Current Concepts in Aesthetic Upper Blepharoplasty

Transcription

1 CME Current Concepts in Aesthetic Upper Blepharoplasty Rod J. Rohrich, M.D., Dana M. Coberly, M.D., Steven Fagien, M.D., and James M. Stuzin, M.D. Dallas, Texas; and Boca Raton and Coconut Grove, Fla. Learning Objectives: After studying this article, the participant should be able to: 1. Discuss nomenclature and anatomy associated with upper blepharoplasty. 2. Perform preoperative assessment, decision-making, and counseling of patients. 3. Describe current surgical planning, eyelid marking, and various techniques used in upper blepharoplasty, including lasers. 4. Recognize and treat postoperative complications from blepharoplasty. Traditional blepharoplasty has often involved the excision of both lax skin and muscle and excessive removal of fat, leaving patients long term with a hollow orbit and a harsh, operated appearance that accelerates the aging process. Current methods of periorbital rejuvenation are more conservative, are based on concise preoperative evaluation, and involve the limited resection of the coveted soft tissue from the eye to restore a youthful appearance. The authors describe anatomy, preoperative assessment, decision-making and counseling of patients, surgical planning, eyelid marking, and various techniques, including lasers, along with postoperative complications associated with current concepts in aesthetic upper blepharoplasty. (Plast. Reconstr. Surg. 113: 32e, 2004.) The eyes, or more precisely, periorbital tissues, are paramount in facial beauty, exhibiting youth and a plethora of expressions. Unfortunately, this area is also one of the first to show aging from the effects of gravity, ultraviolet radiation, and animation. Traditional blepharoplasty has involved the excision of lax skin and muscle and the removal of fat, sometimes leaving patients long term with a hollow orbit and harsh, operated appearance and often accelerating the aging process. Current methods of periorbital rejuvenation are more conservative in the resection of coveted soft tissue from the eye. This is consistent with other areas of the face where precious soft tissue is shaped, not necessarily removed. The ideal youthful appearance can be seen in models and movie stars by studying the appearance of their eyes. Beautiful young eyelids are full, not hollow, with a crisp tarsal upper lid crease and elastic support of the underlying soft tissue, creating a smooth, taut pretarsal and preseptal upper eyelid (Fig. 1). The pretarsal eyelid show is often only 2 to 3 mm in the aesthetically attractive eye. Periorbital skin is smooth with no rhytids or redundant folds. The eyebrows must always be addressed in the evaluation of the eyelid for proper restoration of a youthful and functional eye. HISTORICAL PERSPECTIVE Eyelid surgery was described in an Indian document, the Susruta, more than 2000 years ago. Arabian surgeons cauterized excess eyelid skin to relieve drooping in the tenth and eleventh centuries. 1 Avicenna (980 to 1037) performed the first recorded blepharoplasty, excising excess upper eyelid skin. Paré 2 described the functional correction of excess eyelid skin in the sixteenth century. In the 1830s several authors discussed the resection of redundant eyelid skin. 3 5 Sichel, 6 in 1844, described herniated intraorbital fat. Bourguet 7 reported separate fat compartments in the eyelids and his technique for excising excess fat through a transconjunctival approach to prevent scarring. The modern blepharoplasty and detailed anatomy of the orbital fat compartments were described by Costañares in Loeb 9 and Furnas 10 described removing redundant muscle in the late 1970s. These techniques focused From the University of Texas Southwestern Medical Center. Received for publication May 24, 2002; revised November 13, DOI: /01.PRS e

2 Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY FIG. 1. Periorbital volume depletion with aging. Adapted from Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, on resection of redundant tissue, and only recently have authors gained an appreciation for the conservative resection of periorbital fat Deep or hollow upper eyelid sulci are common results of the modern blepharoplasty, presumably from overresection of soft tissue. 14 This is especially true in patients with a prominent globe or negative upper periorbital vector. Siegel 15 believes that the height of the fold should be determined by the balance of motors the levator versus the orbicularis. If the levator is weak, a slightly lower fold should be chosen. ANATOMICAL CONSIDERATIONS The upper eyelid can be divided into tarsal and orbital portions at the level of the supratarsal fold. In Caucasians, it is located approximately 8 to 10 mm from the palpebral margin and results from a fusion of the levator aponeurosis, orbital septum, and fascia of the orbicularis oculi into the dermis. In the tarsal portion, these layers insert onto the anterior surface of tarsus. This area degenerates with age, which may lead to a high fold, with or without upper lid ptosis, and/or skin laxity of the lid. Loss of crease attachments may cause the skin to rest toward or beyond the upper eyelid/lash margin, with a tendency to interfere with upper outer visual fields. 