Rejuvenation ofthe Upper Eyelid

Sachin Parikh, MD, Sam P. Most, MD*

KEYWORDS

� Upper eyelid � Blepharoplasty � Eyelid rejuvenation

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The eyes are the most captivating feature of theface. Furthermore, attractive eyes are an importantfeature of the youthful face. Although attention isdrawn to the eyes, the surrounding structuresthat frame the eye are key contributors to facialbeauty. The frame of the eye extends down tothe lower eyelid-cheek junction and up to theupper eyelid–brow unit. Thus, the periocular regionis a complex that should be broadly defined toinclude the eyebrow and midface. It is a surgeon’sjob to carefully analyze the underlying anatomy todetermine the surgical approach to achieve thebest aesthetic result.

The youthful upper eyelid is full, not hollow oroverskeletonized. There is a crisp upper lid creasewith elastic support of the underlying soft tissue,creating a smooth, taut pretarsal and preseptalupper eyelid. The eyebrow is often addressed inconjunction with the upper eyelid in upper facerejuvenation. This article focuses solely on surgicalrejuvenation of the upper eyelid. The goal of reju-venation of the upper eyelid should be a moreyouthful but natural-appearing result.

Upper eyelid surgery is the most requestedand performed facial rejuvenation surgery in theUnited States.1 The excision of the eyelids datesback 2000 years. The cauterization of excesseyelid skin to reduce drooping is described inthe Sanskrit document, the Sushruta.2 Americansurgeons began to write about cosmetic surgeryin 1907, with Conrad Miller’s Cosmetic Surgeryand the Correction of Feature Imperfections.3

Over the subsequent decades, surgeons advo-cated the removal of herniated fat pads and orbi-cularis oculi muscle excision. Over the past 20years, the emphasis on technique has shiftedto conservation of fat, skin and muscle excision

Division of Facial Plastic and Reconstructive Surgery, DeStanford University School of Medicine, 801 Welch Road* Corresponding author.E-mail address: smost@ohns.stanford.edu

Facial Plast Surg Clin N Am 18 (2010) 427–433doi:10.1016/j.fsc.2010.04.0051064-7406/10/$ – see front matter ª 2010 Elsevier Inc. All

to avoid a deep, hollow, and skeletonizedappearance to the eyelids.

EYELID ANATOMY

The position and form of the eyebrow has a deepimpact on the appearance of the upper eyelidand eye below. A precise analysis of eyebrowposition and form is a critical first step in the eval-uation of the upper eyelids, a full analysis of whichis beyond the scope of this article. A few salientpoints are discussed. The female brow is archedwith the most superior aspect of the brow posi-tioned directly above the lateral limbus. Laterallythe brow sits above the orbital rim, and centrallythere should be a high arch with a deep superiorsulcus. The ideal position of the female browdiffers from that of the male brow. The malebrow is relatively straight, lying at the level of theorbital rim, and runs perpendicular to the nosewith a minimal sulcus and a low subtle lid crease8 mm above the lash line.4

Fig. 1 depicts many anatomic relationships thatmust be understood when evaluating the eyelidand assessing what needs to be addressed torestore youthfulness. The lateral canthus is typi-cally 2 to 4 mm superior to the medial canthus.The adult palpebral fissure averages 10 to 12mm vertically and 28 to 30 mm horizontally. Thedistance from the lateral canthus to the orbitalrim is typically 5 mm. At rest, the upper eyelidcovers the superior limbus by 1 to 2 mm. The high-est point of the upper lid margin is just nasal toa vertical line drawn through the center of thepupil. This contour should be noted preoperativelywhen evaluating patients for rejuvenation of theupper eyelid so it can be addressed during surgery

partment of Otolaryngology/Head & Neck Surgery,, Stanford, CA 94305, USA

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Fig. 1. Topography of the eyelid. (A) The highestpoint of the brow is at, or lateral to, the laterallimbus. (B) The inferior edge of the brow is typically10 mm superior to the supraorbital rim. (C) Alsoshown are ranges for average palpebral height (10–12 mm), width (28–30 mm), (D) and upper lid fold(8–11 mm, with gender and racial differences). Notethat the lateral canthus is 2 to 4 mm higher than themedial canthus. (E) Intrapalpebral distance measures10 to 12 mm. E1, mean reflex distance 1; E2, meanreflex distance 2. (F) Palpebral width. (G) Upper lidfold is 8 to 11 mm. (From Most SP, Mobley SR,Larrabee WF Jr. Anatomy of the eyelids [review]. FacialPlast Surg Clin North Am 2005;13:487–92; Elsevier;with permission.)

