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Blepharoplasty plastic meeting talk
- 1. Upper and Lower Lid Blepharoplasty Raed Behbehani , MD FRSC
- 2. Upper lid Blepharoplasty • Indictions: Functional/Cosmetic • Cosmetic: Redundant skin, bulging fat, poorly-defined lid crease, brow ptosis , asymmetry
- 3. Upper Lid Blepharoplasty - Paradigm Shift
- 4. Evaluation • Expert/Novice Surgeon • Red flags • Pre-occupied with appearance . • Unrealistic view of self • Many prior surgeries • Body dysmorphic disorder
- 5. Evaluation • Skin • Bony Structure • Dynamic Skin lines • Eyebrows • Orbit contour • Periorbital volume (hollowness)
- 6. Skin • Deflation , volumes loss. • Chemical peels , Laser • Poor filler candidate • Thin skin , deep hollows , edema tendency
- 7. Bony Structure • Facial/bony asymmetry
- 8. Dynamic Skin Lines • Neurotoxin
- 9. Eyebrow • It’s the ROOF not the hair. • Full round appearance in youth . • Deflation in aging .
- 10. Brow ptosis
- 11. Peri-orbital Area • Cheek descent , loss of volume. • Surgery vs Fillers. • Fat injection.
- 12. Goals and Expectations • Improve symmetry: by adjusting lid crease contour, brow height, Tarsal platform show (TPS) , brow fat span (BFS), eyebrow and eyelid contour
- 13. Effect of Upper lid Blepharoplasty • Increase TPS , Decrease BFS BFS TPS BFS TPS
- 14. Look for Eyelid Ptosis • Phenylephrine 2.5 % test
- 15. Eyelid Crease Formation • 8-11 centrally • 4-5 mm medial • 5-7 mm lateral
- 17. Skin-Muscle Flap
- 18. Fat Excision
- 20. Technique • Running closure with 6.0 prolene sutures • Post-operative ophthalmic steroid/antiobiotic ointments , preservative-free tears, and tear gel. • Sutures removed 7-10 days (1st follow up visit)
- 21. Involutional Changes • Fat Herniation • Stretching of orbital septum • Midface-cheek descent • Loss of skin elasticity
- 25. Negative vector
- 26. Dry Eyes
- 27. Mid-face Lift
- 28. Lower Lid Blepharoplasty Plastic and Reconstructive Surgery • December 2015 Ophthal Plast Reconstr Surg, 2017
- 29. Current Trends in Lower Lid Blepharoplasty Current Trends in Upper and Lower Eyelid Blepharoplasty Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members Ophthal Plast Reconstr Surg, 2018
- 30. Technique
- 31. ORL Release and SOOF Lift
- 32. Skin Excision - orbicularis tightening
- 34. Fat Transposition tended Submuscular Blepharoplasty With Orbitomalar Ligament Release and Orbital Fat Repositioning JAMA Facial Plast Surg , 2016
- 36. Summary • Careful patients selection is important in upper and lower lid blepharoplasty. • Careful setting/expectation of objectives is important. • Modern techniques of blepharoplasty aim at preserving volume and address the involutional changes in the peri-orbital region. • Techniques can vary depending on patient needs and expectation.
Editor's Notes
- In this talk I will try to speak about belepharoplasty from an oculoplastic/ophthalmic perspective. Blepharoplasty is one of the most commonly performed aesthetic procedures and is being performed by many specialist (plastic, ENT , Ophthalmology).
- There are many reasons why patients come to ask for blepharoplasty for upper lid blepharoplasty and you have to pay attention since each case is different and one technique cannot be suitable for all patients. Need to set goals and expectations beforehand.
- Days where such outcome was considered good are long gone ! This is a case where 30 years ago would have been considered a success ! Excising lots of skin and fat left these patients skeletenized and hollow . Now emphasis is on preserving volume since we know that many of the aging changes in the periorbital area are due to loss of volume so removing more volume would compound these aging changes.
- The ability to recognize patient types come with experience. With experience you will get to recognize these patients ( focus on small area such as lids and they may ask you to do the eyelid in a certain shape) Even if you reassure them, they don’t accept your reassurance. Body dysmorphic disorder is an extreme and has its own diagnostic criteria With experience you will develop the skill of recognizing which patient is a good candidate for this surgery.
- This how we should approach any patient presenting for blepharoplasty . I try to assess the patient in a systemic fashion from skin /bone/muscle and the perirobital region .
- We don’t do a great job at helping patients who complain of poor skin quality with surgery. As we all age , our skin loses its elasticity and is deflated due to loss of volume and subcutanous tissue. Most skin issues can’t be helped by surgery and in this case better managed by treating the skin such as fillers unless skin is thin , deep hollowing and tendency for edema, and many cases are referred for dermatology (chemical peels,or laser).
- The bone growth can be asymmetric and orbits can be asymmetric as well. I always tell patients that god did not create your face symmetric and therefore it’s not natural not desirable to make this an objective of surgery. You need to emphasize this in the prep and post area because even after you do very good surgery they will complain of minor glitches and want perfect symmetry.
