Blepharoplasty

Illustration depicting incision lines for blepharoplasty

Blepharoplasty (Greek: blepharon, "eyelid" + plassein "to form") is the plastic surgery operation for correcting defects, deformities, and disfigurations of the eyelids; and for aesthetically modifying the eye region of the face. With the excision and the removal, or the repositioning (or both) of excess tissues, such as skin and adipocyte fat, and the reinforcement of the corresponding muscle and tendon tissues, the blepharoplasty procedure resolves functional and cosmetic problems of the periorbita, which is the area from the eyebrow to the upper portion of the cheek. The procedure is more common among women, who accounted for approximately 85% of blepharoplasty procedures in 2014 in the USA and 88% of such procedures in the UK.^[1][2]

The operative goals of a blepharoplastic procedure are the restoration of the correct functioning to the affected eyelid(s) and the restoration of the aesthetics of the eye-region of the face, which are achieved by eliminating excess skin from the eyelid(s), smoothing the underlying eye muscles, tightening the supporting structures, and resecting and re-draping the excess fat of the retroseptal area of the eye, in order to produce a smooth anatomic transition from the lower eyelid to the cheek.

In an eye surgery procedure, the usual correction or modification (or both) is of the upper and the lower eyelids, and of the surrounding tissues of the eyebrows, the upper nasal-bridge area, and the upper portions of the cheeks, which are achieved by modifying the periosteal coverings of the facial bones that form the orbit (eye socket). The periosteum comprises two-layer connective tissues that cover the bones of the human body:

1. the external layer of networks of dense, connective tissues with blood vessels, and
2. the internal, deep layer of collagenous bundles composed of spindle-shaped cells of connective tissue, and a network of thin, elastic fibres.

Indications

Transconjunctival blepharoplasty: The removal of orbital fat for the cosmetic modification of the lower eyelid^[3]

The thorough pre-operative medical and surgical histories, and the physical examination of the patient’s periorbital area (eyebrow-to-cheek-to-nose), determine if the patient can safely undergo a blepharoplasty procedure to feasibly resolve (correct or modify, or both) the functional and aesthetic indications presented by the patient. Sequentially, lower eyelid blepharoplasty can successfully address the anatomic matters of excess eyelid skin, slackness of the eye-muscles and of the orbital septum (palpebral ligament), excess orbital fat, malposition of the lower eyelid, and prominence of the nasojugal groove, where the orbit (eye socket) meets the slope of the nose.

Concerning the upper eyelid, a blepharoplasty procedure can resolve the loss of peripheral vision, caused by the slackness of the upper-eyelid skin draping over the eyelashes; the outer and the upper portions of the field of vision of the patient are affected, and cause him or her difficulty in performing mundane activities such as driving an automobile and reading a book.^[4]

Procedures

Blepharoplasty: The yellow fat (adipose tissue) and the skin (linear tissue) removed during a quadruple blepharoplasty. The fat from the lower eyelid was removed with a transconjunctival technique.

A blepharoplasty procedure usually is performed through external surgical incisions made along the natural skin lines (creases) of the upper and the lower eyelids, which creases then hide the surgical scars from view, especially when effected in the skin creases below the eyelashes of the lower eyelid. According to the technique applied by the plastic surgeon, the incisions can be made from the conjunctiva, the interior surface of the lower eyelid, as in the case of a transconjunctival blepharoplasty.

Transconjunctival blepharoplasty technique was pioneered by Clinical Professor of Surgery at the University of Chicago Medicine,^[5] Dr. Anthony J. Geroulis^[6] and introduced to medical trial in 1998. Transconjunctival Technique has become the norm in the plastic surgery field with most surgeons preferring it over the external surgical incisions. This technique is particularly useful for patients with darker skin tones where standard external incision often leaves a visible white scar.

Transconjunctival blepharoplasty technique permits the excision (cutting and removal) of the lower-eyelid adipose tissue without leaving a visible scar, but, the transconjunctival blepharoplasty technique does not allow the removal of excess eyelid-skin.^[4]

A blepharoplasty operation usually requires 1–3 hours to complete. Post-operatively, the initial swelling and bruising consequent to the surgery will subside and resolve with 1–2 weeks; the final, stable results of the blepharoplastic correction will become apparent after several months. The results of a blepharoplasty procedure are best appreciated by comparing pre- and post-operative (before-and-after) photographs of the eye region of the patient.

