Rejuvenation of the Upper Eyelid Sachin Parikh, MD, Sam P. Most, MD* KEYWORDS Upper eyelid Blepharoplasty Eyelid rejuvenation The eyes are the most captivating feature of the to avoid a deep, hollow, and skeletonized face. Furthermore, attractive eyes are an important appearance to the eyelids. feature of the youthful face. Although attention is drawn to the eyes, the surrounding structures EYELID ANATOMY that frame the eye are key contributors to facial beauty. The frame of the eye extends down to The position and form of the eyebrow has a deep the lower eyelid-cheek junction and up to the impact on the appearance of the upper eyelid upper eyelid–brow unit. Thus, the periocular region and eye below. A precise analysis of eyebrow is a complex that should be broadly defined to position and form is a critical first step in the eval- include the eyebrow and midface. It is a surgeon’s uation of the upper eyelids, a full analysis of which job to carefully analyze the underlying anatomy to is beyond the scope of this article. A few salient determine the surgical approach to achieve the points are discussed. The female brow is arched best aesthetic result. with the most superior aspect of the brow posi- The youthful upper eyelid is full, not hollow or tioned directly above the lateral limbus. Laterally overskeletonized. There is a crisp upper lid crease the brow sits above the orbital rim, and centrally with elastic support of the underlying soft tissue, there should be a high arch with a deep superior creating a smooth, taut pretarsal and preseptal sulcus. The ideal position of the female brow upper eyelid. The eyebrow is often addressed in differs from that of the male brow. The male conjunction with the upper eyelid in upper face brow is relatively straight, lying at the level of the rejuvenation. This article focuses solely on surgical orbital rim, and runs perpendicular to the nose rejuvenation of the upper eyelid. The goal of reju- with a minimal sulcus and a low subtle lid crease venation of the upper eyelid should be a more 8 mm above the lash line.4 youthful but natural-appearing result. Fig. 1 depicts many anatomic relationships that Upper eyelid surgery is the most requested must be understood when evaluating the eyelid and performed facial rejuvenation surgery in the and assessing what needs to be addressed to United States.1 The excision of the eyelids dates restore youthfulness. The lateral canthus is typi- back 2000 years. The cauterization of excess cally 2 to 4 mm superior to the medial canthus. eyelid skin to reduce drooping is described in The adult palpebral fissure averages 10 to 12 the Sanskrit document, the Sushruta.2 American mm vertically and 28 to 30 mm horizontally. The surgeons began to write about cosmetic surgery distance from the lateral canthus to the orbital in 1907, with Conrad Miller’s Cosmetic Surgery rim is typically 5 mm. At rest, the upper eyelid and the Correction of Feature Imperfections.3 covers the superior limbus by 1 to 2 mm. The high- Over the subsequent decades, surgeons advo- est point of the upper lid margin is just nasal to cated the removal of herniated fat pads and orbi- a vertical line drawn through the center of the cularis oculi muscle excision. Over the past 20 pupil. This contour should be noted preoperatively years, the emphasis on technique has shifted when evaluating patients for rejuvenation of the to conservation of fat, skin and muscle excision upper eyelid so it can be addressed during surgery Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology/Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305, USA * Corresponding author. E-mail address: [email protected] Facial Plast Surg Clin N Am 18 (2010) 427–433 doi:10.1016/j.fsc.2010.04.005 1064-7406/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved. facialplastic.theclinics.com 428 Parikh & Most Fig. 2. Orbicularis oculi muscle. The muscle is tradi- tionally divided into orbital and palpebral portions. The orbital portion arises from the anterior aspect of the medial canthal tendon and the periosteum above and below it. The palpebral portion is further subdi- Fig. 1. Topography of the eyelid. (A) The highest vided into pretarsal and preseptal portions, each lying point of the brow is at, or lateral to, the lateral over the tarsal plate or orbital septum, respectively. limbus. (B) The inferior edge of the brow is typically (From Most SP, Mobley SR, Larrabee WF Jr. 10 mm superior to the supraorbital rim. (C) Also Anatomy of the eyelids. Facial Plast Surg Clin North shown are ranges for average palpebral height (10– Am 2005;13:487–92; Elsevier; with permission.) 