CHAPTER 63 Radiofrequency-Assisted Upper Blepharoplasty for the Correction of Dermatochalasis

Lid droop secondary to redundant skin (dermatochalasis) affects nearly all individuals at some point. It is more common on the upper eyelids, but also occurs to a lesser extent on the lower lids. It is typically a bilateral condition, most often manifesting in patients older than 50 years of age. Occasionally, it is observed in younger adults.

Examination of the eyelids reveals redundant, lax skin. An excess fold of skin in the upper lid is characteristic, and the normal upper lid crease may be hidden by the excess tissue. Patients will frequently use the frontalis muscle to augment eyelid opening. This reduces the degree of lid droop, but often results in exaggerated wrinkling or furrowing of the forehead and may lead to muscle tension headaches. Dermatochalasis can present both as a cosmetic problem as well as a functional one by interfering with the superior visual field. In this case, surgical correction is considered reconstructive rather than cosmetic.

The introduction of the 4-MHz Dual-Frequency Surgitron (Ellman International, Inc., Oceanside, NY) has made the successful office-based management of dermatochalasis commonplace. The use of the device’s unique radiofrequency profile coupled with the proprietary electrode handpieces allow for excellent management of the delicate and highly vascular skin of the eyelid. With proper patient selection, office-based blepharoplasty for the treatment of dermatochalasis is an effective and convenient option (see Chapter 30, Radiofrequency Surgery [Modern Electrosurgery]).

Anatomy

Successful surgery on the eyelids requires a detailed knowledge of the normal anatomic structures and their functional relationships. Good surgical outcomes depend on correcting anomalies while maintaining or reestablishing normal anatomic relationships. The anatomy relevant to the successful correction of dermatochalasis is reviewed here. The bibliography at the end of the chapter contains a few excellent text references practitioners may use to supplement the following review.

In the primary position of gaze (i.e., eyes staring straight ahead), the palpebral fissure measures anywhere from 9 to 12 mm vertically. The horizontal dimension is generally 28 to 30 mm. The upper eyelid margin lies 1.5 to 2 mm below the superior corneal limbus in the adult. The upper eyelid’s marginal contour reaches its highest point slightly nasal to the mid-pupillary line. The lower eyelid margin is normally positioned directly at the inferior corneal limbus.

The upper eyelid crease (Fig. 63-1) typically lies 8 to 12 mm above the eyelid margin. It is generally lower in males and higher in females. In non-Asian eyes, the crease needs to be reformed as part of the blepharoplasty procedure to reestablish normal cosmetic appearance. In a large percentage of Asian eyes, the crease may be lower in position than the aforementioned figures or absent altogether. This factor must be taken into account and discussed with the patient before the procedure so that one does not inadvertently “westernize” an Asian eye against the patient’s desires.

Figure 63-1 Schematic showing the components of the eyelid and the invagination that forms the visible lid crease.

The skin of the eyelid is the thinnest skin in the body. The epidermis itself may be only three to four cell layers thick. The combined epidermis and dermis of the eyelid may be only 1 mm thick. The underlying dermis is also scant and poorly defined. It lacks the interdigitations (rete ridges and rete pegs) with the overlying epidermis that are found in thicker skin. Thus, the epidermis is only loosely adherent to the dermis. We exploit this unique characteristic during blepharoplasty by delivering local anesthetic into this space. The skin of the eyelid also lacks the subcutaneous fat present in skin elsewhere. The skin of the eyelid thus lends itself to healing nicely from properly formed incisions. One tends not to see the depressions found in scars in other areas of the body when the collagen fibers and adipose tissue in the dermis are disrupted.

Below the skin of the eyelid lies the orbicularis muscle complex (Fig. 63-2). This is a sheet of striated muscle innervated by branches of the facial nerve that acts to close the eyelid. The muscle is subdivided into an orbital portion, which overlies the orbital rim, and a palpebral portion overlying the eyelid itself. The palpebral orbicularis is further divided into a superior preseptal portion overlying the orbital septum and a pretarsal portion overlying the tarsus of the lid. The pretarsal portion ends medially and laterally in fibers that form components of the canthal tendons that hold the lid margins against the globe. The medial portion is well developed and forms a structure known as Horner’s muscle. Care must be taken when excising redundant skin from these areas not to damage these structures or resultant lid malpositions may develop. The orbicularis functions not only in eyelid closure but in the proper functioning of the lacrimal system.

Figure 63-2 Schematic showing the multiple components of the orbicularis muscle.

Posterior to the orbicularis is an avascular fascial plane composed of loose areolar tissue. Anatomically it separates the orbicularis from the underlying orbital septum–levator aponeurosis complex. This is an important surgical reference plane: it marks the posterior limit of dissection during blepharoplasty for the correction of dermatochalasis.

Note the position of the supraorbital nerve in Figure 63-3 as it emerges from the supraorbital foramen. Care should be taken to avoid this area during administration of anesthesia as well as while making incisions to avoid trauma to this nerve.