Chapter 83. Aesthetic blepharoplasty










859
83
Aesthetic blepharoplasty
V ILANKOVAN and TIAN EE SEAH
INTRODUCTION
Since the rst cervical ap was reported in the early part of
the nineteenth century by von Graefe, blepharoplasty has
evolved into a nite concept.
e eyes are the window to the world and their limits
extend to the forehead and mid-face. As the ageing pro-
cess advances, the peri-orbital prole changes from
convex to concave, and a full, elevated, dened, smooth
contour becomes deated, ptotic, folded and irregular as
it descends. Ageing results in atrophy of fat, weakness of
the ligaments and resorption and apposition of bony sur-
faces. It is interesting that the electromyographic char-
acteristics of the orbicularis oculi do not alter with age.
ANATOMY
e anatomy of the eyelid is divided into anterior, mid-
dle and posterior lamellae. e skin and the orbicularis
oculi form the anterior compartment; the tarsus, sep-
tum, arcus marginalis and orbital fat form the middle;
and the palpebral conjunctiva and the lid retractors form
the posterior compartment. In the upper eyelid, however,
the posterior compartment also involves the levator
aponeurosis, Muller’s muscle, in addition to the palpebral
conjunctiva. e lateral and medial canthal ligaments
are entirely dierent. e retinacular attachment along
the inner wall of the lateral rim is involved in the ageing
process, which results in various changes including mal-
position of the lower lid.
ree important anatomically distinct fat deposits are
directly or indirectly involved in blepharoplasties. First,
orbital fat is closely related to the arcus marginalis which
is more signicant to lower blepharoplasty. Second, sub-
orbicularis oculi fat has two components and is divided
at the junction of the lid and cheek by the orbitomalar
ligament. ird is the malar fat pad, which is inferior to
the infraorbital foramen, mostly localized to the anterior
wall of the maxilla extending towards the malar eminence
(Figures 83.1 and 83.2).
PROBLEMS AND THEIR SOLUTIONS
Problems of the upper eyelid are excess skin with or without
ptosis of the lateral brow, herniation of fat (particularly the
CONTENTS
Introduction 859
Anatomy 859
Problems and their solutions 859
Blepharoplasty 860
Pre-operative planning 860
Upper blepharoplasty 860
Lower blepharoplasty 861
Canthal correction 863
Oriental blepharoplasty 863
Asian upper blepharoplasty: Suturing method 864
Asian upper blepharoplasty: Skin excision method 865
Acknowledgment 866
Suggested readings 866

860 Aesthetic blepharoplasty
medial fat), and also in the middle, with prominence of the
orbicularis oculi muscle and intrinsic changes in the qual-
ity of skin. Similar problems aect the lower lid and include
intrinsic changes in skin, hypertrophy of the orbicularis
oculi muscle and prolapse of orbital fat with deformities of
the tear trough and malar palpebral groove. Lateral canthal
laxity compounds these anatomical problems.
BLEPHAROPLASTY
Technical advance in blepharoplasty has evolved in the
last 100 years, and the rst tranconjunctival approach was
described by Julian Bourguet in 1924. In the recent past,
surgeons who have contributed most to aesthetic blepha-
roplasty are Flowers, Hamra, Barton and Hester. In 1991,
we identied using cadaver dissection an avascular post-
septal plane, which travels to the arcus marginalis behind
the septum in front of the fascial layer that envelops the
peri-orbital fat. is anatomical position, in our opinion,
makes the septal reset procedure in lower lid blepharo-
plasty a reality.
PREOPERATIVE PLANNING
Patients are advised to stop smoking at least 3–4 weeks
prior to surgery. Any homeopathic medication such as
vitamin supplements should be discontinued during the
same period. Furthermore, routine anti-coagulant therapy
such as aspirin should be stopped a week prior to surgery.
If there is any contraindication, this should be discussed
with the patients physician. We recommend patients to
take Arnica tablets (30 g) ve times a day starting a week
before. Anecdotally this practice has denitely reduced
bruising and swelling in the post-operative period.
Patients undergoing treatment under a local anaesthetic
are recommended medication as follows:
On the day of the surgery patients start oral antibiot-
ics, usually Flucloxacillin 250 mg four times a day. Two
hours prior to surgery we advocate 8-mg Dexamethasone
orally, which helps to reduce the swelling and bruising.
Some patients may require oral sedation, usually 10-mg
Diazepam is prescribed 45 minutes prior to surgery.
