4 Lid Blepharoplasty: Proper Incision Placement

By Joseph Walrath, MD | Sep 21, 2015 | Blepharoplasty, Brow lifting, Cosmetic, Uncategorized

There is not a week of office visits that goes by without at least one patient presenting with inappropriately-placed upper lid incisions from prior surgery.  Within the past week, there were two such notable patients:

  1. The first patient manifested lid crease asymmetry, with a 12 mm lid crease (distance from lashes to incision) on the right and an 8 mm lid crease on the left.  This might not sound like a big difference, but if one considers that the “correct” Caucasian lid crease for this patient is about  9 mm, one can start to imagine that the 4 mm difference is substantial.
  2. The second patient initially had the right upper lid lifted years ago, with an incision in the proper place.  Subsequently, a plastic surgeon performed upper blepharoplasty  on both upper lids.  When the patient complained that the skin appeared to be in excess on the right, the surgeon removed some more skin… and then removed some more skin… until the right upper lid had 2mm less skin than the left side. Why?  Because the lid crease was not properly attended to, had lost its fixation, and was giving the appearance of extra skin.  In fact there was a deficit of skin if one were to correct the lid crease abnormality.  One might ask the following:  how does the skin look baggy if too much has been removed?!?!  Well, this is simply because the normal Caucasian upper lid has a crease, and when the skin is folded inwards and attached properly to the crease, it takes more skin to line the upper lid.    

At any rate, the lid crease is important and should be part of every upper lid surgical plan.  Additionally, the placement of the incisions and their surgical closure is very important in cosmetic blepharoplasty.  For reference, a close up of the incisions at 3 months postoperative is presented below, along with a marked up version of the photo, showing where the actual incisions were made.  Full incision healing can take more than 6 months, but the majority of the healing happens within the first month or two, as shown below:




Finally, for the full blepharoplasty result, cropped images of the patients eyelids preoperatively and at 3 months postoperatively can be seen below.  Please note that there was an “internal” brow lift performed with the upper blepharoplasty procedure: basically, the muscles that pull the inner brow downwards were released, and the muscles that pulled the outer brow downward were released as well, and a stabilizing suture was placed under the “tail” of the brow.  This led to some subtle brow lifting and increased the definition of the eyebrow as well.