14 In the Asian eyelid, the orbital septum inserts more inferiorly onto the distal expansion on the levator aponeurosis, which allows more preaponeurotic fat to reside lower on the upper eyelid. This results in a lower or absent eyelid crease. 16 Siegel reported that the levator aponeurosis in Caucasians joins a network of fascia in the upper lid rather than the dermis. 17 He believes the major difference between Caucasian and Asian eyelids is the level at which the fascia fuses to create the fold. The layers of fascia are infiltrated with fat in Asians. 18 The two main compartments of orbital fat are found posterior to the orbital septum. They are the nasal or medial (orbital) and temporal or lateral (preaponeurotic) compartments, which are separated by the superior oblique muscle. The medial fat is usually pale yellow or white, and the lateral fat is yellow. Histologically, the differences are in a greater amount of connective tissue and blood vessels in the medial fat; the lateral fat has a greater amount of carotenoids. 19 Preseptal retroorbicularis fat is located between the orbital septum and the orbicularis. It is often a significant factor in lateral lid hooding and puffiness. Subcutaneous fat may be present between the orbicularis and the skin immediately beneath the eyebrow and also contributes to full upper eyelids. 20,21 The motor nerve supply to the upper eyelids is from the buccal, zygomatic, and frontal branches of the facial nerve. Multiple intercommunications among facial nerve branches result in an extensive nerve supply to all peripheral areas of the orbicularis. 22 Studies in monkeys showed that resection of preseptal and supraorbital orbicularis oculi muscle or pretarsal muscle only did not result in lagophthalmos, but resection of all three components did. 23 During sleep there is a persistent tone of the orbicularis to keep the eyes closed. If the motor nerves are blocked, the upper lid will open. CLINICAL EVALUATION 33e The surgical approach must take into consideration the repositioning of underlying soft tissue and the redraping of skin. These tissues lose elasticity and support with aging, a condition termed dermatochalasis in the skin. Blepharochalasis is a recurrent, intermittent, inflammatory condition of the eyelids resulting in edema, erythema, and thin excess eyelid skin secondary to histamine response and re-

3 34e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004 lated to increased immunoglobulin E. In contrast to dermatochalasis, blepharochalasis is difficult to correct and likely to recur. In the older population, a fold of excess upper eyelid skin can impair the function of the eye, specifically by obstruction of visual fields. A preoperative workup may include a consultation with an ophthalmologist for documentation of visual field impairment to determine whether the obstruction is of visual significance (so that its correction is medically necessary) to qualify patients for potential insurance benefits. Evaluation of the upper eyelid must include an evaluation of the eyebrow. 24 Brow ptosis should be corrected to achieve repositioning of heavy eyebrow skin, which may be compensated by frontalis contraction to keep the eyebrows above the orbital rim. Aging causes the eyebrow fat to descend over the upper lid, giving it a full appearance. Once the visual obstruction has been removed by eyelid skin resection, the brows may look even heavier since elevation is no longer needed for the visual field. This results in a more aged appearance If this tissue is resected rather than resuspended, an overexposure of underlying tissues may result, giving a hollow appearance. 14,28 Medical and ophthalmologic histories must be obtained from the patient, including any history of chronic illness, hypertension, diabetes, cardiac disease, bleeding disorders, thyroid disturbances, or surgery. Medications, including aspirin and other anticoagulants, are listed and withheld for at least 2 weeks preoperatively. Patients must be specifically questioned concerning dietary supplements that may also affect clotting 29 as well as concerning their vision, corrective lenses, previous surgery or trauma, glaucoma, allergic reactions, excess tearing, and dry eyes. 30 A Schirmer test should be conducted if the patient has dry eyes or occasional symptoms, and referral to an ophthalmologist is recommended PREOPERATIVE MARKINGS Preoperative markings are critical to assess and are made with the patient sitting upright and in neutral gaze. The brow needs to be elevated to the proper position before any marks are made. The supratarsal fold is located at approximately 8 to 9 mm above the ciliary margin in women and at 7 to 8 mm in men. A mark should be made just inferior to this fold (Fig. 2). The upper marking must be at least 10 FIG. 2. The planned surgical incision is located 2 to 3 mm below the apparent supratarsal fold. Adapted from Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, mm from the lower edge of the brow and not include any thick brow skin. The use of a pinch test for redraping the skin is helpful. 