UPPER BLEPHAROPLASTY
Skin marking
e aim is to create a supratarsal fold. is is usually
about 10 mm from the lid margin. e skin markings
are carried out while the patient is sitting up. e infe-
rior skin markings extend medially to the upper eyelid
fold. e lateral limit is just above the lateral palpebral
fold. To mark the superior aspect of the skin excision,
the accuracy of the excess upper lid skin should be
assessed carefully. While the patient is sitting up we use
an Adson toothed forceps to pinch the excess while the
patients open and closes the eyes with only a mild eleva-
tion of the eyelashes.
Once the middle part of the superior marking is judged
then the medial extension should follow the inferior mark-
ing to a tapered end. e lateral extension will be longer
than the inferior counterpart so that the nal result can
also correct mild lateral brow ptosis (Figure 83.3).
Orbital fat
Obicularis
SOOF
SOOF
Orbitomalar
ligament
Malar bag
Malar fat pad
Lid cheek junc
tion
SMAS
Figure 83.1 Lateral view and fat distribution. Suborbic-
ularis oculi fat (SOOF), suborbicularis ocular fat.
Figure 83.2 Frontal view and fat distribution. SOOF, sub-
orbicularis ocular fat.
SOOF
Malar
fat pa
d
Mid face fat
Orbital
fat

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85983Aesthetic blepharoplastyV ILANKOVAN and TIAN EE SEAHINTRODUCTIONSince the rst cervical ap was reported in the early part of the nineteenth century by von Graefe, blepharoplasty has evolved into a nite concept.e eyes are the window to the world and their limits extend to the forehead and mid-face. As the ageing pro-cess advances, the peri-orbital prole changes from convex to concave, and a full, elevated, dened, smooth contour becomes deated, ptotic, folded and irregular as it descends. Ageing results in atrophy of fat, weakness of the ligaments and resorption and apposition of bony sur-faces. It is interesting that the electromyographic char-acteristics of the orbicularis oculi do not alter with age.ANATOMYe anatomy of the eyelid is divided into anterior, mid-dle and posterior lamellae. e skin and the orbicularis oculi form the anterior compartment; the tarsus, sep-tum, arcus marginalis and orbital fat form the middle; and the palpebral conjunctiva and the lid retractors form the posterior compartment. In the upper eyelid, however, the posterior compartment also involves the levator aponeurosis, Muller’s muscle, in addition to the palpebral conjunctiva. e lateral and medial canthal ligaments are entirely dierent. e retinacular attachment along the inner wall of the lateral rim is involved in the ageing process, which results in various changes including mal-position of the lower lid.ree important anatomically distinct fat deposits are directly or indirectly involved in blepharoplasties. First, orbital fat is closely related to the arcus marginalis which is more signicant to lower blepharoplasty. Second, sub-orbicularis oculi fat has two components and is divided at the junction of the lid and cheek by the orbitomalar ligament. ird is the malar fat pad, which is inferior to the infraorbital foramen, mostly localized to the anterior wall of the maxilla extending towards the malar eminence (Figures 83.1 and 83.2).PROBLEMS AND THEIR SOLUTIONSProblems of the upper eyelid are excess skin with or without ptosis of the lateral brow, herniation of fat (particularly the CONTENTSIntroduction 859Anatomy 859Problems and their solutions 859Blepharoplasty 860Pre-operative planning 860Upper blepharoplasty 860Lower blepharoplasty 861Canthal correction 863Oriental blepharoplasty 863Asian upper blepharoplasty: Suturing method 864Asian upper blepharoplasty: Skin excision method 865Acknowledgment 866Suggested readings 866 860 Aesthetic blepharoplastymedial fat), and also in the middle, with prominence of the orbicularis oculi muscle and intrinsic changes in the qual-ity of skin. Similar problems aect the lower lid and include intrinsic changes in skin, hypertrophy of the orbicularis oculi muscle and prolapse of orbital fat with deformities of the tear trough and malar palpebral groove. Lateral canthal laxity compounds these anatomical problems.BLEPHAROPLASTYTechnical advance in blepharoplasty has evolved in the last 100 years, and the rst tranconjunctival approach was described by Julian Bourguet in 1924. In the recent past, surgeons who have contributed most to aesthetic blepha-roplasty are Flowers, Hamra, Barton and Hester. In 1991, we identied using cadaver dissection an avascular post-septal plane, which travels to the arcus marginalis behind the septum in front of the fascial layer