Successful upper- and lower-lid blepharoplasty requires attention to detail and fine-tuning through tactics such as temporal anchoring and the suspension suture. The pretreatment examination is particularly important for patients considering blepharoplasty, says Norman J. Pastorek, M.D., a New York facial plastic surgeon in private practice.
After examining the patient's lower lids in repose, he suggests having the patient squint. "If the under-eye bags go away somewhat, it's pretty certain that you're seeing not edema, but pseudo-herniation of fat," he says. If the bags increase when the patient squints, "That skin is on top of the muscle, which indicates edema."
Along with checking for eye dryness and equal facial nerve function around both eyes, Dr. Pastorek says he checks for Bell's phenomenon. "Most people have this — when they close their eyes, the pupil rotates upward. But in some patients, it does not. In those patients, if you have a millimeter of lagophthalmos, they can have corneal problems," he says, adding that sometimes it's impossible to tell if a patient has lagophthalmos without having the patient tilt his or her head backward and look downward.Additionally, "Always make sure you identify asymmetries of the lid. They can be very subtle," he says. If not addressed during surgery, such asymmetries can become more noticeable afterward.
UPPER LIDS Indications for upper-lid blepharoplasty include dermatochalasis, which can occur in patients as young as their 20s, Dr. Pastorek says. Hypertrophic skin and muscle can mask dermatochalasis. Other indications include pseudo-herniation of orbital fat, which he says always has an inherited component. Somewhat similarly, if patients have congenitally heavy upper eyelids, physicians should consult their significant others because these people may love the appearance.
When marking patients preoperatively, Dr. Pastorek says, it's advisable to leave patients in the sitting position, or to account for the change in gravitational pull when they're lying down by pushing down slightly on the eyebrow.
During the procedure, "Avoid taking a lot of fat from the central upper lid. There's nothing more aging than the A-frame deformity, where you've removed as much fat as possible from the central compartment of the lid," he says. Conversely, "In the lateral upper lid, we want as much sculpting as possible so that this area looks beautiful."
Dr. Pastorek also recommends anchoring the upper-lid blepharoplasty to a natural tether in the temple region just above the eyelid crease. "If you put your finger there and try to pull down, it doesn't move much," as opposed to choosing an anchor position at the level of the eyelid crease.
"If we try to put our blepharoplasty scar in that crease because it won't be as noticeable, when you suture things together, it will pull down a bit," he says. "But if you move the scar up a tiny bit when you close the wound, the skin actually pulls up."
For female patients with significant lateral hooding, sometimes it's necessary to extend the incision beyond the orbital rim, Dr. Pastorek says. In such cases, "If you confine the incision to the orbit itself, you'll leave a continuation of the lateral hooding beyond the incision."
However, in men, "It's best not to go outside the orbital rim. Most guys can't tolerate that scar," which women can cover with makeup until it heals, he says. Aesthetically, men can get away with having a little hooding in this area.
Dr. Pastorek also recommends removing as much skin as possible from above the orbicularis but leaving the orbicularis intact because this muscle is usually fairly thin. Conversely, when the orbicularis is excessively thick, he advises removing a central cuff to provide a more sculpted appearance at the upper sulcus.
"When you open the orbital septum, just tease the fat a little bit," and whatever amount of fat naturally extrudes is the maximum amount one can remove safely without producing a deformity, he says. Additionally, "You always want to end at a 30-degree angle to avoid creating a standing cone when the incision is closed."