Muscle-sparing blepharoplasty: a prospective left-right comparative study

Abstract

Background: Standard upper blepharoplasty involves removal of both the skin and a portion of the underlying orbicularis oculi muscle. The senior author had observed sluggishness of eyelid closure, lagophthalmos as well as varying degrees of eye irritation in certain patients during the early postoperative period. He postulated that these findings could be due to orbicularis muscle excision. He therefore undertook a prospective study 27 years ago comparing standard blepharoplasty on one eyelid to skin-only excision on the fellow eyelid.

Methods: A randomized, prospective, single-blinded study was designed using the fellow eye as an internal control. 22 patients undergoing upper blepharoplasty procedure requiring greater than 5 mm of skin resection and with no history of ophthalmologic disease, dry eye, or previous eyelid surgery were selected. Upper blepharoplasty was performed with skin-only removal on one side, and combined skin-muscle removal on the other side. Patients were evaluated until six months after surgery except for two patients who were lost to follow-up after three months. Sluggish eyelid closure, lagophthalmos, dry eye and aesthetic result were outcome measures scored by patient survey, the operating surgeon, and a blinded expert panel.

Results: There were comparable aesthetic outcomes in both eyelids. The incidence of sluggish eyelid closure, lagophthalmos and dry eye syndrome were significantly higher in eyelids where wide segments of muscle had been resected.

Conclusions: Muscle-sparing upper blepharoplasty produces similar aesthetic outcomes as conventional blepharoplasty, while significantly reducing the complications of sluggish eyelid closure, lagophthalmos and dry eye disease. The authors therefore recommend muscle-sparing upper blepharoplasty.

Keywords: Blepharoplasty; Dry eye syndromes; Ptosis.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1

Standard upper blepharoplasty This 60-year-old patient had undergone "standard" upper blepharoplasties six months previously with removal of skin and muscle. She developed sluggish lid closure, lagophthalmos and eye irritation after surgery.

Fig. 2

Preoperative marking Patient has been marked for skin-only excision of upper eyelid skin on one side and combined skin-muscle excision of the contralateral eyelid.

Fig. 3

Intraoperative left-right comparison Intraoperative photograph of a patient at the completion of upper blepharoplasties after skin-only excision of the right upper eyelid and combined skin-muscle excision of the left eyelid in a 54-year-old patient. Tarsal fixation was also performed.

Fig. 4

Postoperative dynamic evaluation Postoperative photograph of a 72-year-old patient taken at extreme downward gaze at one week after surgery. Lagophthalmos is present on the right eyelid where 13 mm of combined skin-muscle was removed. Lower blepharoplasties were also performed. Note the patient's unsuccessful attempt to close her eyes forcefully.

Fig. 5

Preoperative photograph Before photograph of a 58-year-old patient undergoing bilateral upper and lower blepharoplasties. Skin-only resection was randomly assigned to one upper eyelid and muscle-skin resection assigned to the other lid.

Fig. 6

Postoperative left-right comparison Postoperative photograph of the patient in Fig. 5 six months after 8 mm skin-only excision of the left lid and combined skin-muscle excision of the right upper eyelid. Tarsal fixation was done on both sides. Concurrent lower blepharoplasties were also performed. This patient had no postoperative complications.

Fig. 7

Preoperative photograph Before photograph of a 71-year-old patient undergoing bilateral upper blepharoplasties. Skin-only excision was randomly assigned to one eyelid and muscle-sparing excision randomly assigned to the other lid.

Fig. 8

Postoperative left-right comparison Postoperative photograph of the patient in Fig. 7 six months after 13 mm of skin-only excision of the left lid and combined skin-muscle excision of the right upper eyelid. Patient also underwent concurrent lower blepharoplasties. This patient had temporary lagophthalmos and symptoms of dry eye on the right side that lasted less than four weeks. The panel of experts found "good but not comparable" outcomes on both sides and felt she could benefit from right eyebrow lift. The panel graded the outcome as "aesthetically good" on both sides.

Fig. 9

A case of pseudoptosis Before photograph of a 78-year-old patient with bilateral upper eyelid pseudoptosis due to excess skin. No true ptosis was present. Note patient's attempt to improve his visual field by elevating the eyebrows.

Fig. 10

Postoperative left-right comparison Postoperative photograph of the patient in Fig. 9 six months after 21 mm of skin-only excision of the right lid and combined skin-muscle excision of the left upper eyelid. No tarsal fixation was performed. This patient had lagophthalmos of the eye that lasted one week but presented no dry eye symptoms. Note the absence of frontalis hyperactivity and dropping of the eyebrows. The panel of experts found the outcomes as "good and comparable" on both sides and graded the case as "aesthetically good".