that envelops the peri-orbital fat. is anatomical position, in our opinion, makes the septal reset procedure in lower lid blepharo-plasty a reality.PREOPERATIVE PLANNINGPatients are advised to stop smoking at least 3–4 weeks prior to surgery. Any homeopathic medication such as vitamin supplements should be discontinued during the same period. Furthermore, routine anti-coagulant therapy such as aspirin should be stopped a week prior to surgery. If there is any contraindication, this should be discussed with the patient’s physician. We recommend patients to take Arnica tablets (30 g) ve times a day starting a week before. Anecdotally this practice has denitely reduced bruising and swelling in the post-operative period. Patients undergoing treatment under a local anaesthetic are recommended medication as follows:On the day of the surgery patients start oral antibiot-ics, usually Flucloxacillin 250 mg four times a day. Two hours prior to surgery we advocate 8-mg Dexamethasone orally, which helps to reduce the swelling and bruising. Some patients may require oral sedation, usually 10-mg Diazepam is prescribed 45 minutes prior to surgery.UPPER BLEPHAROPLASTYSkin markinge aim is to create a supratarsal fold. is is usually about 10 mm from the lid margin. e skin markings are carried out while the patient is sitting up. e infe-rior skin markings extend medially to the upper eyelid fold. e lateral limit is just above the lateral palpebral fold. To mark the superior aspect of the skin excision, the accuracy of the excess upper lid skin should be assessed carefully. While the patient is sitting up we use an Adson toothed forceps to pinch the excess while the patients open and closes the eyes with only a mild eleva-tion of the eyelashes.Once the middle part of the superior marking is judged then the medial extension should follow the inferior mark-ing to a tapered end. e lateral extension will be longer than the inferior counterpart so that the nal result can also correct mild lateral brow ptosis (Figure 83.3).Orbital fatObicularisSOOFSOOFOrbitomalarligamentMalar bagMalar fat padLid cheek junctionSMASFigure 83.1 Lateral view and fat distribution. Suborbic-ularis oculi fat (SOOF), suborbicularis ocular fat.Figure 83.2 Frontal view and fat distribution. SOOF, sub-orbicularis ocular fat.SOOFMalarfat padMid face fatOrbitalfat Lower blepharoplasty 861Local anaesthesiaConservative eyelid skin removal is advisable to avoid the consequences of over correction. Surgery can be carried out under local or general anaesthetic. Even if under general anaesthesia to achieve haemostasis and a bloodless eld we prefer to inltrate 2% Lignocaine with 1:80,000 Adrenaline in a dental syringe. e injection is carried out incrementally in a subcutaneous plane to minimize bruising. Approximately 2–3 mL of local anaesthetic is adequate to carry out surgery under local anaesthetic.Skin excisione lower limb skin incision is carried out followed by the rest of the skin markings. We prefer to use a No. 15 blade. e skin is excised using a sharp curved scissor with simultaneous counter-traction over the orbicularis oculi muscle. Once the skin is excised, haemostasis is achieved by bipolar cauterization (Figure 83.4).Muscle excisionApproximately 2–3 mm of orbicularis muscle is excised in order to correct the hypertrophic component. is is usu-ally parallel to the superior margin of the tarsus and this process gives exposure to the orbital septum.Septal incision and fat excisionOnce the muscle is excised a gentle pressure along the lower lid does show the bulging fat covered by the orbital septum. e septum is incised to the entire length of the incision which will expose the preaponeurotic fat pad. Dissection to the medial fat is carried out sepa-rately which has a somewhat paler colour compared to the middle fat. e middle fat is excised in a con-trolled fashion whilst achieving good haemostasis. e adequacy of the fat excision would show the Whitnall’s ligament.Repaire next step is to create an anchor point to the new supratarsal fold. ere are various techniques described in the literature. We prefer to place a horizontal mattress stitch, using 5/0 Vicryl undyed suture, starting under the surface of the inferior orbicularis oculi and to the fascial attachment, just above Whitnall’s ligament. Once this is achieved the skin is repaired using a 6/0 Prolene suture. e rst 3–4 sutures are carried out in the middle part of the new supratarsal fold as interrupted sutures extend-ing to complete the lateral suturing, however, the medial defect can be repaired by a continuous running