Anatomical and pathophysiological foundations of eyelid ptosis

The periorbital area is made up of extremely sensitive and delicate tissue layers that include thin skin, the Orbicularis Oculi muscle, the Orbital Septum, and posterior fat pads. With age, the process of collagen and elastin fibers breakdown accelerates, causing skin tissue to become loose and the septum to become loose.

Weakness of the orbital septum allows the fat that supports the eyeball to protrude forward; this pathological phenomenon is known as lipoatrophy or eyelid puffiness. In the upper eyelid, fat accumulation is more prominent in the medial and medial pads, while in the lower eyelid, the three medial, central, and lateral pads are subject to herniation. Awareness of these microscopic structures and the balance between fat removal and redistribution form the main foundation of modern blepharoplasty surgery.

Initial assessment and candidacy criteria

Not all eyelid changes are due to excess skin; differentiating dermatochalasis from true ptosis due to levator muscle dysfunction is the first step in the patient's evaluation. In addition, it is essential to examine the eyebrow position, as brow ptosis is often misdiagnosed as upper eyelid ptosis in many patients.

Principles of surgical techniques in the upper and lower eyelids

Modern blepharoplasty methodology moves beyond the traditional approach of “excessive tissue removal” and focuses on “volume preservation and structural correction.” The ultimate goal is to achieve a completely natural appearance without creating hollowness or dryness in the eyes.

Upper eyelid blepharoplasty

A precise incision is made along the natural crease of the eyelid (usually 8 to 10 mm above the lash line). The surgeon carefully measures and removes a controlled amount of skin and a thin section of the orbicularis muscle. If there is excess fat, especially in the inner corner of the eyelid, the drainage is done with great care to avoid any bleeding or unwanted indentation.

Lower eyelid blepharoplasty

In lower eyelid surgery, two main approaches prevail:

• Transconjunctival technique (through the conjunctiva): Ideal for people who only have fat puffiness and no significant excess skin. This method does not make any incisions on the skin and there is zero risk of external scarring.
• Transcutaneous (sub-lash) technique: If there is excess skin combined with fat, an incision is made below the lash line and, along with fat manipulation, the excess skin is removed and the eyelid structure is stabilized (canthopexy or canthoplasty).
• Fat Repositioning: Instead of discarding the fat pads, they are transferred into the tear trough to smooth out the hollow under the eye.

Table of distinction between types of surgical approaches

Preoperative care protocols

The quality of the surgical procedure is directly dependent on the systematic preparation of the tissue and body. It is of undeniable importance to observe the following points to minimize the amount of bleeding and hematoma formation:

• Stop taking nonsteroidal anti-inflammatory drugs (such as aspirin, ibuprofen), blood-thinning supplements such as vitamin E, ginkgo biloba, and garlic at least 10 days before surgery.
• Stop smoking and alcohol consumption at least two weeks before surgery to maintain optimal oxygenation of the capillaries and accelerate the healing of the skin layers.
• Close blood pressure control, as uncontrolled blood pressure increases the risk of active bleeding during and after surgery.
• Laboratory evaluation of dry eye syndrome using the Schermer test in initial examinations.

Step-by-step recovery period

The tissue healing process after blepharoplasty involves specific timed stages:

Management of possible complications and principles of prevention

Any surgical intervention can be associated with side effects; however, implementation of standard techniques minimizes their occurrence. It is essential to be familiar with these to distinguish normal healing processes from clinical warnings:

• Lagophthalmos (incomplete closure of the eyelid): This is common and temporary in the early days due to swelling; however, if it is caused by excessive skin removal, it requires additional evaluation.
• Ectropion (outward turning of the eyelid margin): Often occurs in the lower eyelid due to laxity of the canthal tendon; the use of canthopexy during surgery prevents this complication.
• Bruising and cross-sectional asymmetry: The healing process on both sides of the face is not necessarily simultaneous, and it will not be possible to judge the definitive symmetry of the eyelids until the tissue edema has completely subsided (at least 6 months).

Fundamental clinical questions