"This material was prepared by resident physicians in partial fulfillment
of educational requirements established for the Postgraduate Training
Program of the UTMB Department of Otolaryngology/Head and Neck Surgery
and was not intended for clinical use in its present form. It was
prepared for the purpose of stimulating group discussion in a conference
setting. No warranties, either express or implied, are made with respect
to its accuracy, completeness, or timeliness. The material does not
necessarily reflect the current or past opinions of members of the UTMB
faculty and should not be used for purposes of diagnosis or treatment
without consulting appropriate literature sources and informed professional
SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: March 1, 1995
RESIDENT PHYSICIAN: Daniel P. Slaughter, M.D.
FACULTY: Karen H. Calhoun, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
- A. Skin
Thinnest skin in the body with minimal subcutaneous fat and excellent
- B. Orbicularis muscle
Divided into the palpebral and the orbital sections. The palpebral is
further divided into the pretarsal and preseptal areas. Pretarsal
portion attaches to the tarsus and to the lateral orbital tubercle
via the lateral canthal tendon.
- C. Subcutaneous fascia
Deep to orbicularis muscle with neural and vascular supply to lid
- D. Septum
Divides extraorbital contents from intraorbital contents. In upper
eyelid it attaches to levator at the superior edge of the
tarsus(western eyelid). In the lower eyelid it attaches to the
inferior edge of the tarsus. Laterally it blends with lateral canthal
tendon, medially extends from upper to lower lid.
- E. Orbital fat
Two compartments in the upper - medial and central
Three compartments in the lower - medial , central, and lateral
- F. Other structures
Levator muscle - primary lid elevator, CN III
Muller's muscle - originates from belly of levator and inserts on the
retrotarsal margin, sympathetic
Tarsal plate - fibrous plate that is 10 mm wide upper lid and
5mm wide in the lower lid in the central aspect. It tapers at the
medial and lateral margins.
Lid crease - line created by the insertion of levator aponeurosis and
orbital septum into the orbicularis, subcutaneous tissue and skin
Lid fold - tissue above lid crease that may prolapse over crease
- A.Impaired vision secondary to overhanging lid skin or brow ptosis
- B. Visual field defect
Superotemporal skin excess or large medial upper fat pad
- C. Asthenopia - sagging skin on to eyelashes causing frequent
blinking and eye fatigue
- D. Interference with optical correction secondary to bulging fat pads
contacting eye glasses
- E. Full thickness skin graft donor site
- A. Blepharochalasis - atony and relaxation of the lid skin which
becomes extremely thin and wrinkled. Etiology unknown, rare, usually
young women, generally poor surgical result
- B. Dermachalasis - relaxation and hypertrophy of the lid skin, the
fascial bands which connect the skin with the orbicularis muscle
become relaxed resulting in a flabby pouch (pseudoptosis). Secondary
to age and sun exposure.
- C. Pseudoherniation of intraorbital fat - secondary to thinning of
the orbital septum and orbicularis. Hereditary.
- D. Hypertrophy of the orbicularis muscle - secondary to blepharospasm
or excessive squinting
- E. Festoons - lower lid with marked thinning and redundancy of the
III. Contraindications (relative)
Proptosis, deep set eyes, dry eyes, coagulopathy, significant ocular
IV. Preoperative evaluation
- A. Complete H and P
- B. Thorough ophthalmologic exam - acuity, pressures, shirmer test,
EOM's, ptosis with scleral show, eyelashes, puncta, lid laxity
test(snap back test- if slowly snaps back or can easily be pulled 6mm
away from globe then must also perform a tightening procedure),
- C. Observe for other concomitant cosmetic deformities
- D. Generalized skin conditions ( acne, keloids )
- E. Document with photographs preoperative and postoperative
- F. Examine for realistic expectations
- G. Review anesthesia choices
V. Operative techniques
- A. Upper lid
Elliptical incision lower most aspect 7 - 12 mm from ciliary margin
in mid-pupillary line following superior border of tarsus.
