Eye shape and contour are important determinants of appearance.

Over the past two decades cosmetic surgery has become increasingly popular, with blepharoplasty being one of the more commonly performed procedures.

This procedure can be very rewarding for both the patient and physician.



Blepharoplasty requires a good understanding of the normal superficial anatomy as well as sexual and racial variations. The normal eyebrow position in a female is above the supraorbital rim with the highest point at the lateral edge of the limbus. The upper eyelid margin should be between the pupil and the limbus, and the lower eyelid margin should be within 1 mm of the lower margin of limbus. The normal palpebral space is 5 mm to 10 mm, varying with the position of the eyelids. The upper eyelid crease is about 10 mm to 12 mm above the lid margin at the tarsal plates upper edge. There should be an area of smooth pretarsal tissue between the lid crease and lid margin. Without this the eye has a heavy, sleepy appearance. This is especially important in women since this is the area where makeup is applied.
The normal male anatomy is different. The male supraorbital rim and glabella are more prominent and the eyebrows are lower and straighter, lying over the supraorbital rim. The eyelid crease is closer to the eyelid margin, about 6 mm to 8 mm above the eyelid margin. The eyelid fold may cover some of the pretarsal tissue.

The upper and lower eyelids have similar structures. Beginning externally, the skin is usually very fine and delicate. Beneath the skin is the orbicularis oculi which is divided into the orbital, preseptal, and pretarsal components. Deep to the orbicularis is the orbital septum and the tarsal plates. The orbital septum extends from the periosteum to the tarsal plate. The tarsal plate is about 10 mm wide in the upper eyelid but only about 5 mm in the lower eyelid. In the upper eyelid the levator aponeurosis inserts into the orbital septum and the tarsal plate, creating the upper eyelid crease. In Orientals this insertion is less well-formed resulting in an upper eyelid crease which is lower and an overhanging upper eyelid fold.

Orbital fat lies deep to the orbital septum and superficial to the extraocular muscles. It is divided into different compartments in the upper and lower eyelids. The upper eyelid has a medial and central compartment; the lower lid has three compartments: the medial, central and temporal. The upper fat compartments are separated by the superior oblique. The lower fat compartments are separated by the inferior oblique medially and the arcuate expanse of the inferior oblique laterally. The fat is lobulated and contains fibrous septae with blood vessels and nerves. The fat in the upper medial compartment is denser and whiter than the yellowish fat that is found in the other compartments.
Several basic terms are used in blepharoplasty.

Blepharochalasis is an uncommon disorder characterized by repeated episodes of nonpainful eyelid edema. The edema is nonpitting and is relatively refractory to antihistamines and corticosteroids. Over time this leads to weakening of the periorbital tissues and causes redundant upper eyelids, blepharoptosis, and baggy lower eyelids. It is a disease of young people with the onset of symptoms occurring before the age of 20 in more than 80% of cases.

Dermatochalasis is characterized by excess eyelid skin and variable amounts of fat herniation and prolapse. These changes occur from middle age onwards and are characteristic of normal aging. There is also a familial tendency.

Herniated orbital fat results from orbital fat pushing against an attenuated orbital septum. This does not a result from too much fat but from weakness of the orbital septum. This is more common in the lower eyelids and there is familial tendency.

Blepharoptosis is drooping of the upper eyelid, resulting from dehiscence of the levator aponeurosis caused by aging or surgical manipulation. Neuromuscular problems such as myasthenia gravis or Horners syndrome are other causes that must be ruled out.

Orbicularis oculi muscle hypertrophy can be manifested by a ridge of bulging muscle and is more common in the younger patient. Elderly people may develop large bags of redundant skin and muscle called festoons.

Crows feet are the lateral, canthal skin rhytids and are not corrected by traditional blepharoplasty.

Medical history should focus on systemic disorders that may affect the procedure and on the eye itself. Eye symptoms such as dry eye, visual complaints, diplopia and motility problems should be pursued. The symptoms of dry eye include irritability, epiphora, excessive blinking, or a gritty feeling in the eye. These patients have difficulty wearing contact lenses and difficulty when flying. The patients general medical history should be thoroughly evaluated, including allergies, medications, medical problems, past surgical history, and social history. It is important to identify any medications that may affect coagulation, with particular emphasis placed on aspirin and anti-inflammatory agents. Each patient must be questioned for any history of hypertension, bleeding, easy bruisability, compromised renal or liver function, diabetes, or thyroid disease. Thyroid disease is especially important because of proptosis and tissue changes in the eyelids.

Relative contraindications for blepharoplasty are proptosis, dry eye syndrome, unilateral blindness, thyroid disease, coagulation disorders, and uncontrolled hypertension.
Aesthetic assessment should be systematic, and racial, cultural, and sexual differences must be considered. A general assessment of the face considering the relationship of the eyes to the other facial structures should be made. The eyebrows should be examined next, followed by the upper eyelids and then the lower lids. It is important to test the lower eyelid for laxity by the snap back test. Patients with lax lower eyelids are at high risk of ectropion.
A thorough ophthalmologic exam is necessary, beginning with visual acuity, which may be determined with an eye chart. Visual fields should be tested to detect any field defects. Pupillary function and extraocular motility are tested. A fundoscopic exam should be performed. It is very important to assess tear function although the best method of testing is controversial. The cornea and eye can be examined for tear film using a slit lamp. Excessive blinking may indicate a dry eye with the normal person blinking every 6 seconds. The Schirmers test has been used to test tear production, but the utility of this test have been questioned by several authors. Any history of eye disease or abnormality on the eye exam can necessitate an ophthalmology consultation prior to blepharoplasty.

All patients should have adequate photographic documentation before blepharoplasty. Typically, this consists of five views made with the camera at the same height as the patients eyes and a level Frankfort plane. The image should include the major part of the forehead, both ears, and the lower edge of the upper lip. The five standard views are three frontal views and right and left lateral views. The frontal views should be taken with the patient looking directly at the lens, looking upward, and with eyes closed. Patients should be instructed to relax their brows since they will often try to lift them in order to see better.