Residency · Residency · Plastic Surgery
Blepharoplasty: Upper and Lower Eyelid Surgery
Introduction
Blepharoplasty is one of the most commonly performed aesthetic procedures, addressing excess skin, protruding fat, and structural changes of the aging eyelids. The eyelids are functionally critical for globe protection, tear distribution, and vision; aesthetic eyelid surgery must prioritize function. Understanding periorbital anatomy, aging changes, and the relationship between the eyelid and brow is essential for safe and effective surgery. Complications including corneal injury, ectropion, and retrobulbar hemorrhage make meticulous technique and preoperative assessment mandatory.
Periorbital Anatomy
Upper Eyelid
Skin: thinnest skin in the body (0.5 mm); loosely attached to underlying orbicularis. Orbicularis oculi muscle: pretarsal, preseptal, and orbital portions; responsible for eyelid closure (CN VII). Orbital septum: fibrous membrane from the arcus marginalis to the levator aponeurosis (fuses 2-5 mm above the tarsal plate in Caucasians; lower in Asians). Levator palpebrae superioris: primary eyelid elevator (CN III); aponeurosis inserts into the anterior tarsal surface and the pretarsal skin (creates the supratarsal crease).
Supratarsal crease: approximately 8-10 mm above the lash line in females, 7-8 mm in males; absent or low in the Asian eyelid (levator aponeurosis does not insert into skin). Muller's muscle: sympathetically innervated smooth muscle; provides 2 mm of additional lid elevation; deep to the levator. Tarsal plate: dense connective tissue; upper tarsus is 10-12 mm in height; provides structural support. Preaponeurotic fat: two fat pads — medial (nasal, paler/whiter, surrounds the trochlea) and central (preaponeurotic, yellow).
The lacrimal gland occupies the lateral upper eyelid; it is firm, pink-gray, and bilobed; must not be confused with or excised as fat.
Lower Eyelid
Retractors: capsulopalpebral fascia (analogous to levator aponeurosis) and inferior tarsal muscle (analogous to Muller's). Orbital septum: fuses with the capsulopalpebral fascia below the tarsal plate. Fat compartments: three — medial (nasal), central, and lateral. The inferior oblique muscle runs between the medial and central fat compartments; must be identified and protected.
Lower tarsus: 4-5 mm in height (smaller than upper). Canthal tendons: medial canthal tendon attaches to the frontal process of the maxilla; lateral canthal tendon (Whitnall's tubercle) attaches to the inner aspect of the lateral orbital rim, 2 mm posterior to the orbital rim.
Lacrimal System
Puncta: located on the medial aspect of each eyelid margin; drains tears into the canaliculi. Must be preserved during all eyelid surgery.
Aging Changes of the Eyelids
Upper eyelid: dermatochalasis (excess skin), fat pseudoherniation (orbital septum weakening), levator dehiscence (ptosis), brow ptosis (often the primary cause of apparent upper eyelid fullness). Lower eyelid: fat pseudoherniation (bags), skin redundancy, laxity of the lower eyelid support structures (canthal tendons, orbicularis), tear trough deformity (hollowing at the orbital rim-cheek junction), malar festoons/malar mounds. Brow-eyelid continuum: brow ptosis contributes to apparent upper eyelid excess; must be addressed separately or the patient will be dissatisfied with blepharoplasty alone.
Preoperative Evaluation
History
Visual symptoms: peripheral vision loss from dermatochalasis (documented with visual field testing for insurance). Dry eye symptoms: burning, tearing, foreign body sensation. Contact lens use (increased dry eye risk). Prior eyelid surgery, brow lift, or LASIK. Thyroid disease (thyroid eye disease: proptosis, lid retraction, dry eye). Autoimmune conditions (Sjogren syndrome).
Examination
Visual acuity: document baseline. Brow position: assess brow ptosis; if present, brow lift should be considered before or concurrent with upper blepharoplasty. Correct brow ptosis first; failure to address brow descent leads to inadequate upper blepharoplasty or compensatory frontalis overactivity. Marginal reflex distance (MRD): MRD1: distance from corneal light reflex to upper eyelid margin; normal 4-5 mm; <2 mm suggests ptosis. MRD2: distance from corneal light reflex to lower eyelid margin; normal 5-6 mm. Levator function: measured as upper eyelid excursion from downgaze to upgaze; normal >12 mm. Snap test: lower eyelid pulled away from globe and released; should snap back immediately; delayed return suggests laxity (risk of ectropion).