suture.Post-operative wound careImmediately aer the operation we use 1% Chloromycetin ointment as a topical application although it is not recom-mended for percutaneous usage. We have used this tech-nique for the last 25 years with no adverse eect. Patients are discharged home with instructions, antibiotic and analgesics.LOWER BLEPHAROPLASTYCareful pre-operative assessment and planning is manda-tory prior to any surgical procedure along the lower lid. e consequences of over correction in the lower eyelid surgery are much more obvious compared to the upper. e aim here is to create a normal ‘S’ shaped curvature to the lower lid.Skin markingTraditionally, a standard lower blepharoplasty is carried out via a subcilliary approach. e incision is marked approximately 2 mm below the ciliary margin of the lower lid beginning from the medial end just below the lower lacrimal canaliculi. e lateral extension is marked Figure 83.4 Demonstrating skin excision.Figure 83.3 Skin marking of upper blepharoplasty. 862 Aesthetic blepharoplastyextending into one of the naturally occurring creases along the crow’s foot. e lateral extension varies from 5 to 7 mm (Figure 83.5).Local anaesthesiae anaesthetic procedure is the same as for the upper lid. If the surgery is carried out entirely under local anaesthetic approximately 3–4 mL of 2% Lignocaine with 1:80,000 Adrenaline is inltrated subcutaneously in an incremen-tal fashion. is volume is adequate to carry out the whole procedure.Flap elevation and septal resete skin ap or skin muscle ap are the two basic opera-tive procedures used for lower blepharoplasty.If a skin ap is used, the skin is carefully separated from the underlying orbicularis oculi muscle. is can be done either using Tenotomy scissors or mono-polar diathermy needle. Good haemostasis is achieved (Figure83.6).If a skin muscle ap is used the skin incision is the same. To elevate the muscle with the ap, the incision is extended deep to the orbicularis oculi muscle. We use an 8-cm Reynolds tenotomy scissors to perform the dissec-tion. e tip of the scissors is inserted through the orbi-cularis oculi muscle and the areolar plane between the septum and orbicularis oculi is dened by blunt dissec-tion. An important measure with the skin muscle ap is to leave at least 5 mm of the pretarsal muscle intact as a site to anchor the ap once the surgery is completed. If a skin ap is raised the orbicularis muscle is split half way along the supra inferior dimension. is division would expose the herniated fat encased in a pocket completely covered by the septum (Figure 83.7).e dissection is carried out along the plane superior to the arcus marginalis to expose the tear trough and the malar palpebral groove. is allows dissection of the her-niated fat with the septum which is to be sutured along the infraorbital rim (Figure 83.8). Once the redrapping of the fat is achieved followed by haemostasis, the split muscle is repaired using either 5/0 Vicryl Rapide suture or a bipolar electric cauterization as ‘welding’.Figure 83.7 Orbital fat exposure encased by orbital septum.Figure 83.8 Suture of the herniated fat to the arcus margi-nalis (septal reset). (Courtesy of Jan Stanek.)Figure 83.5 Skin marking for lower blepharoplasty with crow’s foot extension.Figure 83.6 Elevation of the skin ap using tenotomy scissors. Oriental blepharoplasty 863Skin excision and repairIn both the skin ap and the skin muscle ap, once the fat management is carried out the skin is draped over the eyelashes. Passive excision of the excess skin or skin muscle is carried out (Figure 83.9). Further haemostasis is achieved. It is always helpful to divide the superior part of the orbicularis oculi muscle laterally so that plication of the muscle can be carried out using a 5/0 vicryl suture. e excess muscle is trimmed. Subsequent to that the skin is repaired with a 6/0 Prolene subcutaneous suture to the eyelid skin and interrupted sutures to the lateral extension or interrupted all the way (Figure 83.10).e benet of a septal reset on a background of skin ap is that the innervation to the orbicularis oculi muscle is undisturbed. e fat volume is preserved and over correc-tion of the skin excision is minimized.Many surgeons continue to carry out formal excision of the medial, middle and lateral fats once exposed simi-lar to the upper blepharoplasty. e technique here is to incise the orbital septum to its entire length and careful excision of the herniated fat with simultaneous haemo-stasis. e rest of the surgical procedure is as described earlier.Pinch blepharoplasty is a well-known technique