After the procedure, a type of stitch known as a canthopexy is placed near the outer corner of the lower eyelid, which is inside the tissue. This allows the eyelid's position to remain fixed during the healing process. The canthopexy is dissolved after four to six weeks of use. For particular patients, a mid-face elevation may be required to rejuvenate the lower eyelid-cheek complex.^[7]

The anatomic condition of the eyelids, the (wear-and-tear) quality of the patient’s skin, his or her age, and the general condition of the adjacent tissues, consequent to the anatomic conditions of the patient, affect the functional and aesthetic results achieved with the eyelid surgery. Additional to the anatomic conditions of the eye region of the patient, the occurrence, or not, of medical complications is determined by factors such as:

• Dry-eye syndrome — which can become exacerbated by the disruption of the natural, lacrimal (tear) film of the eyes
• Palpebral skin laxity — looseness of the lower eyelid margin, which predisposes the lower eyelid to malposition
• Eyeball prominence — the protrusion of the eyeball in relation to the malar (cheek) complex, which predisposes the lower eyelid to malposition

Transconjunctival blepharoplasty of the right lower eyelid.

Fat is removed from the lower eyelid by means of an incision to the inner surface of the eyelid. A surgical suture retains the inner tissue of the eyelid over the eyeball.  The fat is held with forceps (left), and clamped with a hemostat (right), while a small medical retractor keeps away the extra tissue, so that the surgeon can operate (bottom right).  The fat is excised (cut away) with surgical scissors.

East Asian blepharoplasty (double eyelid surgery) is a procedure used to create a supratarsal epicanthic fold in the upper eyelid of the patient who lacks such a crease.^[8] The supratarsal epicanthic fold is common to most ethnic groups, but is absent in approximately half of the Asian population.

Society and culture

Removal of single eyelid

A South Korean woman, before (left) and after (right) undergoing East Asian blepharoplasty

"East Asian blepharoplasty", also known as "double eyelid surgery", is a type of cosmetic surgery where the skin around the eye is reshaped (blepharoplasty). The purpose of the procedure is to create an upper eyelid with a crease (i.e. "double eyelid") from an eyelid that is naturally without a crease (also known as a "single eyelid" or "monolid").^[9]

Anatomically, there are a number of subtle differences in the upper eyelids of East Asians, compared with the eyelids of Whites and Blacks.^[10] While some East Asians have a double eyelid and some do not, there is also a large variation in the crease position (double eyelid size) of the East Asian upper eyelid. The upper lid fold can range from 1 mm (0.039 in) above the eyelash line to about 10 mm (0.39 in). Several methods can be used to create the double eyelid — including the full-incisional, partial incision and no incision methods (e.g. the DST method). Each has its advantages depending on the patient's anatomy and desires.

East Asian blepharoplasty have been reported to be the most common aesthetic procedure in Taiwan,^[11] South Korea and other parts of East Asia. The procedure has been reported to have some risk of complications, but is generally quite safe if done by an expert plastic surgeon.^[12] Practitioners of East Asian blepharoplasty include plastic surgeons (facial plastic and reconstructive surgeons), otolaryngologists, oral and maxillofacial surgeons, and ophthalmologists (oculoplastic surgeons). A procedure to remove the epicanthal fold (i.e. an epicanthoplasty) is often performed in conjunction with an East Asian blepharoplasty.^[13]

The procedure to alter the natural East Asian "single eyelid" appearance has been a subject of controversy. For example, opponents of the procedure, such as author David Mura, described it as being "indoctrinated by white standards of beauty", although New York-based cosmetic surgeon Dr. Edward Kwak states that many patients who get the procedure done are "not trying to look white", but look like the many Asians who naturally have an eyelid fold. There is also a belief that double eyelids provide a more energetic appearance, and the procedure is popular among high school graduates in China with the view that it will improve their job prospects.^[14]

History

Initial incision along the upper left eyelid

As techniques began developing the ancient Greeks and Romans began writing down and collecting everything they knew involving these procedures. Aulus Cornelius Celsus, a first-century Roman, described making an excision in the skin to relax the eyelids in his book De Medicina.^[15]

Karl Ferdinand von Gräfe coined the phrase blepharoplasty in 1818 when the technique was used for repairing deformities caused by cancer in the eyelids.

Laser

Laser blepharoplasty is the performance of eyelid surgery using a laser instead of a scalpel. Laser blepharoplasty is often combined with laser eyelid rejuvenation, as the two procedures can be performed in conjunction.

Historically there has been some contention as to the categorisation of laser treatment on upper or lower eyelids as blepharoplasty, which is itself by definition surgical. The statutory definition of surgery and that supported by the American College of Surgeons states that surgery is the "treatment ... by any instrument causing localized alteration or transportation of live human tissue, which include lasers.." .^[16]

See also

• Eye surgery
• Oculoplastics
• Cosmetic surgery
• Plastic surgery
• Maxillofacial surgery

References

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