Upper blepharoplasty — Marking, technique and variants

Anatomy I — What is being reproduced

It is worth having the goal in mind before picking up the marker, because upper blepharoplasty is surgery of shape, not of quantity. The youthful lid has four constant features. First, little lid show between crease and lashes, more marked in women than in men. Second, convexity in the lateral and central thirds: the youthful lid is full, not empty. Third, a slight medial concavity, the only area where some hollow is acceptable. And fourth, an elevated brow tail, peaking between the lateral limbus and lateral canthus in women, while in men the brow is flatter and lower. The whole indication follows from these four: resect what hides the convexity — skin — and preserve what creates it — muscle and central fat.

Anatomy II — The layers and what lies behind the septum

From surface to depth: skin, orbicularis, orbital septum, preaponeurotic fat, levator aponeurosis, Müller’s muscleSmooth muscle with sympathetic innervation contributing 1-2 mm of additional lid elevation, tarsus and conjunctiva. The subcutaneous plane is extremely thin — eyelid skin is the thinnest in the body — which demands precise dissection and explains why the marking is made by stippling rather than a continuous line. Behind the septum lie two fat compartments, not three as in the lower lid: the medial (nasal), characteristically paler, whitish and more fibrous, and the central or preaponeurotic, more yellow owing to its higher carotenoid content. That colour difference is the practical landmark distinguishing them in the field. And one fact governs the safety of this operation: the levator aponeurosis lies immediately behind the preaponeurotic fat. Hence the rule: do not cross the septum unless deliberately going for fat, and do so through a small, controlled opening.

Examination: three diagnoses that get confused

The patient says “my eyelid feels heavy”, but that can come from three different places and only one is solved by resecting skin. DermatochalasisTrue excess upper eyelid skin, hanging over the crease and in advanced cases over the lashes is the blepharoplasty indication. Eyelid ptosis is different: the lid margin covers part of the pupil because the levator has lost power or its aponeurosis has disinserted, objectified by MRD1Margin-reflex distance 1: from corneal light reflex to upper lid margin; normal 4-5 mm and by levator functionLid margin excursion from maximal downgaze to upgaze with the brow blocked by the thumb; normal above 12 mm. And brow descent mimics skin excess because it drags forehead tissue downward; it is uncovered by lifting the brow with a finger to its correct position and seeing how much skin is truly redundant then. Operating on the lid when it is the brow that has dropped does not fix the problem and may worsen it, because closing the incision pulls the brow tail further down.

Lid, brow or ptosis?

The marking, millimetre by millimetre

The marking is done with the patient sitting and awake, before infiltration, and by stippling: the skin is so thin that a continuous line distorts when stretched. Excess skin is grasped with bayonet or Green forceps. Lower line: stretch the skin upward and draw a line parallel to the lid margin along the lid crease, at 8 mm in men and 10 mm in women — a wider upper lid reads as more feminine. Upper line: now stretch the redundant skin downward and draw a second parallel line above it, always leaving 10 mm of skin up to the orbital rim. The one-centimetre rule still holds as a reference, adapted to each anatomy. The two ends have their own shape: medially the lines meet in a downward-pointing apex, and here one must be especially sparing, because removing much tissue at the inner angle causes retraction and webbing; laterally they meet in an upward apex following a static crease of the periorbital rhytidosis.

Surgical sequence

1. 1. Position→Surgeon at the head of the patient, with symmetric view of both lids
2. 2. Anaesthesia→Entry point with a fine needle and a blunt 27 G, 38 mm cannula in the subcutaneous plane, visible under the skin, with articaine and adrenaline
3. 3. Incision→Fine-tip electrocautery along the marking from lateral to medial; assistant with two gauzes providing counter-traction
4. 4. Skin resection→Dissection in the very thin subcutaneous plane, coagulating any bleeding vessel in the deep plane
5. 5. Muscle (optional)→Only if indicated: a strip of orbicularis. Never cross the septum at this step
6. 6. Fat→Small septal incision over the compartment to be treated; assistant applying globe pressure to deliver the pad
7. 7. Haemostasis→Retract the pad, clamp with a mosquito, trim with scissors and coagulate the stump above the clamp before releasing
8. 8. Closure→Muscle layer with 5/0 Vicryl covering the septal opening — the septum is not sutured —; skin with a 5/0 prolene subcuticular suture, medial to lateral

Variants according to the finding

The lateral dog-ear and how to solve it

At the end of closure a redundant fold may remain at the lateral end — the dog-earRedundant skin fold forming at the end of an incision when the two edges differ in length. It does not flatten on its own, so it is dealt with during the same procedure: extend the scar with Converse, Iris or Stevens scissors along the same periorbital crease used to end the incision. That lateral extension benefits from safety stitches of fast chromic catgut or 6/0 Vicryl rapide, since it is the area under most tension. Anticipating it at the marking stage — extending the lateral end from the outset when the excess is obvious — saves this step.

Postoperative regimen

1. On finishing→While the second eye is operated, the first is covered with cold moist gauze. Iodine applied with a fine tip and adhesive strips
2. Expectation→Warn of pain and deformity for two weeks: the least well tolerated phase and the one generating most calls
3. Analgesia→Paracetamol 1 g + dexketoprofen 25 mg + prednisone 30 mg for one week
4. Eye care→Antibiotic ointment every 12 h for one week, alternating with artificial tears every 8 h
5. Sutures→Removed at 7 days