
anaesthesia
•Anaesthetic agent injected
subcutaneously, into fat pad
and subconjuctivally
•A colorado needle is applied
to inferior palpebral conjuctiva
halfway between the fornix
and inferior tarsal border and
used to severe conjuctiva
from medial to temporal end
of eyelid

46. •With forceps, the
surgeon and surgeons
assistant grasps the
inferior and superior
edges of severed
palpebral conjuctiva to
facilitate dissection of
muller muscle and
capsulopalpebral fascia
until fat is seen with
colorado needle

47. •A 4-0 black silk suture
is placed through the
inferior edge of
conjuctiva, muller
muscle and
capsulopalpebral fascia
and is pulled upward
and clamped and taped
to drap

48. •Removes the temporal
fat pad first, and then
central and nasal orbital
fat pad by cutting along
the hemostat blade and
then applying a cautery
to fat stump

49. •The conjuctiva is
reapproximated with
three 6-0 plain catgut
buried sutures

51. Complication
 Hemorrhage
 Postoperative residual dermatochalasis
 Motility problem if procedure combined with tarsal
strip procedure
 Residual herniated orbital fat
 Shrunken lower eyelid

52. Lower blepharoplasty
 Traditional lower blepharoplasty, performed 20 yr ago
typically incorporated a lower eyelid, infraciliary
skin/muscle flap and excision of orbital fat through this
incision by violating orbital septum and without
canthal reinforcement
 Aging pathology of lower periorbita is due to
complicated combination of life long animation,
descend and hypotonia of orbicularis and atrophy of
adjacent periorbita soft tissue.
 These days lateral retinacular suspension procedure
to skin flap lower eyelid surgery has been the
mainstay
 Advantage of preserving orbicularis muscle is
eliminating postoperative eyelid retraction and
ectropion and decreasing post operative edema from

53. Skin flap approach

54. Surgical technique
•Performed under local
anaesthesia
•Infratarsal, subconjuctival
and subcutaneous
infiltration done
•Incision is placed midway
between inferior tarsal
border and inferior fornix

55. •After incision, contouring of
lateral fat pad done first
follow by medial through
transconjuctival approach
•When minimal fat pad is
noted , diathermy may be
used to shrinkage of fat pad
•Contouring is performed to
the extent that lower
periorbital bulges are
satisfactory transposed,
excised or shrunk to the point
of optimal concavity when the
globe is balloted posteriorly
with surgeon finger.

56. •If there is a significant
‘Tear trough deformity’ a
small pocket is dissected
through the
transconjuctival incison.
•If mild, blunt
dissection/reflection of
medial orbicularis oculi
muscle attachment to
inferomedial bony orbit
adjacent to visible trough
is carried out.
•If significant, free fat
graft is positioned into

57. Lower eyelid skin incision-
after injecting anaesthetic
solution subdermally, subciliary
incision is made
•Subdermal dissection is
performed
•Extent of which dependent on
the amount and type of skin
pathology to address as well as
extent of exposure of lateral
orbicularis muscle and inferior
retinaculum required

58. •Orbicularis muscle
incision then made 2-3
mm below the lateral
commisure beginning at
the level of commisure
and determined by the
amount that require
mobilization and
suspension to achieve
the desired effect.
•Extent of dissection will
depend on the amount of
elevation desired with
canthoplasty

59. •Dissection is performed
to lateral orbital rim and
for as much release as
required for both
mobilization of orbicularis
muscle, release of inferior
retinaculam from lateral
canthal tendon, and
release of inferior tarsal
strap depending on how
much super placement is
required.

60. Lateral retinacular
suspension
•Place the suture
through the lateral
canthal tendon,
through the inner
aspect of lateral orbital
rim through
periosteum and then
direct this through the
orbicularis muscle at
the upper eyelid
•Suture are placed 2-3

61. Orbicularis aculi muscle
suspension
•Usually 1 to 3 suture are
placed toward the cephalad
portion of wound through the
lateral orbital rim periosteum
medially, temporalis fascia
laterally and then advance the
flap of orbicularis muscle to
this region
•It raises the eyelid cheek
junction without distracting the
lateral commissure and lateral
lower eyelid from the globe

62. •After orbicularis muscle
suspension, skin
redraping and excision is
performed which can
vary from no excision to
at times significant skin
excision depending on
patient presentation

63. •Skin closure is
performed with
interrupted or
continuous 6-0 nylon
suture.
•Sometime lateral suture
tarsorraphy is
performed to promote
good lateral lid position
in immediate post
operative period

64. Skin muscle flap approach
 Performed in patients who have excessive lower
eyelid skin and orbicularis usually associated with
cheek bag.
 Combined with lateral canthal tendon tightening

65. Surgical technique
•Infralash and lateral
canthal skin incision
given 1.5 mm beneath
the lower eyelid lashes.
Incision begin below
the punctum and
extend temporally for a
distance of 2-3 mm
temporal to lateral
canthus. The incision is
extended for another 1
cm in horizontally
direction

66. •After incision orbicularis
muscle is severed along
the skin incision site
with scissor and blunt
dissection done under
orbicularis oculi muscle.

67. •After submuscular
dissection nasal,
central and temporal
herniated orbital fat
pad are now visible.
•A small opening is
made in the temporal
orbital fat capsule and
fat removed
•After temporal fat
pad, the central and
nasal fat pad
removed.

68. •After fat removal, skin
and orbicularis muscle
are draped over the
incision site and are
excised.
•A strip of orbicularis
muscle is routinely
excised over the skin
muscle flap, temporally to
nasally, for a distance 4-5
mm beneath the flap to
prevent postoperative
fullness

69. •A 6-0 black silk
suture is run
continuously from
lateral canthus to
temporal end of the
incision.
•A second 6-0
black silk suture is
run continuously
from the nasal end
of incision to lateral
canthus.

70. Post operative care
 Apply cold compress to lid for 2-3 hrs
postoperatively
 Head end elevated 45 degree to reduce edema
 Check for bleeding associated with proptosis,
pain or vision by finger counting every 15 minutes
for first 2-3 hr postop and then hourly.
 If patient cannot count fingers or there is severe
pain and proptosis, patient should immediately
return to emergency facility for evaluation of
possible retrobulbar hematoma
 Sutures removed 5-7 day postoperatively

71. Postoperative complication
 Eyelid retraction and ectropion
 If too much skin removed, a cicatricial ectropion
can occure
 Loss of eyelashes
 Suture cyst
 Retrobulbar hemorrage

72. THANK YOU