where only excess skin is removed through a subcilliary approach. is corrects only the skin excess in the anterior lamellae and makes no other anatomical corrections.CANTHAL CORRECTIONA standard procedure to correct lateral canthal weakness is a canthotomy followed by excision of the tissue and reat-tachment of the lower lid tarsus by a deep suture. However, this has been reported to produce webbing along the lateral canthal contour. We prefer to use a technique described by Hester (Figure 83.11a and b) where a limited composite excision of the lateral lower lid with simultaneous repair of the tarsus is done. is has the benet of maintaining the integrity of the lateral canthal contour and correcting lid malposition.ORIENTAL BLEPHAROPLASTYe aim of Asian blepharoplasty is to create an upper eye-lid crease which exists only in 50% of the Asian population.AnatomyAnatomically, the Asian eyelid is dierent from the Caucasian eyelid at the anterior and middle lamellae. First, Figure 83.9 Excision of the excess skin following initial anchor suture.Figure 83.10 Simple interrupted suture of the skin using a 6/0 Prolene suture.(a)Figure 83.11 (a and b) Management for lower lid malposi-tion by composite excision of tarsal plate and primary repair without blunting the canthal denition.(b) 864 Aesthetic blepharoplastyin the Asian eyelid, the orbital septum fuses diusely with the levator aponeurosis in a more inferior position allow-ing the downward herniation of the orbital fat. Second, it lacks the dermal attachment of the levator palpebrae apo-neurosis. ird, there is more subcutaneous and preapo-neurotic fat. is creates a fuller upper eyelid look without an upper eyelid crease. ere are a few ways to create the superior eyelid crease, and these can be broadly classied into suturing method and incision method.ASIAN UPPER BLEPHAROPLASTY: SUTURING METHODis method is to create an upper eyelid crease by strategi-cally placing nonresorbable sutures at the superior margin of the tarsus.Skin markinge upper eyelid is everted and the tarsus is measured using a pair of calipers. In the Asian population, the tarsal height is 7–10 mm (Figure 83.12). Once it has been ascertained, the height of the tarsus is marked on the eyelid skin as a smooth line that would converge medially. One to three pairs of points, each pair 4–5 mm apart, are marked on this line. e centre pair of points is in line with the pupil, while the other two pairs of points are placed equidistant from the medial and lateral canthus to the centre point.Local anaesthesiaTopical Alcaine (proparacaine hydrochloride 0.5% oph-thalmic solution) is applied on the conjunctival mucosa. is eyelid skin and the mucosa are injected with 2% Lignocaine with adrenaline at 1:80,000.SuturingSuturing is carried with CV-11 6/0 Polypropylene suture with double armed 3/8 13-mm needle commencing at the mucosa side. is is rst done at the centre pair of points. e rst needle is passed under the mucosa of the everted upper eyelid (Figure 83.13). Once that is done, both nee-dles are passed from the mucosa to the skin (Figure 83.14), one at the medial and one at the distal point of the centre pair, through the skin. e medial needle is then rein-serted through the medial point to pass under the skin so as to exit from the distal point. An interrupted suture is then tied and buried in the skin. is bunches up the tis-sues and creates a crease (Figure 83.15). At the mucosa, the suture should be superior to the tarsus so that it sits on the tarsal recesses and is kept away from the cornea.Figure 83.12 Measuring tarsal height for Asian blepharoplasty.Figure 83.13 Asian upper blepharoplasty, initial suture in suturing method.Figure 83.14 Passing of both needles from mucosa to skin.Figure 83.15 Final suture pass prior to making the knot. Asian upper blepharoplasty: Skin excision method 865Further points can be created at sites medial and distal to the central point. is helps to maintain an upper eyelid crease (Figures 83.16 and 83.17).ASIAN UPPER BLEPHAROPLASTY: SKIN EXCISION METHODis method is to create an upper eyelid crease by excising skin and muscle at the superior margin of the tarsus. Occasionally, orbital fat can be trimmed if it is excessive.Skin markinge height of the skin excised is usually less than in Caucasian counterparts. e skin pinch technique can be used to ascertain how much skin is to be removed. Similar to the suturing technique, the height of the upper eyelid tarsus is everted and measured using a pair of calipers. Once it has been ascertained, the height of the tarsus is marked on the eyelid skin as a