14 The shape of the skin resection is lenticular in younger patients and more trapezoid-shaped laterally in older patients (Fig. 3). The index of safety is much higher laterally (one can remove more skin) and becomes more critical as the incision proceeds medially (Figs. 4 and 5). The incision may need to be extended laterally with a larger excision, but extension lateral to the orbital rim should be avoided if possible to prevent a prominent scar, especially in male patients and patients with thick skin. Similarly, the medial markings should not be extended medial to the medial canthus for larger resections because extensions onto the nasal sidewall result in webbing. If excessive skin is present medially, a W-plasty may need to be performed. The amount of fat to be resected should be determined preoperatively, with the patient in up-gaze, down-gaze, and medial and lateral ranges of motion, with photographic documentation. SURGICAL TECHNIQUE Subcutaneous injection with 3 cc of 1% lidocaine with 1:100,000 epinephrine using a 27- gauge, inch needle 7 minutes before operative scrub preparation will allow time for maximum vasoconstriction. Hyaluronidase has been added to the local anesthetic for more rapid and even spreading of local anesthesia, but diplopia and pupillary dilatation can occur secondary to posterior spread of lidocaine. 28 The local anesthetic should be injected superficially to avoid any subcutaneous or intraorbicularis hematoma formation. Incisions are made superficially with a fresh no. 15 blade through the epidermis only, and the pre-

4 Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY 35e white fat; this fat is usually preserved to avoid volume depletion of the upper periorbita that can manifest as notches or depressions in this region (Fig. 9). Once fat resection is completed, a lower lid lateral canthopexy may be performed through the upper blepharoplasty incision (Figs. 10 and 11). An incision is made laterally to expose the lateral orbital rim. A 5-0 Vicryl suture is placed through the anterior lamella of the lateral canthus and secured to periosteum on the inside of the lateral orbital rim at the level of the upper limbus. It is important to place this suture inside the rim and posteriorly to avoid tenting the lower lid over the eye. This lift will be subtle and will resolve over time while preventing ectropion in the postoperative course. Once hemostasis is obtained, any final adjustments concerning shape are made, especially laterally, to maximize the appearance of bilateral eyelid symmetry. The incision is closed FIG. 3. Upper eyelid skin resection increases in size both vertically and laterally as the periorbital area ages: young (above), middle age (center), and old (below). Adapted from Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, marked strip of skin is resected with fine curved scissors (Fig. 6). If redundant orbicularis muscle is present, this resection can include the predetermined amount of orbicularis muscle to be resected. This can also be used to define the supratarsal fold. Hemostasis is obtained using pinpoint insulated cautery (Colorado microdissection needle, Stryker- Leibinger, Inc., Kalamazoo, Mich.). A small incision is made into each fat compartment of the eyelid in which resection of redundant fat has been planned. The fat is teased out and resected using pinpoint cautery (Fig. 7). This fat usually includes the medial or nasal compartment, which contains white fat (Fig. 8). Yellow fat can also be found in this area but it is usually more superficial and lateral to the FIG. 4. Surgical markings in a lenticular shape. Adapted from Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, FIG. 5. Preoperative markings.

5 36e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004 LASER BLEPHAROPLASTY Laser blepharoplasty was first described in 1984 by Baker et al. 34 Incisions may be made with a scalpel or with a laser. The 1997 American Society for Aesthetic Plastic Surgery/ American Society of Plastic and Reconstructive FIG. 8. White fat resection, medial compartment (only if indicated). Necessity is determined preoperatively by a physical examination. FIG. 6. Skin resection. (Above) During resection. (Below) Resection completed. FIG. 9. Amount of fat to be resected is determined preoperatively. FIG. 7. Yellow fat resection, medial compartment (only if indicated). Necessity is determined preoperatively by a physical examination. using a running subcutaneous 6-0 Prolene suture followed by interrupted simple 6-0 nylon sutures. At the conclusion of the case, the patient should have approximately 2 to 3 mm of lagophthalmos bilaterally (Fig. 12). Sutures should be placed 1 mm into skin over an intact orbicularis, allowing the muscle to fold on itself in a pleated fashion with skin closure (Fig. 13). 14 FIG. 10. Intraoperative view of a lower lid canthopexy performed through the upper lid incision. Adapted from Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, 2002.

