Blepharoplasty

Anatomy & Indications - Eye Lift Essentials

• Eyelid Layers (Ant → Post): Skin → Orbicularis Oculi → Orbital Septum → Orbital Fat → Levator Aponeurosis → Müller's Muscle → Conjunctiva.
  • 📌 Mnemonic: "Some Old Oily Otters Love Munching Carrots"
• Fat Pads:
  • Upper Lid: 2 (Central, Medial/Nasal).
  • Lower Lid: 3 (Medial/Nasal, Central, Lateral/Temporal).
• Key Structures: Orbital Septum, Tarsal Plates, Canthal Tendons, Levator & Müller's muscles.
• Blepharoplasty Goals:
  • Functional: Improve visual field.
  • Aesthetic: Rejuvenate appearance.
• Common Indications:
  • Dermatochalasis (excess skin).
  • Steatoblepharon (fat herniation).
  • Functional VF loss (>30% or >12°).
• Key Contraindications:
  • Absolute: Unrealistic expectations, active infection.
  • Relative: ⚠️ Severe Dry Eye (KCS), bleeding issues, unstable thyroid eye disease.

⭐ The orbital septum is a critical surgical landmark differentiating preseptal from orbital fat; its violation can lead to deeper orbital complications.

Pre-op & Planning - Setting the Stage

• Comprehensive History:
  • Ocular: Dry eye symptoms, prior surgeries, contact lens use.
  • Medical: Bleeding disorders (e.g., Von Willebrand), HTN, DM, thyroid disease.
  • Medications: Stop anticoagulants/antiplatelets (e.g., aspirin, warfarin, clopidogrel, NSAIDs) 7-10 days pre-op, herbal supplements.
• Detailed Examination:
  • Visual acuity, visual fields, extraocular movements.
  • Eyelid: Margin Reflex Distance 1 (MRD1: ~4mm), MRD2 (~5mm), Palpebral Fissure Height (~9-12mm), Levator function (>10-12mm is good).
  • Brow position & ptosis assessment (distinguish from dermatochalasis).
  • Skin: Quality, quantity of excess, laxity, festoons, malar bags.
  • Lower Lid Tone: Snap-back test (normal <1 sec), distraction test (normal <6-8mm from globe).
  • Tear Film: Schirmer's I test, Tear Break-Up Time (TBUT >10 sec).
  • Corneal sensation, Bell's phenomenon.
• Photographic Documentation: Standardized views (e.g., frontal, lateral, oblique, close-ups).
• Surgical Plan & Markings: Tailored to anatomy & patient goals; upper lid (supratarsal crease), lower lid approach (subciliary vs. transconjunctival).

⭐ Schirmer's Test I (no anesthesia): Assesses basal & reflex tearing. Normal is >10mm wetting in 5 minutes. Values <5mm indicate severe dry eye, a significant caution for blepharoplasty due to risk of exacerbation.

Techniques - Sculpting the Lids

• Upper Blepharoplasty:

  • Marking: Upright, patient looking straight; skin pinch test to determine excess.
  • Excision: Skin, orbicularis oculi muscle (conservative strip), orbital fat (medial & central pads typically targeted).
  • Crease Formation: Anchoring skin/orbicularis to levator aponeurosis or superior tarsal border.

• Lower Blepharoplasty:

  • Approaches:
    • Transconjunctival (TCJ): Incision on palpebral conjunctiva. Primarily for fat removal/repositioning; no direct skin excision.
    • Transcutaneous (TCU): Subciliary incision (~2mm below lash line). For fat +/- skin/muscle excision.
  • Fat Management: Excision (conservative to avoid hollowness) or Repositioning (arcus marginalis release, fat pedicle advanced over infraorbital rim for tear trough).
  • Canthal Support: Canthopexy (suture fixation) or Canthoplasty (tendon shortening/reconstruction) if lid laxity present. 📌 "Can't hold? Pexy or Plasty!"

• Lower Lid Approach Comparison:

  Feature	Transconjunctival (TCJ)	Transcutaneous (TCU)
  Incision	Internal (conjunctiva)	External (subciliary)
  Skin Excision	No	Yes
  Visible Scar	None	Minimal, subciliary
  Orbicularis	Spared	Incised/Resected
  Ideal For	Fat prolapse, no skin excess	Fat prolapse + skin excess
  Lid Malposition Risk	↓ Lower	↑ Higher

⭐ The transconjunctival approach for lower blepharoplasty is generally preferred in patients without significant skin excess due to a lower risk of postoperative lower eyelid malposition (e.g., ectropion, scleral show).

Complications & Post-op - Smooth Recovery

• Early Complications:
  • Hematoma: Most common. Retrobulbar hematoma ⚠️ (proptosis, ↓vision, ophthalmoplegia) = surgical emergency!
  • Infection: Rare; manage with antibiotics.
  • Pain: Usually mild, managed with analgesics.
• Late Complications:
  • Dry Eyes (Keratoconjunctivitis Sicca): Common, often transient.
  • Lagophthalmos: Incomplete eyelid closure.
  • Ectropion/Entropion: Lid malposition.
  • Diplopia: Rare, due to muscle injury.
• Post-operative Care:
  • Head elevation 30-45°.
  • Cold compresses: First 24-48 hrs.
  • Topical antibiotic ointment.
  • Suture removal: Typically 5-7 days.
  • Avoid strenuous activity for 2 weeks.

⭐ Retrobulbar hemorrhage is a critical, sight-threatening complication requiring immediate lateral canthotomy and cantholysis.

High-Yield Points - ⚡ Biggest Takeaways

• Primary indications: Dermatochalasis (excess skin) and steatoblepharon (fat herniation).
• Upper blepharoplasty utilizes a supratarsal crease incision, removing skin +/- muscle.
• Lower blepharoplasty: Transconjunctival for fat (no skin scar); transcutaneous for skin/muscle excess.
• The orbital septum is a crucial barrier retaining preaponeurotic fat pads.
• Most feared complication: Retrobulbar hemorrhage, potentially causing vision loss.
• Always evaluate for brow ptosis and lower lid laxity for comprehensive results.
• Pre-existing dry eyes are a relative contraindication; can worsen post-operatively.