12 mm), width (28–30 mm), (D) and upper lid fold (8–11 mm, with gender and racial differences). Note that the lateral canthus is 2 to 4 mm higher than the medial canthus. (E) Intrapalpebral distance measures surgeons must protect the trochlea to avoid supe- 6 10 to 12 mm. E1, mean reflex distance 1; E2, mean rior oblique palsy or Brown syndrome. The medial reflex distance 2. (F) Palpebral width. (G) Upper lid fat pad is paler and denser and recognition of fold is 8 to 11 mm. (From Most SP, Mobley SR, these subtle differences is crucial for successful Larrabee WF Jr. Anatomy of the eyelids [review]. Facial blepharoplasty with fat excision. The lacrimal Plast Surg Clin North Am 2005;13:487–92; Elsevier; gland occupies the lateral compartment. The with permission.) retro-orbicularis oculi fat (ROOF) pad is a submus- cular fat pad that sits deep to the interdigitation of the frontalis and orbicularis oculi muscles (Fig. 3).4 to create a more aesthetic and appropriate lid position. The upper lid crease lies 8 to 11 mm AGING OF THE EYES above the lash line in whites but this varies with ethnic background. In Asians, the upper lid crease The appearance of the upper eyelid may be may be lower or absent owing to the lower inser- affected by changes in the eyebrow position. tion of the septum and variable or absent insertion Lateral ptosis of the eyebrow may add to fullness of the levator aponeurosis into the upper lid skin. of the upper eyelid compounding the effect of The layers of the upper eyelid can be separated the existing skin redundancy. In severe cases, into an anterior lamella and a posterior lamella. The this may cause visual field loss. The hallmarks of anterior lamella is comprised of the thinnest skin of upper eyelid facial aging are lateral hooding, der- the human body and the orbicularis oculi muscle. matochalasis, and fat pseudoherniation in the The posterior lamella is comprised of the levator medial aspect of the upper eyelids. The upper aponeurosis, tarsus, Mu¨ ller muscle, and conjucti- eyelids become more redundant due to excess va.5 Deep to the skin lies the orbicularis oculi eyelid skin and eyebrow descent.7 Rejuvenation muscle, which can be divided into an orbital of the upper eyelid is intended to elevate ptotic portion and a palpebral portion. The palpebral tissues and remove any tissue redundancy. portion is further subdivided into a pretarsal and As a person ages, the loss of volume in the entire preseptal portion lying over the tarsal plate and frontal region and loss of skin elasticity in the orbital septum, respectively (Fig. 2). temporal region may account for brow ptosis, for The postseptal fat of the superior orbit is divided those in whom this occurs. The tendency to coun- into 2 compartments: the central (or preaponeur- teract this by raising the eyebrows causes an otic) and the medial (or nasal) fat pads separated accentuation of the hollowness under the eyes.8 by the trochlea and fascial strands from the Whit- This also leads to a decrease in the lateral fullness nall ligament.4 During upper eyelid surgery, of the upper eyelid. When the frontalis is relaxed, Rejuvenation of the Upper Eyelid 429 Fig. 4. The aging upper eyelid. Weakening of the orbital septum is thought to cause herniation of orbital fat in the upper and lower lids. (From From Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. Facial Plast Surg Clin North Am 2005;13:487–92; Elsevier; with permission.) Fig. 3. Cross-sectional anatomy of the upper and lower lids. The capsulopalpebral fascia and inferior evaluation of the general medical history, tarsal muscle are retractors of the lower lid whereas ophthalmologic history, and psychological moti- Mu¨ ller muscle and the levator muscle and its aponeu- vations of a patient. Medical history should rosis are retractors of the upper lid. Note the preseptal include a history of chronic illnesses, hyperten- positioning of the ROOF and suborbicularis oculi fat sion, diabetes, bleeding disorders, and any anti- (SOOF). The orbitomalar ligament arises from the ar- coagulant medications. Key points in the history cus marginalis of the inferior orbital rim and inserts on skin of the lower lid, forming the nasojugal fold. include any previous ophthalmologic procedures, (From Most SP, Mobley SR, Larrabee WF Jr. Anatomy history of thyroid eye disease, previous facial of the eyelids. Facial Plast Surg Clin North Am trauma, recent botulinm toxin type A treatments, 2005;13:487–92; Elsevier; with permission.) and a history of dry eyes. Dry eye syndrome can be associated with medical systemic diseases, such as Sjo¨ gren syndrome, collagen vascular the redundant skin hangs lower, and the distance diseases, Wegener granulomatosis, and Ste- between the eyebrow and eyelashes is shortened.