Fig. 2. Orbicularis oculi muscle. The muscle is tradi-tionally divided into orbital and palpebral portions.The orbital portion arises from the anterior aspect ofthe medial canthal tendon and the periosteum aboveand below it. The palpebral portion is further subdi-vided into pretarsal and preseptal portions, each lyingover the tarsal plate or orbital septum, respectively.(From Most SP, Mobley SR, Larrabee WF Jr.Anatomy of the eyelids. Facial Plast Surg Clin NorthAm 2005;13:487–92; Elsevier; with permission.)

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to create a more aesthetic and appropriate lidposition. The upper lid crease lies 8 to 11 mmabove the lash line in whites but this varies withethnic background. In Asians, the upper lid creasemay be lower or absent owing to the lower inser-tion of the septum and variable or absent insertionof the levator aponeurosis into the upper lid skin.

The layers of the upper eyelid can be separatedinto an anterior lamella and a posterior lamella. Theanterior lamella is comprised of the thinnest skin ofthe human body and the orbicularis oculi muscle.The posterior lamella is comprised of the levatoraponeurosis, tarsus, Muller muscle, and conjucti-va.5 Deep to the skin lies the orbicularis oculimuscle, which can be divided into an orbitalportion and a palpebral portion. The palpebralportion is further subdivided into a pretarsal andpreseptal portion lying over the tarsal plate andorbital septum, respectively (Fig. 2).

The postseptal fat of the superior orbit is dividedinto 2 compartments: the central (or preaponeur-otic) and the medial (or nasal) fat pads separatedby the trochlea and fascial strands from the Whit-nall ligament.4 During upper eyelid surgery,

surgeons must protect the trochlea to avoid supe-rior oblique palsy or Brown syndrome.6 The medialfat pad is paler and denser and recognition ofthese subtle differences is crucial for successfulblepharoplasty with fat excision. The lacrimalgland occupies the lateral compartment. Theretro-orbicularis oculi fat (ROOF) pad is a submus-cular fat pad that sits deep to the interdigitation ofthe frontalis and orbicularis oculi muscles (Fig. 3).4

AGING OF THE EYES

The appearance of the upper eyelid may beaffected by changes in the eyebrow position.Lateral ptosis of the eyebrow may add to fullnessof the upper eyelid compounding the effect ofthe existing skin redundancy. In severe cases,this may cause visual field loss. The hallmarks ofupper eyelid facial aging are lateral hooding, der-matochalasis, and fat pseudoherniation in themedial aspect of the upper eyelids. The uppereyelids become more redundant due to excesseyelid skin and eyebrow descent.7 Rejuvenationof the upper eyelid is intended to elevate ptotictissues and remove any tissue redundancy.

As a person ages, the loss of volume in the entirefrontal region and loss of skin elasticity in thetemporal region may account for brow ptosis, forthose in whom this occurs. The tendency to coun-teract this by raising the eyebrows causes anaccentuation of the hollowness under the eyes.8

This also leads to a decrease in the lateral fullnessof the upper eyelid. When the frontalis is relaxed,

Fig. 3. Cross-sectional anatomy of the upper andlower lids. The capsulopalpebral fascia and inferiortarsal muscle are retractors of the lower lid whereasMuller muscle and the levator muscle and its aponeu-rosis are retractors of the upper lid. Note the preseptalpositioning of the ROOF and suborbicularis oculi fat(SOOF). The orbitomalar ligament arises from the ar-cus marginalis of the inferior orbital rim and insertson skin of the lower lid, forming the nasojugal fold.(From Most SP, Mobley SR, Larrabee WF Jr. Anatomyof the eyelids. Facial Plast Surg Clin North Am2005;13:487–92; Elsevier; with permission.)