6 Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY FIG. 11. Illustration demonstrating suture placement. Adapted from Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, e when compared with electrocautery, resulting in better scars and decreased postoperative edema and ecchymosis. 12 Safety issues include eye protection for the patient with stainless steel eye shields and for the operative team with protective goggles. 35 In our experience, laser use does not have a significant advantage and is used infrequently. Before the initial incision is made, it must be decided whether laser resurfacing is to be performed. This results in at least 4 to 6 mm of upper lid shortening, so skin resection must be adjusted accordingly. Cutting of the skin should be performed in the ultrapulse mode. Dissection is then performed in the continuous mode for more coagulation. Conservative fat resection may also be performed using the laser. Once the incision is closed, the carbon dioxide laser, alone or in combination with the erbium:yttrium-aluminum-garnet laser, may be used for resurfacing. 36 Eye shields are placed to protect the eyes, and eyelids need to be reflected with a wet cotton-tipped applicator. The skin is covered postoperatively with a semipermeable dressing to maintain moisture and minimize pain. 37 Seckel et al. 38 use the carbon dioxide laser directly on the orbicularis muscle to cause visible shrinking of the muscle and septum. MALE BLEPHAROPLASTY In the United States, 16 percent of blepharoplasties are performed on men, and blepharoplasty is the second most common cosmetic surgery performed on male patients. 39 Men FIG. 12. Closure of incisions: (above) a 6-0 Prolene running subcuticular suture; (below) 6-0 nylon interrupted simple sutures. Approximately 2 mm of lagophthalmos is noted at the completion of the procedure. Surgeons Laser Task Force Survey found that 84 percent of respondents performed laser blepharoplasty. A median time of 3 hours of hands-on training with the technique was received before it was incorporated into their practice. Disadvantages of the laser technique include the potential for poor wound healing, loss of tactile (sensation) feedback, time spent learning, and expense. Possible advantages include decreased bleeding, less time spent obtaining hemostasis, and less tissue damage FIG. 13. Sutures should be placed 1 mm into skin over an intact orbicularis, allowing the muscle to fold on itself (left) in a pleated fashion with skin closure (right). Adapted from Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, 2002.

7 38e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004 tend to seek out blepharoplasty more for functional reasons than women, but this difference has become less and less distinct in recent years. A more natural look is preferred, and the operated look will not be tolerated well by most male patients. Men will typically not be wearing cosmetics, so all scars must be carefully concealed. This also makes male patients suboptimal candidates for laser resurfacing. The lateral incision should only infrequently be extended beyond the later orbital rim. In men with heavy brows, resection of upper eyelid skin only will result in profoundly ptotic brows. Therefore, one should counsel combined brow surgery with upper blepharoplasty. Many men are reluctant to have cosmetic surgery to correct brow ptosis, so careful preoperative counseling is needed to prevent a dissatisfied patient with worse brow ptosis postoperatively. 40 Often, conservative eyelid resection is all that is required. POSTOPERATIVE MANAGEMENT Postoperative care should include a chilled light gel compress (Swiss Eye Therapy, Invotec International, Jacksonville, Fla.) for 48 hours, saline eye drops (Refresh Plus, Allergan Inc., Irvine, Calif.) while the patient is awake, and lubricating ointment (Refresh P.M., Allergan) for night use. Tobramycin ophthalmic drops may be used prophylactically in the early postoperative period, typically three times per day for 3 to 5 days. The patient s head should remain elevated to reduce edema and ophthalmic pressure. The patient is seen in the recovery room to evaluate and document vision before discharge and followed up 4 to 5 days postoperatively, when all sutures are removed. Lagophthalmos is usually secondary to periorbital edema and resolves in 1 to 2 weeks. Preoperative and postoperative patient education on the use of eye drops and ointment, especially at night, is essential to prevent corneal abrasions and exposure problems. COMPLICATIONS Vision loss due to retrobulbar hematoma is the most feared complication resulting from blepharoplasty; fortunately, the occurrence is rare. The incidence is reportedly 0.04 percent, or one in 2500 cases. 