Enhancing blepharoplasty results requires addressing laxity of the eyelids and ptosis of the eyelashes or brow during the blepharoplasty when needed, says Bradley N. Lemke, M.D. For laxity of the medial canthal tendon (MCT) in particular, he recommends a subcaruncular approach over more complex surgeries.
"The key is to do a careful examination before you do the surgery, so that you can recognize problems such as a drooping eyelid, drooping eyelashes, or drooping brow and forehead before performing the surgery," says Dr. Lemke, clinical professor of oculofacial plastic surgery, volunteer faculty, department of ophthalmology and visual sciences, University of Wisconsin-Madison. He is also an oculofacial plastic and facial cosmetic surgeon in private practice.
"If you don't educate the patient about these problems beforehand, you might have to explain why they exist afterwards," he says, adding that, fortunately, surgeons can address such problems during the course of blepharoplasty.To fix a droopy eyelid, Dr. Lemke says he prefers an external levator repair. Some surgeons repair a droopy eyelid from a posterior approach, performing a conjunctival Müller's muscle resection. Physicians taking this approach will need a Putterman clamp, which is used to grasp the tissue to be excised, he says.
However, Dr. Lemke says, "My preferred technique is to raise the lid from the front. I make an incision through the orbital septum to expose the levator aponeurosis, and I clean the external surface of the levator and tarsus. Then I place sutures between the aponeurosis and the tarsus to raise the lid."
For drooping lashes, "Oftentimes when one closes the blepharoplasty incision, the lashes will rotate upward," he explains. "If one needs to produce more of a lift, one can bluntly undermine the pretarsal muscle to free the orbicularis muscle from the tarsus. That allows the eyelid margin to rotate better."
To raise the brow, Dr. Lemke says techniques include the coronal, the pretrichial or the small-incision endoscopic browlift. He says he personally prefers the pretrichial lift.
PRETRICHIAL LIFT To perform a pretrichial lift, "I make an incision along the hairline. Often, I spare the central aspect of the hairline, beginning the incision paracentrally above the medial canthus or pupil and extending laterally into the temporal hair. Make a meandering incision following the hairline, rather than a straight incision," Dr. Lemke says, adding that this incision is beveled and trichophytic.
Dr. Lemke also says that dissecting subcutaneously allows one to preserve the frontal muscle, along with its nerves. "Sensory nerves travel upwards along the posterior aspect of the muscle until they perforate. And the motor nerve is on the anterior aspect of the frontalis," he says.
The next steps include elevating the brow, trimming the excess skin and closing the incision. In the medial area, "I use a running subcuticular 5-0 Monocryl suture (poliglecaprone 25, Ethicon) buried knot. And in the hair laterally, we use staples," Dr. Lemke explains.
A drooping brow can cause patients to have excess eyelid skin that will be apparent laterally after a standard blepharoplasty. If a blepharoplasty patient appears likely to have this problem, "The patient should be told about that, and maybe the patient should have a browlift — or at least that discussion should be had," Dr. Lemke says. "Otherwise, the patient would not understand that he or she will not have the perfect result because of the drooping brow that causes the skin in the upper lid to hang down."
Upper eyelid problems stem primarily from vertical vectors: drooping of the lid, lashes and brow, Dr. Lemke says. In the lower lid, however, "The structural factors are horizontal. Horizontal eyelid laxity can be medial, lateral or in both places," he says.
If one does not correct lower lid laxity at the time of cosmetic lower-lid blepharoplasty, the patient might develop an ectropion or retraction of the lid, or possibly both. The result of retraction is scleral show. Conversely, "If you do a horizontal tightening, you're less likely to have those two complications," he says.