Fig. 4. The aging upper eyelid. Weakening of theorbital septum is thought to cause herniation of orbitalfat in the upper and lower lids. (From From Most SP,Mobley SR, Larrabee WF Jr. Anatomy of the eyelids.Facial Plast Surg Clin North Am 2005;13:487–92;Elsevier; with permission.)

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the redundant skin hangs lower, and the distancebetween the eyebrow and eyelashes is shortened.The weakening of the orbital septum also causesherniation of the orbital fat (Fig. 4). The lateralorbital region skin will develop rhytids, or crow’sfeet. The orbicularis oculi muscle may hypertrophyover time, causing the preseptal portion tobecome redundant and roll over the firmlyattached pretarsal orbicularis, exacerbating theredundancy.8 These factors all contribute topatients complaining of ‘‘looking tired, old, andnot alert.’’

CLINICAL EVALUATION

As with any elective cosmetic procedure, thedecision to perform a procedure to rejuvenatethe upper eyelid is based on a thorough

evaluation of the general medical history,ophthalmologic history, and psychological moti-vations of a patient. Medical history shouldinclude a history of chronic illnesses, hyperten-sion, diabetes, bleeding disorders, and any anti-coagulant medications. Key points in the historyinclude any previous ophthalmologic procedures,history of thyroid eye disease, previous facialtrauma, recent botulinm toxin type A treatments,and a history of dry eyes. Dry eye syndrome canbe associated with medical systemic diseases,such as Sjogren syndrome, collagen vasculardiseases, Wegener granulomatosis, and Ste-vens-Johnson syndrome. If a patient has dryeyes, a Schirmer test can be performed, butreferral to an ophthalmologist is recommended.

An in-depth discussion between patient andsurgeon must address their concerns and expec-tations. This allows both parties to ensure fluidcommunication, determine whether or not theirassessments coincide, and reaffirm there are nounrealistic expectations. Surgeons must criticallyanalyze and elicit patients’ expectations andexplain thoroughly that results can differ basedon preoperative findings and ethnicity. Forexample, the Asian eyelid has more fullness ofthe upper eyelid, a lower lid crease, more narrowpalpebral fissures, and possibly a medial epican-thal fold. Surgeons must discuss lid crease posi-tion with patients to determine their desires

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regarding postoperative lid crease position. Stan-dardized preoperative photo documentationshould be obtained. The authors also routinelyobtain close-up views of the eyes in primary upgaze and down gaze in the frontal and in bothlateral views.9 Another helpful tool is reviewingpatients’ pictures from an earlier age. Analysis ofsuch photos may help determine the contributionof brow ptosis to upper lid aging.

A physical examination must include a generaloverview of a patient’s face, eyes, and eyelids. Itis paramount to determine the brow contributionto aging of the upper lids when counseling patientsfor upper eyelid surgery, because this can altera surgical plan. If there is any asymmetry of thepalpebral fissures, it must be pointed out. Asym-metry is unmasked after a blepharoplasty andcan become a source of dissatisfaction anda focus of attention for patients. It is imperativeto also document visual acuity and extraocularmovements and assess for dry eye, proptosis,and ptosis. If visual field obstruction is a concern,it is prudent to consult with an ophthalmologist fordocumentation and to determine whether or notthe obstruction is clinically significant. The docu-mentation of concurrent ptosis of the upper eyelidshould also include measurements to the nearest0.5 mm, if possible, using margin-to-reflexdistance and levator excursion.10 Surgeons mustalso check the conjuctiva for any erythema oredema. Finally, surgeons can assess how muchcan skin can be excised by using the pinch tech-nique to grasp redundant skin with a forceps toensure that there is no elevation of the lid margin.This reaffirms that excision of this skin can besafely undertaken without causing lagophthalmos.

Fig. 5. A caliper is used to measure from the lidmargin to the proposed upper lid crease.

