BlepharoplastBlepharoplasty Techniquesy Techniques

Yael Halaas M.D.

AnatomyAnatomy• Lateral canthus

inclined 10-15 degrees cephalad compared to medial canthus

• Upper lid: midway between the upper pupil and limbus. Apex medial to pupil

• Lower lid: 1-2mm over the corneoscleral junction. Central lowest portion

The Beautiful EyeThe Beautiful Eye• Brow- centrally on

rim, laterally above rim

• Upper lid crease <10mm above lid margin

• Fuller sulcus below the orbital rim

• Lateral lid free of hooding

Fat pocketsFat pockets

The Signs of Aging The Signs of Aging • Dermatochalasis- thin

loose skin secondary to aging

• Blepharochalasis- hypertrophy & excess draping of skin secondary to recurrent edemao not age-related, found

in young women o rare

• Pseudoherniation of fat (Steatoblepharon)

Lid EvaluationLid Evaluation• Fat pads- identify where pseudoherniation

exists• Lacrimal gland• Eyelid crease (7-9mm)• Epicanthal folds (Asian lid)• Orbicularis oculi • Lid ptosis- palpebral fissure symmetry

o Levator function: >12mm difference in lid aperture between extreme up and down gaze

• Skin lesions- xanthomas, pigmentation, blepharitis

• PHOTODOCUMENTATION• Discuss findings with the patient

What’s the difference?What’s the difference?

Ophthalmic exam Ophthalmic exam • Condition of corneal, sclera and conjunctiva

o Lack of injection, edema

• Basic visual acuity- Snellen card• Baseline tear production- Schirmer test

o At 5 min, low (0-9mm), mod (10-20mm), high (21-30mm)• Tests greater superficial petrosal nerve function

• Tear film breakup timeo Usually >20 seconds

ContradictionsContradictions• Thyroid disease- exopthalmos• Dry Eye Syndrome- burning, tearing, use of

artificial tears, waking at night with stinging eye pain

• Sensitivity to lidocaine with epinephrine• Anti-coagulation

o Nutritional supplements- gingko biloba, garlic, vitamin E, fish oil

The Asian EyelidThe Asian Eyelid• Small or absent

supratarsal crease• Adipose fullness• Epicanthal fold• Narrow palpebral

fissure

Creation of the Double Creation of the Double EyelidEyelid

• Suture• Partial Incision• Full Incision

Special techniquesSpecial techniques• Transconjunctiv

al upper bleph approacho Only for medial

fato No levator

aponeurosis between conjunctiva & subseptal fat

• Internal brow elevation

Complications of Upper Complications of Upper

BlepharoplastyBlepharoplasty• Hematoma• Subconjunctival Ecchymosis• Chemosis• Lagophtalmos – incomplete eye closure

o Dry Eye Syndrome

• Poor Scarso Milia

• Loss of Vision

Before & AfterBefore & After

Preoperative Preoperative Evaluation- lower lidEvaluation- lower lid

• Same as upper blepharoplasty evaluationo Dermatochalasis, etc.o Double convexity

• Lid position- extremely important

• Ectropion/entropion• Lid laxity• Tear trough deformity• Festoons

o Draping folds of orbicularis +/- fat

• Malar Bagso Soft-tissue fullness

• Lid distraction (snap) test- movement of lid > 10mm is abnormal

• Lid retraction test- puncta movement > 3mm from medial canthus is abnormalo Slow return or requiring multiple blinks = poor

lid tone

Before and AfterBefore and After

Lower Lid Blepharoplasty Lower Lid Blepharoplasty

TechniquesTechniques• Transconjunctival• Subciliary

o Skin flapo Skin Muscle flap

• With muscle suspension stitch• "Canthoplasty" refers to a procedure designed to

reinforce lower eyelid support by detaching the lateral canthal tendon from the orbital bone and constructing a replacement.

• "Canthopexy," on the other hand, refers to a less invasive procedure designed to stabilize the existing tendon (as well as surrounding structures) without removing it from its normal attachment.

• Orbital Fat Repositioning (Repair)• Orbital Fat Mobilization• Ancillary procedures

Lower Lid Blepharoplasty Lower Lid Blepharoplasty

IncisionsIncisions

TechniqueTechnique

Skin-muscle flap Skin-muscle flap

& Muscle suspension stitch& Muscle suspension stitch

Complications of Lower Lid Complications of Lower Lid

BlepharoplastyBlepharoplasty• Ectropion

o Subciliary- 20% lower lid retraction• Hematoma• Blindness• Epiphora• Suture Line Complications• Wound Healing Complications• Skin Discoloration• Ocular Injury• Contour Irregularities

Which technique?Which technique?

Complimentary lower lid Complimentary lower lid

proceduresprocedures• SOOF lift• Composite Rhytidectomy• Endoscopic midface lift• Tear trough implant• Restylane and other fillers

o Excellent for malar festoons & bags

• Fat transfer• Skin resurfacing

SOOFSOOF• Fat pad between orbicularis oculi & periosteum• Release arcus marginalis, lift fat, fixate SOOF to

periosteum at inferior orbital rim• Contour irregularities, vertical lid retraction

SiliconeSilicone

Fat transferFat transfer

For More InformationFor More Information

• Visit http://www.drhalaas.com/