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INTRODUCTION

CLINICAL PEARLS

  • Avoid over-resection of orbital fat, which will result in a hollow appearance around the eye. Take only the fat that protrudes with gentle globe pressure.

  • Determine the underlying defect leading to the deformity—skin laxity, fat pseudoherniation, weakness of the orbicularis oculi, or multiple—to insure the culprit is addressed by your treatment.

  • Limit skin resection in Asian blepharoplasty and create a new crease by suturing the skin to the underlying levator aponeurosis.

  • Utilize soft-tissue fillers, fat grafting, neuromodulators, and skin resurfacing in addition to surgery when indicated to achieve patient’s goals for periocular rejuvenation.

  • Maintain hemostasis during blepharoplasty to mitigate the risk of devastating postoperative orbital complications.

ANATOMY

Eyelid Surface

Eyelid skin is the thinnest in the body with relatively sparse subcutaneous fat. This allows free movement of the lid in closure and blinking. The upper eyelid skin is thinner than that of the lower lid. The skin itself has many fine hairs as well as sebaceous and sweat glands. Healing occurs quickly in this area and scarring is usually minute.

The lid crease of the upper eyelid is formed by the insertion of the levator aponeurosis fibers into the skin and the orbicularis oculi muscle. It is approximately 8 to 12 mm superior to the lash line and lies just at the level of the upper edge of the tarsal plate. Medially and laterally, the crease is closer to the lid margin and has an arc shape across the lid. The Asian eye usually lacks this crease due to the lower insertion of the levator aponeurosis on the tarsus.

The lid fold describes the tissue above the lid crease and may extend throughout the length of the upper lid or it may be more localized. Excess tissue may develop in the aging face and sag over the lid crease, sometimes obscuring vision. A combination of excess skin, hypertrophied orbicularis oculi muscle, and herniated fat can be responsible for this process.

Orbicularis Oculi Muscle

The orbicularis oculi muscle provides the main mimetic function to the eyelid. It receives its innervation from the temporal and zygomatic branches of the facial nerve. The muscle is elliptical and classified as 3 bands (the pretarsal, preseptal, and preorbital), which attach to the bony orbit at the medial and lateral canthal tendons. The muscle can become hypertrophied over time and result in a full appearance of the eyelids.

Orbital Fat

Orbital fat cushions the globe and its associated structures, and its anterior limit is the orbital septum. In the upper eyelid, the fat separates the levator aponeurosis posteriorly and the orbital septum anteriorly. Here it is divided into 2 fat compartments: central and medial. The lacrimal gland occupies the space lateral to the central fat pad in the upper lid. In the lower lid, there ...

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