SURGICAL TECHNIQUE

The authors prefer to obtain initial preoperativemarkings with patients in the upright position inneutral gaze. This is especially important if patientsare to have a general anesthetic (eg, if the upperblepharoplasty is performed in conjunction withother procedures). In this position, the midpoint,medial extent, and lateral extent of the naturalsupratarsal creases on each side are marked.The lateral extent of the natural crease is noted—this approximates the lateral extent of the incision.The amount of lateral hooding is marked. Theamount of redundant skin is noted. If a patient isto undergo browlift, the brows are elevated slightlyand the amount of redundant skin noted. The browis operated on first when done in conjunction withupper blepharoplasty because it reduces theamount of upper lid skin excision. If excess skin

is removed from the upper eyelid without browlift-ing, the brow can be drawn further downward.

In the operating room, patients are placedsupine. The lid crease markings are noted. Usinga caliper, the previously performed markings aremeasured (Fig. 5). In occidental lids, the femaleupper lid crease is ideally placed 10 to 12 mmabove the lid margin whereas in the male the idealis 8 to 10 mm.4 In many cases, the lid creases arenoted as asymmetric. Typically, the authors selectthe side closest to the ideal for a patient and re-draw the lower limb incision on the opposite sideto match this.

Surgeons must be mindful of going far lateralpast the lateral canthus because the incisionbecomes more visible in this area, especially inpatients with thick skin. The lateral extent of thecrease, noted preoperatively, is used as a guide.The pinch test is used to determine the amountof redundant skin that can be excised withoutcausing lagophthalmos. In this test, a Green orBrown forceps is used to gently pinch the upperlid skin. The lower tine is placed on the proposedlower lid incision, and the upper tine position isvaried until, when pinched, the upper lid lashesjust begin to evert. This is the position of the supe-rior incision. The medial extent of the incision is thepunctum. If an excessive amount of skin is goingto be excised medially, a W-plasty may need tobe performed.11 The point of maximal excision islateral to the midpupillary line. The lateral extentof the incision can vary, depending on the extentof lateral hooding, patient acceptance of morevisible scars, and the extent of the natural lidcrease. Generally, it extends 5 to 10 mm beyondthe lateral canthus. If the redundant skin extendswell beyond the lateral canthus and the incisionis performed more laterally, it may leave a visiblescar. The thicker eyebrow skin that is removedlaterally does not align favorably with the thinnereyelid skin inferiorly.

Fig. 6. Panels A & B represent two variations of the lenticular incision used in upper blepharoplasty. The medialextent is the punctum. The lower incision is 6 to 8 mm from the lid margin. The upper incision follows the contourof the brow.

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The shape of the lower limb can vary mediallyand laterally (Fig. 6). Some surgeons prefer toconverge the upper and lower limb incisions curvi-linearly whereas others prefer a slight upturn to thelower limb medially and laterally. The authorsprefer the latter, because it allows the upper andlower limb incision lengths to match moreprecisely, reducing the likelihood of redundancyof the upper limb skin at the medial and lateralextents of the incision (see Fig. 6).

Upper lid blepharoplasty can be performedunder local anesthesia with or without sedationor under general anesthesia. A subcutaneousinjection with 1% lidocaine with 1:100,000 unitsof epinephrine using a 1.25-inch, 27-gauge needleis performed. Local anesthetic should be injectedsuperficial to the muscle to reduce the likelihoodof formation of a hematoma. Incisions are madewith a no.15 scalpel through the skin only. Thestrip of skin is removed with fine tip scissors(Fig. 7). In some cases, a 2- to 3-mm strip of orbi-cularis muscle is excised at the junction of theupper one-third and lower two-thirds of the wound

Fig. 7. A strip of skin is excised from the upper eyelid.

site. The excision of orbicularis oculi muscle is in-tended to define a good eyelid crease definition.Patients with thin skin usually require little or nomuscle excision, whereas patients with thick skinwith redundant orbicularis muscle may requireconsiderably more excision. In cases wheremedial fat excision is required, a small incisioninto the orbital septum is made medially. Themedial fat is typically paler than the preaponeur-otic fat and is more fibrous. Only fat that comeseasily into the wound is excised. Meticuloushemostasis is maintained. The fat is labeled andkept so a surgeon can compare the amount oftissue removed from each eyelid. The authorsavoid removal of the preaponeurotic fat to avoida hollow, overoperated look. The skin incisionmay be closed with a running or interrupted sutureusing various absorbable or permanent sutures.The authors prefer a running 7-0 prolene suture.Immediately after surgery, antibiotic ophthalmicointment is placed over the incisions and into thecornea. Patients are asked to apply antibiotic oint-ment twice per day. Sutures should be removedwithin 5 to 7 days. Patients may resume lightaerobic activity at that time but must avoidbending over or lifting more than 8 pounds for 2weeks. Nonsteroidal anti-inflammatory medicinesmust be avoided for 2 weeks pre- andpostoperatively.