41,42 Acute retrobulbar hematoma may compress neurovascular structures, leading to ischemia of the retina, central artery, and optic nerve. Symptoms include severe pain, visual changes, including hemianopsia or amaurosis fugax (like a window shade over the lower half of the visual field), and scintillating scotomas (sparkles and flashes) (Fig. 14). Examination will often reveal a tense and protuberant periorbital area with diminished or absent extraocular movements. Once the diagnosis is made, treatment should be implemented immediately because 90 to 120 minutes of ischemia leads to irreversible blindness. Wolfort et al. 43 reviewed the diagnosis and treatment of retrobulbar hematoma. All dressings should be removed and sutures need to be released. An ophthalmologic consultation should be obtained immediately. The patient should be given mannitol 20% 1.5 to 2 g/kg intravenously (with the first 12.5 g over a 3-minute period and the remainder over a 30- minute period), 500 mg of Diamox (acetazolamide; Lederle Pharmaceutical Division, American Cyanamid Company, Pearl River, N.Y.) intravenously, 95 percent oxygen/5 percent carbon dioxide to dilate intraocular vessels, Solu-Medrol (Pharmacia & Upjohn, New York, N.Y.) 100 mg intravenously, and Betoptic (Allen USA, Fort Worth, Texas), one drop immediately, then twice daily. These actions should be taken as the patient is being taken back to the operating room for reexploration and evacuation of hematoma, as well as possible lateral canthotomy and release of the arcus marginalis. Vision loss can also result from globe perforation 44 during infiltration with local anesthetic. This is extremely rare and, along with corneal abrasion, can be prevented with corneal protectors. Superficial hematomas usually result from orbicularis muscle vessel bleeding and do not threaten vision. When small, they can usually be allowed to resolve spontaneously. If larger, they can be evacuated after liquefaction occurs 7 to 10 days later. 45 Careful control of blood pressure, use of ice, and elevation of the head help to prevent hematoma and ecchymosis. Diplopia may result from impaired ocular motility, more commonly in lower blepharoplasty from involvement of the inferior oblique but also from upper lid surgery from the vertical recti and superior oblique. The etiology is postulated to be from edema or stretch resulting in perimuscular hemorrhage. Conservative management is recommended since the diplopia will often resolve as the edema and inflammation subside. 46,47 Lagophthalmos may result from edema or

8 Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY 39e FIG. 14. Algorithm for retrobulbar hematoma diagnosis and treatment. excessive skin resection, but is usually managed conservatively with patient reassurance, light massage, taping, and proper nocturnal lubrication. Studies show no change in blink dynamics following blepharoplasty. 48 Cellulitis is extremely rare in this highly vascular area, but it can be treated with topical and/or systemic antibiotics. If a fluid collection is present, it should be drained. 49 Postblepharoplasty ptosis is a common finding in the recovery room and for several hours following the procedure, due to the effect of local anesthesia on the levator. Ptosis that develops in the postoperative period is an uncommon com-

