Tips may improve blepharoplasty results

A surgeon offers pearls to make this common procedure easier to perform.

Issue: May 1, 2001

LAGUNA NIGUEL, Calif. — Blepharoplasty is one of the best enhancement procedures used in cosmetic surgery, but avoiding dry eye postoperatively is sometimes difficult, said Don O. Kikkawa, MD.

“Patients benefit from both functional and aesthetic results. The benefits can be long lasting and the recovery time is fast,” he said (figure 1a and 1b).

In a presentation at the Ocular Drug and Surgical Therapy Update meeting, sponsored by Ocular Surgery News through an educational grant provided by Allergan, Dr. Kikkawa said that since blepharoplasty is such a common procedure, it is best for surgeons to learn tips to avoid dry eye.

“Just be conservative,” he said. “I’m sure many of you have seen patients who have had overzealous blepharoplasty who come in with dry eyes or lagophthalmos. Probably the best advice I can give you to avoid that result is to be conservative.”

Blepharoplasty versus brow lifts

A surgeon must determine whether the patient is actually in need of blepharoplasty or a brow lift, said Dr. Kikkawa, an associate professor of ophthalmology at the University of California-San Diego.

Patient prior to blepharoplasty.	Same patient after undergoing upper lid blepharoplasty and lower lid arcus marginalis release.
An asian patient desiring a lid crease, preoperatively.	Same patient after upper lid blepharoplasty with crease fixation sutures.

“Patients come in with complaints of upper lid heaviness and, as you can see if you assess the eyebrow position, patients will have a low eyebrow,” he said. “Typically, the eyebrow rests at the superior orbital rim and, upon manual elevation of the eyebrow, you can see that the dermatochalasis or the extra skin disappears.”

Another way to determine which procedure is needed is to look at the eyebrow depressors.

“The muscles in a facial expression that cause furrowing of the eyebrow and depression of the eyebrow are the corrugator and the procerus. Typically that leads to vertical and horizontal folds in the eyebrow region, so patients with these findings will often benefit from a brow lift as opposed to a blepharoplasty,” Dr. Kikkawa said.

Another key technique in deciding how much skin to remove is to mark it strategically.

“When I first learned this operation as a resident, I was told never to excise skin medial to the upper punctum,” Dr. Kikkawa told attendees. “Often we would stop right at the upper punctum and patients would complain postoperatively of still having residual upper eyelid skin medially.”

But Dr. Kikkawa said he has modified the technique by extending the mark medial to the punctum but expanded upwards.

“If I were to extend this mark and continue this in the normal curvature you’ve already drawn, you might lead to the development of a web, and patients will have an epicanthul fold when they open their eyes. So if you extend this mark medially and you angle upward, you will have a nice result medially and you will be able to excise the medial redundancy that many patients have.”

Younger patients and medial fatpad

Dr. Kikkawa also advised to avoid extending the skin incision past the lateral canthus in younger patients.

“Younger patients typically are more interested in the cosmetic effect. They are not handicapped from the visual aspects of the extra skin and they typically don’t have a lot of hooding laterally. In an older patient who does have significant hooding laterally, you can extend this incision and typically it doesn’t lead to any severe scarring that you might see in a younger patient,” he said.

Also, Dr. Kikkawa said he feels the medial fatpad plays a key part during blepharoplasty.

“When you perform upper eyelid blepharoplasty, typically we include a fat excision at the same time, and the preaponeurotic fatpad is the easiest to find. It takes a little extra work to try to find the medial fatpad that causes the bulging just above the medial canthus.”

But he said extra care must be used when attempting this part of the operation.

“Probably one of the more dangerous parts of the upper eyelid blepharoplasty is when you dissect the medial fatpad, because the trochlea, which is the pulley system for the superior oblique muscle, is located just in the region where the preaponeurotic and medial fatpads are located.”

More tips

Another helpful thing is to consider placing lid crease sutures to accentuate the upper eyelid crease.

“The eyelid crease is formed by attachments of the levator aponeurosis to the skin; when the eyelid is open, it folds over right at the level of that crease,” Dr. Kikkawa said. “In some patients who don’t have a crease, to accentuate the cosmetic look, it’s necessary to place sutures to accentuate this attachment.”

According to Dr. Kikkawa, this is particularly common in Asian patients because they have a rudimentary eyelid crease (figure 2a and 2b).

Another tip is to combine ptosis repair and blepharoplasty.

“Many of these patients have coexistent ptosis in addition to dermatochalasis. The general guideline I follow is that if the ptosis is greater than 2 mm, I will perform a levator advancement at the same time of the blepharoplasty. If the ptosis is less than 2 mm we will perform a conjunctival muellerectomy, which is an operation performed posteriorly to advance Mueller’s muscle,” Dr. Kikkawa said.

Complications

One complication of blepharoplasty is asymmetry.

“Unfortunately, it’s almost impossible to lower the crease on the side with the higher crease due to the attachments that are created from the skin to the levator aponeurosis,” Dr. Kikkawa said of a patient who came in with marked asymmetric eyelid creases. “There’s scar tissue that develops and any attempt to try to lyse adhesions between the levator and the skin are unsuccessful.”

Another complication can be lagophthalmos, which can occur after skin excision.

“If the amount of skin pinched preoperatively does not lead to the lagophthalmos, then most likely postoperatively there won’t be a problem. Some of the complications I don’t need to remind you of: lagophthalmos can be seen after blepharoplasty and also aggressive fat removal can lead to the hollowed-out appearance,” Dr. Kikkawa said.

For Your Information:

Don O. Kikkawa, MD, can be reached at UCSD Shiley Eye Ctr., 9415 Campus Point Dr., La Jolla, CA, 92093; (858) 534-7402; fax: (858) 534-7859; e-mail: dkikkawa@ucsd.edu.