COMPLICATIONS

Complications from upper lid rejuvenation areinfrequent and usually minor and transient. Themost serious complication is partial or completevisual loss secondary to ischemic optic neuropathyor retrobulbar hemorrhage.12 This complication israre but treatment should be on an emergency

Fig. 8. Preoperative (top) and 4-month postoperative(bottom) images of patient who underwent conserva-tive upper lid blepharoplasty and endoscopic browlift.Note that preoperatively, this patient had very fullupper lids, particularly laterally. This fullness was nota result of aging, and reduction of this would notrejuvenate this patients eyelids. Preservation of epi-canthal contour was important and this anatomywas maintained. Postoperatively, the patient has re-gained her more youthful, but full, upper eyelid/brow contour.

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basis. These patients complain of severe orbitalpain and visual deficits. Physical examinationshows proptosis, tense globe, chemosis,increased intraocular pressures, and ophthalmo-plegia. Emergency treatment involves explorationof the affected eye with evacuation of hematomaif present. If the vision is rapidly decompensatingand intraocular pressures are high, lateral canthot-omy and cantholysis with administration of ocularhypotensive agents may be necessary. The othervisual complications can include an oculomotordisorder, epiphora, chemosis of lymphatic origin,and keratoconjuctivitis sicca.

A common complaint after surgery is a sensationof a dry or itchy eye. If this does not resolve aftera few days, it should not be discounted asa corneal abrasion, but dry eye syndrome mustbe considered, which is a group of disorderscaused by reduced tear production or excessivetear evaporation that may cause disease of theocular surface. The pathophysiology can be ex-plained by postoperative edema interfering withnormal production and flow of tears. It is impera-tive to recognize preoperative risk factors throughhistory and physical examination. Initially, dry eyesyndrome is treated with artificial tears,ophthalmic lubricants, topical antibiotic, andsteroid drops to help reduce the inflammatoryresponse and prevent conjunctivitis.13 Systemiccorticosteroids can be added and tapered over 5days. If the problem persists for more than 2weeks, damage to the lacrimal gland should beruled out. The presence of chemosis may altermanagement. If symptoms persist, an ophthalmol-ogist should be consulted.

More common are eyelid issues from overre-section or asymmetry.12 These include ptosisof the upper lid, lagophthalmos, and eyelid foldanomalies. Ptosis is most often hidden on phys-ical examination in patients with extreme derma-tochalasis. If ptosis exists preoperatively, it canbe addressed during the blepharoplasty. La-gophthalmos is frequent but transient andshould be treated conservatively with lubricatingsubstances and closure of the eyelids at night.Up to 3 to 4 mm of initial (eg, intraoperativeand temporary) lagophthalmos may be observedafter wound closure.14 As the swelling resolves,the lagophthalmos improves. If there is a signifi-cant degree of lagophthalmos (up to 6 mm cen-trally and 1 to 2 mm medially), the excisedeyelid skin should be replaced with a full-thick-ness skin graft.14 If patients are refractory tomedical treatment, reconstruction of the anteriorlamella with a full-thickness skin graft should beconsidered.12 If there is postoperative asymme-try, surgical revision can be discussed.

SUMMARY

Rejuvenation of the upper eyelid has undergonea change in philosophy over the past 20 yearswith the realization that preservation of facialvolume, and periocular volume in particular, isdesirable in most cases. An attractive face is char-acterized by lateral fullness of the upper eyelid/brow area with wide-open eyes and tight uppereyelid skin. The authors advocate minimal excisionof skin, muscle, and fat to preserve a fuller, morenatural look of the youthful eyelid (Fig. 8). Surgical

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rejuvenation of the upper eyelid can be achievedthrough various methods, including brow lift, fron-totemporal lift, endoscopic forehead lift, Botoxtreatment, autologous fat tissue transplantation,and the use of injectable materials. The standarddecision is whether or not to excise skin; skinand muscle; or skin, muscle, and fat.