Distraction test: lower eyelid pulled anteriorly; >6 mm distraction indicates significant laxity. Bell's phenomenon: upward rotation of the globe with eyelid closure; absent Bell's increases risk of corneal exposure after upper blepharoplasty. Schirmer's test: measures tear production; <10 mm in 5 minutes suggests dry eye; increased risk of postoperative corneal problems. Hertel exophthalmometry: measures proptosis; elevated in thyroid eye disease.
<image>Anatomical cross-section illustration of the upper eyelid showing the layered anatomy relevant to blepharoplasty. The cross-section is oriented with the anterior skin surface at the top and the posterior conjunctival surface at the bottom. From superficial to deep, the layers shown are: skin (labeled as the thinnest in the body at 0.5 mm), orbicularis oculi muscle (preseptal portion labeled), orbital septum (shown as a fibrous band extending from the arcus marginalis at the orbital rim to the levator aponeurosis), preaponeurotic fat pad (shown in yellow behind the septum and in front of the levator), levator aponeurosis (shown as a broad aponeurotic expansion inserting into the anterior surface of the tarsal plate and sending fibers through the orbicularis to the skin to create the supratarsal crease), Muller's muscle (shown as a thin pink layer deep to the levator aponeurosis and superficial to the conjunctiva), tarsal plate (shown as a dense white band 10-12 mm tall), and conjunctiva (the deepest layer in contact with the globe). The supratarsal crease is indicated at the level where the levator fibers insert into the skin. The lacrimal gland is shown in the superolateral position, labeled as distinct from orbital fat. The eyelash follicles are shown at the eyelid margin. Labels identify each layer, the arcus marginalis at the orbital rim, and the position of the supratarsal crease.</image>
Upper Blepharoplasty
Surgical Technique
Marking: performed with the patient upright; mark the existing supratarsal crease as the lower incision line; pinch the excess skin to determine the upper incision line. Critical rule: leave minimum 20 mm of skin between the upper incision and the brow to prevent lagophthalmos. Upper incision should not extend beyond the lateral orbital rim (lateral hooding may require separate brow lift). Excision: skin or skin-orbicularis flap excised; stay superficial to the orbital septum unless addressing fat.
Fat removal: open the orbital septum to access the preaponeurotic fat; remove only protruding fat conservatively. Medial fat pad: pale/white; adjacent to the trochlea. Do NOT excise the lacrimal gland: located laterally; firm, pink-gray, bilobed; excision causes permanent dry eye. Conservative approach: over-resection of skin causes lagophthalmos; over-resection of fat creates a hollow, skeletonized appearance ("surgical look"). Closure: running or interrupted 6-0 nylon or fast-absorbing gut; remove at 5-7 days.
Asian Blepharoplasty (Double Eyelid Surgery)
Creates or enhances the supratarsal crease in the Asian eyelid. Anatomic basis: in the Asian eyelid, the orbital septum fuses with the levator aponeurosis closer to the tarsal plate, and preaponeurotic fat descends lower; the levator does not send fibers through the orbicularis to the skin. Techniques: suture method (non-incisional, for patients with thin eyelids and minimal fat) or incisional method (skin excision, fat removal, fixation of skin to levator). Respect the patient's ethnic identity; goal is not Westernization but creation of a defined crease at the patient's desired height.
Lower Blepharoplasty
Approaches
Transcutaneous (Skin-Muscle Flap)
Subciliary incision 1-2 mm below the lash line. Skin-muscle flap elevated to expose the orbital septum and fat compartments. Allows skin excision (for significant dermatochalasis) and fat repositioning/removal. Risk of ectropion: highest with this approach; occurs from excessive skin removal, scar contracture, or failure to support a lax eyelid. Conservative skin removal: "pinch test" determines safe amount; remove less than you think necessary.
Transconjunctival
Incision through the conjunctiva below the tarsal plate (preseptal approach) or behind the orbital septum (retroseptal approach). No external scar; lower risk of ectropion. Ideal for patients with fat pseudoherniation but minimal skin excess. Can be combined with a skin pinch for mild skin excess or laser resurfacing.
Fat Management
Traditional excision: removal of protruding fat from medial, central, and lateral compartments. Risk of hollow appearance and accentuated tear trough. Fat repositioning (transposition): preferred modern technique; herniated fat is mobilized on its pedicle and transposed inferiorly over the orbital rim to fill the tear trough. Addresses the tear trough deformity and fat pseudoherniation simultaneously. Creates a smooth lid-cheek junction instead of a hollow orbit.