- I try to observe the dynamic wrinkle lines that many patients complain of and again we cannot help these patients with surgery and these patients can be helped by botox as in this case of a patient with crow’s feet .
- A full brow is a sign of youth and most of the time it’s not the fullness but the drooping of the brows and with aging of course what you get is deflation of the brows and drooping and if that’s the case would you want to do an additional procedure to address the brows such as (brow lift whether direct or endoscopic or pre-trichinal or browpexy)
- Again look for brow ptosis and determine if the patient needs an adjunct brow procedure like internal browpexy, direct brow lift or pre-trichial or endoscopic brow lift and if you do that you will find that you don’t need to excise as much skin of the eyelids and you will have a happier patient.
- In the peri-orbital region it’s important to look for peri-orbital hollowing , descent of the mid-face . The reason is that you want to know if the patient wants a non-surgical option that you can offer. There are also techniques which I will show in the videos that is popular in treating this tear-trough deformity (ORL release , fat transposition) or possibly even doing a mid-face lift (SMAS)
- Normal BFS should be 20 mm, if less it would give lagophthalmos and then problem with exposure keratopathy and dry eyes. What happens with aging is that you have low TPS and high BFS
- The aim in upper lid blepharoplasty is to increase the TPS and to decrease the BFS. High TPS usually is associated with aging and/or ptosis .
- This is one of the things that can be missed by other specialties and can lead to unhappy patient post-surgery. This is a simple test to do the clinic and is to instill phenyelphrine in the eye and to see if the patient ptosis improves . Muller resection is my preferred technique for eyelid ptosis .
- Precise eyelid crease formation is essential and often in non-ophthalmic plastic surgeons this is placed either too high or too low and in inappropriate for gender. Re-define lid crease : higher in women (7-8 mm than men 5-6mm).
- I am using a blade here but you can use a colorado needle or CO2 laser
- there is controversy about whether you should excise skin or skin-muscle. I tend to excise skin-muscle flap. In patients with dry eye for example you may want to consider excision of skin only as to not worsen lagophthalmos.
- I tend to open the septum medially over the medial fat pocket . Others may open it cnetrally. Here I am excising the medial fat pocket . The central fat pocket is not excised and should be left alone so you don’t cause hollowing and deep upper lid sulcus deformity.
- Here I am dissecting the orbicularis and brow fat pads off the roof .. exposing the perisoteum and then having made a mark above the orbital rim of 1 cm . I pass the sutures (mattress fashion from the periosteum to the brow fat pad to secure them at the desired height).
- Most of the changes we see in the lower lids and face are due to stretching and lengthening of the lower lids. Orbicularis muscle become oblong due to loss of tone. There is evidence of bone reabsorption causing lengthening of the lids.
- Here I am showing two important structures : 1- Orbitomalar ligament- at orbit-cheek junction and it’s the condensation of attachment of OO at the orbital rim. 2- Palpebral part of OO 3- Tear trough ligament (TTL) - splits the orbital and palpebral part of OO - tethering
- This is an patient patient with also bags and dark circles but also has fat prolapse and tear trough deformity and descent of mid face . So I did transcutaneous with fat excision and release of the orbitomalar ligament with SOOF suspension for tear trough deformity.
- This a young patient with excess fat and good skin tone so I did an upper lid bleph skin with medial fat pocket excision and then because of good skin quality in lower lid I do transconj lower lid bleph only.
- Beware of maxillary hypoplasia as patients with this are at a higher risk for ectropion and lower eyelid malposition following lower lid blepharoplasty.
- Patients with chronic dry eyes and patients with prior LASIK .
- Technique should address 1) the prominent eye bags; 2) the sagging and laxity of the cheeks; and 3) the deflation or volume loss that occurs with aging. Again many authors have discussed the importance of release of the TTL and Palpebral part of OO medially and the ORL laterally to address both the tear trough deformity and also for to ensure free elevation of the midcheek. This can also be combined with either fat resection , transposition or fat injection for addressing deflation of the midcheek .
- There are numerous techniques most famously the 5 and then 6-step for establishing the continuity of the lid-cheek junction that involves release of the ORL and also fat injection in the deep malar space and in the lower lid in the scubmscular plane with canthopexy. Other studies have questioned that value of releasing the ORL since it can be associated with prolonged swelling and sometimes ectropion.
- This is from a recent paper and you will see most of the Ophthalmic plastic surgeons in the US excise fat and skin , less so repositioning and many do canthal suspension and Less common adjunctive procedures include laser skin resurfacing (36%) and chemical peels (29%) since they require additional training.
- * You must be able to recognize the red flags in patients who you don’t want to operate upon (patients with unreasonable expectation, or distorted perception of themselves) * Careful setting of expectation and goals in terms of what do you want to achieve . Modern techniques of blepharoplasty is not about just excising fat and skin but the goal is address the involutional changes (such as cheek descent, hollowness around the peri-orbital region) and some of these changes can be addressed by non-surgical options so surgery is not the solution to everything . There is no single technique that suits all patients and you have to tailor the technique depending on patient needs and expectation.