There are a few new directions surgeons aretaking in standard upper eyelid blepharoplastythat warrant mention. One group has espousedremoval, cutting, and reimplantation of the medialfat pad within an imbricated layer of orbicularis oculimuscle.15 This technique is designed to enhancea lateral, convex fullness and recreate key charac-teristics of the youthful eyelid. Fat can also be har-vested and transplanted into upper eyelid tissue.16

It remains to be seen if these techniques becomewidely adopted by facial plastic surgeons.

Rejuvenation of the upper eyelid is a dynamicsurgical procedure that should be highly success-ful. A detailed understanding of the anatomic rela-tionships of the eyelid is needed to achieve a niceaesthetic outcome. The keys to a good result arecareful analysis on physical examination and ofpreoperative photos. The brow must also beanalyzed and addressed if necessary. Standardresection of muscle and fat during upper lid bleph-aroplasty is no longer done routinely because thephilosophy for conservative excision has becomemore accepted. The focus of resection should beon conservative reduction of redundant soft tissue.A youthful periocular region has subtle highlightsand lateral fullness of the upper eyelid, creatingan attractive frame for the eyes.

REFERENCES

1. American Academy of Facial Plastic and Recon-

structive Surgery annual survey, 2004. Available at:

www.aafprs.org. Accessed October 5, 2005.

2. Dupuis C, Rees TD. Historical notes on blepharo-

plasty. Plast Reconstr Surg 1971;47:246–51.

3. Miller CC. Cosmetic surgery and the correction of

feature imperfections. 1907.

4. Most SP, Mobley SR, Larrabee WFJ. Anatomy of the

eyelids. Facial Plast Surg Clin North Am 2005;13:

487–92, v.

5. Becker DG, Kim S, Kallman JE. Aesthetic implica-

tions of surgical anatomy in blepharoplasty. Facial

Plast Surg 1999;15:165–71.

6. Neely KA, Ernest JT, Mottier M. Combined superior

oblique paresis and Brown’s syndrome after blepha-

roplasty. Am J Ophthalmol 1990;109:347–9.

7. Lam SM, Chang EW, Rhee JS, et al. Perspective:

rejuvenation of the periocular region: a unified

approach to the eyebrow, midface, and eyelid

complex. Ophthal Plast Reconstr Surg 2004;20:1–9.

8. Ross AT, Neal JG. Rejuvenation of the aging eyelid.

Facial Plast Surg 2006;22:97–104.

9. Swamy RS, Most SP. Pre- and post-operative portrait

photography: standardized photos for various proce-

dures. Facial Plast Surg Clin North Am 2010;18(2).

10. Gentile RD. Upper lid blepharoplasty. Facial Plast

Surg Clin North Am 2005;13:511–24, v–vi.

11. Rohrich RJ, Coberly DM, Fagien S, et al. Current

concepts in aesthetic upper blepharoplasty. Plast

Reconstr Surg 2004;113:32e–42e.

12. Morax S, Touitou V. Complications of blepharoplasty.

Orbit 2006;25:303–18.

13. Hamawy AH, Farkas JP, Fagien S, et al. Preventing

and managing dry eyes after periorbital surgery:

a retrospective review. Plast Reconstr Surg 2009;

123:353–9.

14. Romo T, Millman AL. Aesthetic facial plastic surgery:

a multidisciplinary approach. 2000. p. 266–7. Avail-

able at: http://www.amazon.com/Aesthetic-Facial-

Plastic-Surgery-Thomas/dp/product-description/

0865778078. Accessed April 15, 2010.

15. Gulyas G. Improving the lateral fullness of the upper

eyelid. Aesthetic Plast Surg 2006;30:641–8 [discus-

sion: 649–50].

16. Trepsat F. Periorbital rejuvenation combining fat

grafting and blepharoplasties. Aesthetic Plast Surg

2003;27:243–53.