9 40e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004 FIG. 15. Upper blepharoplasty using selective skin resection only with orbicularis preservation. No fat removal was performed. Lower blepharoplasty was also performed. (Left) Preoperative and (right) 2-year postoperative views. FIG. 16. Upper blepharoplasty using selective skin resection, orbicularis preservation, and central fad pad removal. Endoscopic brow lift, laser resurfacing, and lower blepharoplasty were also performed, with no lower lid skin resection. (Left) Preoperative and (right) 15-month postoperative views. FIG. 17. Selective skin resection only, with orbicularis preservation and central fat pad removal. Levator advancement and lowering of the supratarsal fold for correction of levator dehiscence. (Left) Preoperative and (right) 13-month postoperative views. plication of blepharoplasty that should be evaluated thoroughly to determine the cause. Lid asymmetry that persists after surgery or develops postoperatively should be evaluated to determine the degree of ptosis and the amount of levator function. Ptosis can be secondary to edema, operative technique, or injury to the levator complex. Severe ptosis with poor levator function requires reexploration with levator repair. Mild cases may resolve spontaneously and can be managed expectantly. 50 CONCLUSIONS Blepharoplasty is a highly successful aesthetic surgical procedure that requires careful preoperative planning and examination of the patient s concerns and desires (Figs. 15, 16, and 17). Standard resections of fat and muscle have been replaced with conservative and careful resections of only redundant soft tissue. Ptotic soft tissues are relocated rather than resected. The eyelid must always be considered in conjunction with the eyebrow, and correction of periorbital aging may require brow repositioning as well. Careful perioperative technique, meticulous hemostasis, and attentive postoperative management of blood pressure will prevent most complications. Rod J. Rohrich, M.D. Department of Plastic Surgery University of Texas Southwestern Medical Center 5323 Harry Hines Boulevard, Suite E7.210 Dallas, Texas rod.rohrich@utsouthwestern.edu

10 Vol. 113, No. 3 / AESTHETIC UPPER BLEPHAROPLASTY ACKNOWLEDGMENT We sincerely thank Vikram Gavande, M.S., University of Texas Southwestern Medical School, Dallas, Texas, for his assistance with the manuscript. 41e REFERENCES 1. Dupuis, C., and Rees, T. D. Historical notes on blepharoplasty. Plast. Reconstr. Surg. 47: 246, Paré, A. (translated by T. Johnson). The Works of That Famous Chirurgeon Ambroise Parey [Ambroise Paré]. London: Mary Clark, Mackenzie, W. A Practical Treatise on the Diseases of the Eye. London: Longman, Alibert, J. L. Monographie des Dermatoses ou Precis Theorique et Pratique des Maladies de la Peau. Paris: Paynac, Graf, D. Oertliche erbliche Erschlaffung der Lidhaut. Wochenschrift fur die gesammte Heilkunde, P Sichel, A. Aphorismes pratiques sur divers points d ophtalmologie. Ann. Ocul. 12: 185, Bourguet, J. Notre traitement chirurgical de poches sous les yeux sans cicatrice. Arch. Fr. Belg. Chir. 31: 133, Costañares, S. Blepharoplasty for herniated intra-orbital fat: Anatomical basis for a new approach. Plast. Reconstr. Surg. 8: 46, Loeb, R. Necessity for partial resection of the orbicularis oculi muscle in blepharoplasties in some young patients. Plast. Reconstr. Surg. 60: 176, Furnas, D. W. Festoons of orbicularis muscle as a cause of baggy eyelids. Plast. Reconstr. Surg. 61: 540, Hudson, D. A. A paradigm shift for plastic surgeons: No longer focusing on excising skin excess. Plast. Reconstr. Surg. 106: 497, Fagien, S. Algorithm for canthoplasty: The lateral retinacular suspension: A simplified suture canthopexy. Plast. Reconstr. Surg. 103: 2042, Lessner, A. M., and Fagien, S. Laser blepharoplasty. Semin. Ophthalmol. 13: 90, Fagien, S. Advanced rejuvenative upper blepharoplasty: Enhancing aesthetics of the upper periorbita. Plast. Reconstr. Surg. 110: 278, Siegel, R. J. Advanced upper lid blepharoplasty. Clin. Plast. Surg. 19: 319, Doxanas, M. T., and Anderson, R. L. Oriental eyelids: An anatomic study. Arch. Ophthalmol. 102: 1232, Siegel, R. J. Essential anatomy for contemporary upper lid blepharoplasty. Clin. Plast. Surg. 20: 209, Siegel, R. J. Oriental blepharoplasty. In L. M. Vistnes (Ed.) Procedures in Plastic and Reconstructive Surgery: How They Do It. Boston: Little, Brown, Pp Sires, B. S., Saari, J. C., Garwin, G. G., Hurst, J. S., and van Kuijk, F. J. The color difference in orbital fat. Arch. Ophthalmol. 