Blepharoplasty of Upper Eyelids. Is fat and muscle removed or just skin?

Dear Cerro

Classically upper blepharoplasty involved removal of skin, muscle, and fat.  However, it is the details that separate a beautiful upper blepharoplasty from a butchery.  Generally surgeons go wrong with these surgeries by removing too much of everything.  Skeletonizing an eyelid only makes the eye look like it had surgery.  It does not make for a rejuvenated look.  It is not enough to make someone look different.  It is essential to make them look better.  Often this is best done by being conservative.  Upper eyelid surgery cannot elevate the brow.  A common mistake that is made in upper blepharoplasty is to ignore a heavy brow when what is needed is a forehead procedure rather than upper eyelid surgery.  It is important that the surgeon place the crease of the upper eyelid (which will be were the lowest eyelid incision is made) at the right height.  It is all too common that these are made a 10 mm and they then heal to 12 mm because this is what text books advise.  Upper eyelid surgery is a sculpting and draping procedure not a cutting and removing procedure.  Commonly fat does not need to be excised or only excised in a limited fashion helping to preserve upper eyelid fold volume.  Weakness in the levator aponeurosis, the tendon insertion of the muscle that raises the eyelid is often ignored.  Blepharoplasty is an excellent opportunity to reinforce a weak tendon insertion that is causing a fall in the position of the eyelid margin.  However, many eyelid surgeons lack the training, skill, and experience to expertly expose the levator tendon and tighten it as part of their eyelid surgery.  Finally, for many patients laxity of the skin on the eyelid platform, the part of the eyelid between the eyelashes and the upper eyelid crease, is ignored.  By carefully tailoring surgery, it is possible to firm and tighten this skin by expertly anchoring it to the upper eyelid levator tendon.  This can be a very important detail that helps create a brighter looking eye.

The nature of the surgery is tailored to each patient's needs.  Usually skin is removed with often a small amount of fat removal in the inner corner of the lid.  The scars often fade quickly and are beautifully tucked into the natural lid crease.

The primary goal of the blepharoplasty procedure is to remove excess skin from the upper eyelids.  Additionally, fat is usually removed from the medial compartment closest to the nose.  On rare occasions middle fat is also removed in the central component of the eyelid if it is very heavy.  If there is also excess orbicularis oculi muscle folded over upon itself, a small strip of muscle can be removed which will also deepen the crease.  This is all customized depending upon the patient’s needs, wishes, and desires and preoperative conditions.