Adjunctive Procedures
Canthopexy/canthoplasty: lateral canthal tightening; essential if snap test or distraction test indicates laxity. Canthopexy: reinforcing suture to tighten the lateral canthal tendon without detaching it. Canthoplasty: detachment and reattachment of the lateral canthal tendon to the periosteum of the inner orbital rim (Whitnall's tubercle). Midface lift: elevation of the descended malar fat pad; addresses the malar groove. Chemical peel or laser resurfacing: for fine wrinkles and skin texture.
<image>Illustration of lower blepharoplasty fat repositioning technique to address the tear trough deformity. Panel A shows a preoperative frontal view of the lower eyelid with prominent fat pseudoherniation creating a bag beneath the lower eyelid and a deep tear trough (nasojugal groove) visible as a shadow along the orbital rim at the lid-cheek junction. Panel B shows an intraoperative sagittal cross-section: the transconjunctival approach has been used to access the orbital fat. Instead of excising the fat, the herniated orbital fat pedicle from the medial and central compartments is shown being mobilized and transposed inferiorly over the orbital rim. The fat is sutured to the periosteum below the rim to fill the depression of the tear trough. Panel C shows the postoperative frontal view with the fat bags resolved and the tear trough filled, creating a smooth convex contour from the lower eyelid to the cheek without hollowing. Labels identify the orbital fat pedicle, orbital rim, tear trough (nasojugal groove), periosteum, and transposed fat position.</image>
Complications
Minor Complications
Chemosis: conjunctival edema; usually resolves spontaneously; lubricating drops. Ecchymosis: expected; resolves in 1-2 weeks. Asymmetry: minor differences common; reoperation for significant asymmetry after 3-6 months. Milia/inclusion cysts: along the incision line; needle drainage.
Major Complications
Ectropion: lower eyelid pulls away from the globe; results from excessive skin removal, scar contracture, or failure to address eyelid laxity. Treatment: conservative (massage, taping, lubricating drops) for mild cases; canthoplasty and possible skin graft for severe cases. Lagophthalmos: inability to close the eyelid completely; from excessive upper eyelid skin removal. Leads to corneal exposure, dryness, and ulceration.
Treatment: aggressive lubrication; FTSG if persistent. Ptosis: injury to the levator aponeurosis during upper blepharoplasty; repair if persistent after 3-6 months. Dry eye: worsening of pre-existing dry eye; lacrimal gland injury; aggressive lubrication. Retrobulbar hemorrhage: surgical emergency; incidence 0.05%; presents with proptosis, severe pain, visual changes, tense orbit, afferent pupillary defect.
Treatment: immediate lateral canthotomy and inferior cantholysis to decompress the orbit; do not wait for imaging. Permanent vision loss if not treated within 60-90 minutes.
Key Clinical Pearls
Always assess brow position before upper blepharoplasty; brow ptosis is the most commonly missed contributor to apparent upper eyelid excess, and failure to address it leads to suboptimal results and the need for aggressive skin excision that risks lagophthalmos. The minimum 20 mm rule (skin between upper blepharoplasty incision and brow) must be respected to prevent lagophthalmos; err on the side of conservative skin excision. Fat repositioning has largely replaced fat excision in lower blepharoplasty; transposing orbital fat over the orbital rim to fill the tear trough creates a youthful, smooth lid-cheek contour and avoids the hollow, skeletonized appearance of over-resection. The snap test and distraction test must be performed on every lower blepharoplasty candidate; patients with lower eyelid laxity require concurrent lateral canthal tightening to prevent postoperative ectropion. Retrobulbar hemorrhage is the most feared complication of blepharoplasty; every surgeon performing blepharoplasty must be prepared to perform emergent lateral canthotomy and cantholysis, as permanent vision loss occurs within 60-90 minutes if the orbit is not decompressed.
References
- Codner MA, McCord CD, Hester TR. The lateral canthoplasty. Oper Tech Plast Reconstr Surg. 1998;5(2):90-98.
- Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Blindness following blepharoplasty: two case reports, and a discussion of management. Ophthalmic Surg. 1990;21(2):85-89.
- Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg. 2004;113(3):32e-42e.
- Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011;127(1):386-395.