Lateral edge is slanted upwards to avoid dog ear and tighten skin of
lateral canthus. A skin or skin muscle flap should be performed. One
should pinch the flap and ensure that no more than 1- 2mm of eyelid
opening occurs. Remove fat from medial and central fat pads while
taking care not to injure the superior oblique muscle which separates
them. Close with fine nylon suture. Variations include:
- the production of a supratarsal fold by directly sewing the levator
aponeurosis to the lower skin incision.
- Silver's technique involves the development of a flap after the lower
incision is made and then draping the excess skin over the incision
and excising this skin only.
- A Lewis interpolation is designed to remove excess skin in the
lateral canthus by connecting the upper and lower elipses with a Z
- Laser blepharoplasty performs all the steps with the laser. It's
advantage is decreased time and swelling.
- B. Lower lid
A skin or skin muscle flap with an incision 2 mm below the ciliary
margin or in the first natural crease. Extend laterally into a
natural crease. Applying gentle pressure to the globe after the
septum has been incised allows for better identification of the
orbital fat. Absolute hemostasis is necessary. Care must be taken to
avoid excess fat removal laterally to avoid a hollow appearance.
Remove half of the skin you feel would remove all the excess to avoid
ectropion. Close with fine suture.
- Hypertrophy of the orbicularis oculi muscle. Can excise or imbricate
- Festoons can trim muscle and suture to soft tissue or periosteum.
Senile lids with marked skin excess but little fat herniation. Excise
greater amount of skin and consider temporary tarsorrhaphy postop to
allow skin to readhere to the muscle. Silver's technique as in upper
- Transconjuctival approach - advantages include decreased edema and no
scar. Incidence of ectropion, scleral show, and epiphora is also
lower. Unable to excise excess skin. May perform preseptal or
- Lower lid tightening procedures may also be necessary. They should be
tailored to the site of laxity (medial or lateral)
Cool compresses, close observation to rule out hematoma, HOB
elevated, bacitracin. Suture removal in approximately 3-4 days.
Makeup in 1 week.
- A. Dissatisfied patient
- B. Dry eye syndrome - patients with inferior scleral show,
exophthalmos, proptosis, sagging lower lid, abnormal shirmer's test,
excessive skin removal, iatrogenic injury to lacrimal sac. Treat with
corneal lubrication and observation initially.
- C. Epiphora - Common postop for the first few days secondary to
swelling. Remember that the lower canaliculus is responsible for 85%
of the drainage and that no dissection medial to the puncta should be
performed. Excessive skin and muscle excision can also result in
eversion of the punctum. Treat with observation initially.
- D. Corneal injury - BE CAREFUL to protect cornea during all aspects
of the surgery. POSTOPERATIVE PAIN THAT IS PERSISTENT MUST BE
EVALUATED WITH FLUORESCEIN STAIN TO RULE OUT CORNEAL ABRASION.
- E. Subcutaneous or submuscular hematoma - allow liquification and
attempt needle aspiration. Early steroid injections may also help
reduce scar formation.
- F. Retrobulbar hematoma - look for signs of hard, proptotic eye.
Decrease visual acuity is a late sign. Begin mannitol, cold compress,
perform lateral canthotomy, open incision.
- G. Blindness - etiology unknown. Felt to primarily be related to
retrobulbar hematoma with pressure on the central retinal vessels
- H. Enophthalmos - beware in patients with prominent infraorbital bony
margin of excessive fat removal.
- I. Ptosis - damage to levator aponeurosis. Must repair primarily.
- J. Infections - rare. Treat as usual.
- K. Skin loss - exceptionally rare because of excellent blood supply
- L. EOM muscle imbalance - Inferior oblique is vulnerable between
medial and middle fat pads of inferior bleph (especially
transconjunctival). Most smaller injuries will resolve on their own
in time. If imbalance exists after 6 months then surgical correction
- M. Ectropion - Must take all precautions listed above in preoperative
and operative steps.
- N. Lagophthalmos - may be normal in early postoperative period.
Permanent if excised to much skin. May require FTSG.