The ocular surface is a delicate and complex anatomic and physiologic system that maintains the health of the cornea and, therefore, vision. Primary and accessory lacrimal glands produce the 3 layers of the tear film. The eyelids, through a complex and delicate blink mechanism, spread the tear film evenly across the cornea and modulate the evaporation of tears. Blepharoplasty can impact the anatomy and physiology of the ocular surface through a variety of mechanisms. Some of the perturbations are mild and transient, but extreme iatrogenic disruption of ocular surface protective mechanisms can lead to disabling effects on comfort or vision. Potential mechanisms of ocular-surface disruption associated with blepharoplasty are lacrimal gland or lacrimal nerve injury, anterior lamellar shortening, middle lamellar shortening (full-thickness eyelid scar), orbicularis paralysis with inadequate blink, and conjunctival injury or inflammation.

It is not possible to eliminate the risk of ocular surface injury in blepharoplasty. An element of unpredictability is inherent in surgery, and even expertly performed blepharoplasty occasionally results in ocular surface problems. However, there are measures that minimize the risk of postoperative ocular surface problems.

Patient selection

I cannot predict with certainty which patients will experience symptomatic dry eye after blepharoplasty, but some factors clearly increase the risk. Patients with a history of symptomatic dry eye, laser-assisted in situ keratomileusis (LASIK) surgery, blepharoplasty, or facial palsy are at increased risk. The Schirmer test is not adequately sensitive or specific, in my experience, to significantly add to the patient’s history and examination findings, and I do not routinely perform it. During the initial patient evaluation, I pay attention to orbicularis weakness, tight eyelids, or other causes of incomplete blink.

The relatively proptotic eye places the eyelid at mechanical disadvantage; patients with this characteristic frequently demonstrate preoperative scleral show. Repositioning of the globe, relative to its bony support, may be appropriate before or in conjunction with blepharoplasty. A rapid blink rate can sometimes indicate a borderline-compensated ocular surface and, of course, obvious conjunctivitis, blepharitis, or keratitis may indicate chronic ocular surface problems. These risk factors do not eliminate the possibility that surgery can be safely performed, but they should provoke a thorough patient analysis.
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Treatment of the skin and orbicularis

We require about 20 mm of upper eyelid skin to close our eyelids comfortably (Figure 1). If the eyebrow is surgically elevated, the requirement for eyelid skin may be even greater. I try to be as conservative as possible when excising skin. Much upper eyelid aesthetic improvement results from forehead lift and from improved skin quality; excellent aesthetic results can be achieved without extensive skin resection.

Lagophthalmos resulting from inadequate anterior lamella after upper blepharoplasty. Only 14 mm of skin remained from the eyelid margin to the eyebrow. (Courtesy of the Regents of the University of California. Copyright © 2003; used by permission.)

Another risk of extensive upper eyelid surgery is orbicularis weakness. Risk is heightened when additional insult to the orbicularis or its nerve supply occurs during canthoplasty or transcutaneous midface lift. Subtle orbicularis weakness often occurs after blepharoplasty; it is underdiagnosed and acts synergistically with anterior lamellar inadequacy to impair eyelid closure and blink mechanism (Figure 2).

Upper eyelid orbicularis weakness after blepharoplasty, combined with anterior lamellar inadequacy, causing impaired blink. Note the spontaneous eversion of the upper eyelid margin with forced closure. (Courtesy of the Regents of the University of California. Copyright © 2003; used by permission.)

The lower eyelid is even more vulnerable to anterior lamellar inadequacy. The vector forces on the lower eyelid are unforgiving. Gravity and globe curvature (especially if the globe is relatively prominent) tend to push the lower eyelid down. It is only the vertical vector force of the “clothesline” of horizontal eyelid tension that fights these downward forces to maintain the eyelid margin at the corneal limbus. Even a slight increase in the downward vector force caused by anterior lamellar inadequacy can tip the delicate balance, creating eyelid retraction or eyelid tethering with inadequate blink.

As with the upper eyelid, the orbicularis plays an important role: If the orbicularis is weakened as a result of surgery or scarring, eyelid retraction and impairment of the normal blink mechanism are compounded. In the worst-case scenario, untreatable paralytic-cicatricial eyelid retraction occurs (Figure 3).

Combined paralytic-cicatricial lower eyelid retraction with impaired blink caused by anterior lamella inadequacy, orbicularis weakness, and full-thickness eyelid scarring after skin-muscle–flap blepharoplasty. With forced closure, orbicularis weakness is demonstrated. (Courtesy of the Regents of the University of California. Copyright © 2003; used by permission.)

I almost never excise lower eyelid skin, and I never excise lower orbicularis. I believe that there are safer and more aesthetically effective methods of improving the lower eyelid skin, which ages more by losing elasticity than by becoming redundant. Chemical peel, laser resurfacing, botulinum toxin, and fillers or implants to address deflation are safer and more effective than a skin muscle flap. If you cannot resist the temptation to remove skin — and there are occasional patients in whom I do remove lower eyelid skin — I recommend a skin pinch or other conservative superficial orbicularis-sparing technique. If you must manipulate the orbital fat, I recommend doing so through a separate conjunctival incision, avoiding the creation of a full-thickness skin-orbicularis-septum scar and thereby substantially decreasing the risk of lower eyelid retraction (Figure 4 and Figure 5).

Figure 4. A, Preoperative view of a 60-year-old man. B, Postoperative view, 6 months after transconjunctival fat repositioning. The skin was improved with CO2 laser resurfacing and botulinum toxin. I do not believe that a skin muscle flap is any more effective in addressing skin problems, and it carries a high risk of disturbance of eyelid function. (Courtesy of the Regents of the University of California. Copyright © 2003; used by permission.)

A, Preoperative view of a 48-year-old woman. B, Postoperative view, 6 months after transconjunctival fat repositioning. The skin was improved with CO2 laser resurfacing and botulinum toxin.