119: 868, Owsley, J. Q. Resection of the prominent lateral fat pad during upper lid blepharoplasty. Plast. Reconstr. Surg. 66: 165, May, J. W., Jr., Fearon, J., and Zingarelli, P. Retro-orbicularis oculi fat (ROOF) resection in aesthetic blepharoplasty: A 6-year study in 63 patients. Plast. Reconstr. Surg. 86: 682, Knize, D. M. Muscles that act on glabellar skin: A closer look. Plast. Reconstr. Surg. 105: 350, Craig, D. M., and Sullivan, P. K. The resection of orbicularis oculi muscle from the upper eyelid in experimental surgery on the monkey. Plast. Reconstr. Surg. 87: 32, Gunter, J. P., and Antrobus, S. D. Aesthetic analysis of the eyebrows. Plast. Reconstr. Surg. 99: 1808, Flowers, R. S., and Flowers, S. S. Precision planning in blepharoplasty: The importance of preoperative mapping. Clin. Plast. Surg. 20: 303, Flowers, R. S., Caputy, G. G., and Flowers, S. S. The biomechanics of brow and frontalis function and its effect on blepharoplasty. Clin. Plast. Surg. 20: 255, Fagien, S. Eyebrow analysis after blepharoplasty in patients with brow ptosis. Ophthal. Plast. Reconstr. Surg. 8: 210, Baylis, H. I., Goldberg, R. A., Kerivan, K. M., and Jacobs, J. L. Blepharoplasty and periorbital surgery. Dermatol. Clin. 15: 635, Ang-Lee, M. K., Moss, J., and Yuan, C. S. Herbal medicines and perioperative care. J.A.M.A. 286: 208, Jelks, G. W., and Jelks, E. B. Preoperative evaluation of the blepharoplasty patient: Bypassing the pitfalls. Clin. Plast. Surg. 20: 213, Rees, T. D., and Jelks, G. W. Blepharoplasty and the dry eye syndrome: Guidelines for surgery? Plast. Reconstr. Surg. 68: 249, McKinney, P., and Byun, M. The value of tear film breakup and Schirmer s tests in preoperative blepharoplasty evaluation. Plast. Reconstr. Surg. 104: 566, Fagien, S. The value of tear film breakup and Schirmer s test in preoperative blepharoplasty evaluation (Discussion). Plast. Reconstr. Surg. 104: 570, Baker, S. S., Muenzler, W. S., Small, R. G., and Leonard, J. E. Carbon dioxide laser blepharoplasty. Ophthalmology 91: 238, Mele, J. A., III, Kulick, M. I., and Lee, D. Laser blepharoplasty: Is it safe? Aesthetic Plast. Surg. 22: 9, Millman, A. L., and Mannor, G. E. Histologic and clinical evaluation of combined eyelid erbium: YAG and CO 2 laser resurfacing. Am. J. Ophthalmol. 127: 614, Roberts, T. L., III. Laser blepharoplasty and laser resurfacing of the periorbital area. Clin. Plast. Surg. 25: 95, Seckel, B. R., Kovanda, C. J., Cetrulo, C. L., Jr., Passmore, A. K., Meneses, P. G., and White, T. Laser blepharoplasty with transconjunctival orbicularis muscle/ septum tightening and periocular skin resurfacing: A safe and advantageous technique. Plast. Reconstr. Surg. 106: 1127, American Society of Plastic Surgeons Gender distribution: Cosmetic surgery. Arlington Heights: American Society of Plastic Surgeons, Available at education/ loader.cfm?url /commonspot/security/getfile.cfm&page ID Accessed December 29, Flowers, R. S. Periorbital aesthetic surgery for men: Eyelids and related structures. Clin. Plast. Surg. 18: 689, Callahan, M. A. Prevention of blindness after blepharoplasty. Ophthalmology 90: 1047, DeMere, M., Wood, T., and Austin, W. Eye complications with blepharoplasty or other eyelid surgery: A national survey. Plast. Reconstr. Surg. 53: 634, Wolfort, F. G., Vaughan, T. E., Wolfort, S. F., and Nevarre,

11 42e PLASTIC AND RECONSTRUCTIVE SURGERY, March 2004 D. R. Retrobulbar hematoma and blepharoplasty. Plast. Reconstr. Surg. 104: 2154, Schechter, R. J. Management of inadvertent intraocular injections. Ann. Ophthalmol. 17: 771, Lyon, D. B., and Raphtis, C. S. Management of complications of blepharoplasty. Int. Ophthalmol. Clin. 37: 205, Harley, R. D., Nelson, L. B., Flanagan, J. C., and Calhoun, J. H. Ocular motility disturbances following cosmetic blepharoplasty. Arch. Ophthalmol. 104: 542, Lisman, R. D., Hyde, K., and Smith, B. Complications of blepharoplasty. Clin. Plast. Surg. 15: 309, Abell, K. M., Cowen, D. E., Baker, R. S., and Poter, J. D. Eyelid kinematics following blepharoplasty. Ophthal. Plast. Reconstr. Surg. 15: 236, Rees, T. D., Craig, S. M., and Fisher, Y. Orbital abscess following blepharoplasty. Plast. Reconstr. Surg. 73: 126, Wolfort, F. G., and Poblete, J. V. Ptosis after blepharoplasty. Ann. Plast. Surg. 34: 264, 1995.