smooth line that would con-verge medially. Laterally, it curves towards the most supe-rior crow’s foot (Figure 83.18). Superiorly, the height can be determined by the skin pinch test for a mature patient with excess skin. For younger patients, the skin excision is more conservative and is about 2–3 mm in height.Local anaesthesiais eyelid skin is injected with 2% Lignocaine with adrenaline at 1:80,000.Skin excisione skin is excised as per skin marking (Figure 83.19). e skin is undermined inferiorly to expose the pretarsal orbi-cularis oculi muscle. Up to 1/3 of the pretarsal orbicularis oculi muscle can be excised (Figure 83.20).Fat excisione septum is divided with an electrocauthery, No. 11 blade or tenotomy scissors to expose and allow the middle Figure 83.16 The pre-operative view of an Asian eyelid crease.Figure 83.17 The post-operative view of the new eyelid crease.Figure 83.20 Excision of the pre tarsal orbicularis oculi muscle.Figure 83.19 Skin excision for Asian blepharoplasty.Figure 83.18 Skin marking of Asian blepharoplasty for muscle excision. 866 Aesthetic blepharoplastyorbital fat to prolapse out. e fat to be excised is clamped with a mosquito artery forceps, and the fat excised and haemostasis achieved by cauterization (Figure 83.21).ClosureSuture with 6/0 Prolene. Start by catching the lower eyelid skin, septum, levator aponeurosis if seen, prese-ptal orbicularis oculi muscle and upper skin and plac-ing interrupted or continuous running sutures (Figures 83.22 and 83.23).ACKNOWLEDGEMENTWe are grateful for the help and support of Anna Sayan and Jane Porter in preparing this manuscript.SUGGESTED READINGSBarton FE Jr., Ha R and Awada M. Fat extrusion and sep-tal reset in patients with tear trough triad: A critical appraisal. Plast Reconstr Surg. 2004; 113: 115–2121.Bourget J. La veritable chirurgie esthetique du visage. Paris: Plon. Pub 1936.Castanares S. Blepharoplasty for herniated intraorbital fat: Anatomical basis for a new approach. Plast Reconstr Surg. 1951; 8: 46–58.Flowers S. Canthopexy as routine blepharoplasty compo-nent. Clin Plast Surg. 1993; 20: 351.Hamra ST. e zygorbicular dissection in composite rhyt-idectomy. Plast Reconstr Surg. 1998; 102: 1646.Hamra ST. Arcus marginalis release and orbital fat preser-vation in midface rejuvenation. Plast Reconstr Surg. 1995; 96: 35.Hamra ST. e role of the septal reset in creating a youth-ful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg. 2004; 113: 2124.Hester TR, Codner MA and McCord CD. Subperiosteal malar cheek li with lower lid blepharoplasty. In McCord CD, Codner MA (eds.), Eyelid sur-gery: Principles and Techniques. Philadelphia, PA: Lippincott-Raven; 1995. p. 210.Hester TR, Codner MA, McCord CD, Nahai F and Giannopoulos A. Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: Maximising results and minimizing complications in a ve year experience. Plast Reconstr Surg. 2000; 105: 393.Hester TR. Evolution of lower lid support following lower lid/midface rejuvenation. e pretarsal orbicularis lateral canthopexy. Clin Plast Surg. 2001; 28: 639.Ilankovan V. Transconjunctival approach to the infraor-bital region: A cadaveric and clinical study. Br J Oral Maxillofac Surg. 1991; 29(3): 169–172.Jeong SI, Lemke BN, Dortzbach RK, Park YG and Kang HK. e Asian upper eyelid: An anatomical study Top tips • Be very careful that the patient’s expectations are realistic. • Pre-operative photographs are essential as a record should the patient question the result at future date. • Pre-operative markings should be made with the patient sitting up. The soft tissues redraw in the supine position. • When operating remember to inltrate the fat pads before manipulating them to prevent an acute brady-cardia due to occulocardiac reex. • Meticulous haemostats are essential.Figure 83.21 Excision of fat.Figure 83.22 Pre-operative view of an Asian eyelid prior upper blepharoplasty.Figure 83.23 Pre- and post-operative view after upper eyelid skin and fat excision. Suggested readings 867with comparison to the Caucasian eyelid. Arch Ophthalmol. 1999 Jul; 117(7): 907–912.Pottier F, El-Shazly N and El Shazly AE. Aging of the orbi-cularis oculi: Anatomophysiologic consideration in upper blepharoplasty. Arch Facial Plast Surg. 2008; 10(5): 346–349.Wong JK, Zhou X, Ai Y and Wang Z. A simple, minimally invasive method for creation of the superior palpe-bral fold in Asians with the modied continuous buried tarsal stitch: A joint assessment from Toronto, Ontario Canada, and Chengdu, China. Arch Facial Plast Surg. 2010 Jul–Aug; 12(4): 269–273.

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